The only renal disease that we must consider in this connection is atrophic nephritis. As far as I can see very little attention has so far been bestowed on the prognostic importance of dietary treatment in patients with contracted kidneys.

This is surprising, particularly as we fully realize that the fate of these patients is to such a large extent dependent on the functional powers of the heart and that the heart's action is always endangered by excessive fat deposits. In the studies I have made of the treatment of contracted kidney (reported in sketch before the Congress of Internal Medicine, 1899), I have given particular attention to these points, and I do not hesitate to state that in my opinion obesity is as dangerous for patients afflicted with contracted kidney as for patients suffering from heart disease, and that prevention of obesity, or treatment of obesity if it exists, is as beneficial for patients with atrophic nephritis as for heart cases. We are altogether unable to influence the anatomic changes that have occurred in the kidneys and that lead to albuminuria, and we are only to a very slight extent enabled to influence the excretion of albumen, consequently all our efforts should be directed towards the important aim of upholding and strengthening the powers of the heart. In order to do this it is just as important to combat any tendency to obesity as it is to reduce the amount of water allowed these patients, a system of protective therapy that I have advocated in another place.

In general practice these fundamental principles are frequently violated. I frequently see cases of atrophic nephritis that were formerly lean or in a normal state of weight fed on so inappropriate a diet (several liters of milk, butter, farinaceous foods, bread and other vegetables) that they soon become much heavier and may without hesitancy be called actually obese. Whereas these patients, notwithstanding the existence of albuminuria, felt comparatively well, they now develop a variety of secondary disturbances on the part of the heart, in particular stenocardiac attacks that may all disappear again (provided the disease has not progressed too far) as soon as a considerable reduction of the accumulated fat is brought about.

I may be permitted to sketch a case of this kind.

The patient was an official of 40 years, in whose urine an abundant quantity of albumen was discovered when he was examined for life insurance. At the time this discovery was made he felt perfectly well. His physician made the diagnosis of contracted kidney, that was undoubtedly correct, and prescribed a diet of milk and farinaceous foods, and at the same time prohibited the use of meat and eggs. Within three months the body weight of this patient increased from 130 to 170 pounds. At the same time the patient began to suffer from frequent attacks of dyspnea and also developed several mild sternocardiac attacks at night. He consulted me for the first time when he was in this condition. The apex beat was found about 15 centimeters away from the median line. The degree of albuminuria was about 0.03 per cent., that is about as high as it had been at the time when the disease of the kidneys was first discovered three months before (according to an analysis that the patient submitted, the original degree of albuminuria was 0.033 per cent.). I prescribed a reduction in the amount of liquid nourishment to 5-4ths of a liter combined with a diet that contained few calories (about 25 calories per kilo); at the same time the patient was ordered to take cold rubs and later to undergo a course of treatment in Homburg. The result of this treatment was excellent. Within six weeks the weight of the patient was reduced to about 150 pounds, and after ten weeks to 135 pounds. The albuminuria naturally persisted but all the distressing subjective symptoms disappeared; at the same time the apex beat was found three centimeters nearer to the median line, and the patient in this way escaped the danger of heart failure that was imminent.

I hope that others may be stimulated to follow my example in treating cases of this kind in this way and that more attention will hereafter be bestowed on the circumstances that I have described. I believe that many cases of renal disease will derive great benefit from a careful regulation of the diet directed not alone toward relieving albuminuria but also toward improvement of the general state of nutrition of the patient.