An overburdening of the circulation can be produced by a rela tively small supply of fluid which will augment the disturbances of circulation already existing, the stasis and peripheral resistance. The supply of liquids furnished as drinks, therefore, must adapt itself to the condition of the circulatory apparatus. Where the action of the heart is normal it ought not to exceed the physiological measure of 1,500 c.c. and only in cases of very tall patients and high daily temperature may it be increased to 1,800 or 2,000. In other cases the measure must be lower and reduced to from 750 to 1,200 c.c. More points, especially in regard to the amount of secretion by the kidneys, will be given below. The water introduced in the solids is excreted entirely through the skin. In the following tables I will give some points of value in the regulation of different diets. It will be easy to fix the diet in any given case according to its necessary supply of albumin and according to the quantity of fat-forming substances —fat and carbohydrates—which may be allowed. Thus the table permits us to individualize in the most minute way.
In this diet list it is evident that the fat may be replaced by car bohydrates in a quantity adapted to the special case or the carbohy drates may be replaced by fat. In this substitution we must be guided by the individual peculiarity, the facility with which the pa tient adapts himself to the diet, and his inclination or aversion as regards fat and carbohydrates, and by the digestibility and availa bility of these substances in the organism. The albumin given ought to depend firstly upon the albumin of the body. Likewise certain changes can be introduced into this diet scheme so that the allowance of bread, cheese, or fruit is increased, giving altogether an increase of albumin of about 154 grams, fat 45 grams, carbohydrates 102 grams, equal to 1,520 calories, or we may proceed by temporarily allowing instead of these for lunch, 100 grams farinaceous food, with 8.7 albumin, 15 grams fat, and 20.9 grams carbohydrates.
In order not to be compelled to weigh his food daily the patient is instructed to learn to estimate its quantity by certain indica tions, such as bulk or thickness, measured by taking the size of the hand or other object of familiar size as the standard, telling him to eat a quarter, a half, or an entire roll, a heaped-up or even coffee- or tablespoonful, etc. It will not be found difficult to give the patient proper directions in this regard, and only in this way do we have a sufficient guarantee that the diet is carried out as prescribed.
You Noorden has recently demonstrated that the amount of albu min of the body can be preserved by a suitable diet favorable to fat reduction. He found by experiment that it is always easier to pre serve the albumin of the body if food of a variety to which the patient has been accustomed is employed. The patient, if habituated to a diet of meat, will stand an equally large diminution of fats and carbohydrates, but he who has been used to consume more carbo hydrates and less fat will preserve his proper amount of albumin under a marked diminution of fat and an increase in the number of carbohydrates ; conversely he who is habituated to much fat and greasy food will remain uninjured by a decrease of the carbohydrates.
A change in the sense of increasing or lowering the one or the other variety of food can always be easily arranged within the limits of the tables given above.
While it is only possible in the most exceptional cases for the practitioner to satisfy himself iu regard to the amount of albumin by directly determining the quantity of nitrogen taken in with the food or the quantity of nitrogen in the feces and urine, he has sufficient indications in the examination of the specific gravity of the blood, its percentage of hemoglobin, in the increase of the patient's muscular energy, his general strength and sensations of increased vitality and well-being which were previously lacking, and all ,of these during the slowly decreasing bodily weight. These indications do not only mean the preservation of the amount of albumin but may also show an increase of the latter. If occasionally with these manifestations, however, a small diminution of nitrogen can be shown by analysis, it is surely only a transitory occurrence and amounts to little so far as the patient is concerned. Practical experiments have established this fact over and over again. The danger of considerable loss of albumin is only present if fat-reduction is carried out incautiously and with too great rapidity, or if the patient gets weak, anaemic, has loss of appetite, indigestion, etc. In this case the attempt at re duction must be changed or given up for a time. The safest means we have, however, at our command of maintaining and increasing the albumin of the body, is the methodical increase of the working power of the muscular apparatus (see below).