The results claimed by Oppenheim, Debove, et al. were immediately challenged--and it is now generally admitted, not without some justice--by Germain See. It seems certain, to say the least, that water taken during the repast does tend to augment the quantity and facilitate the elimination of urine. Abundance of beverage, moreover, presents other advantages, in that it facilitates digestion by reason of its diluent action, a fact well worth bearing in mind when treating the obese who are possessed of gouty diathesis, and whose kidneys are accordingly encumbered with uric and oxalic acids. The foregoing presents the ground upon which Germain See permits an abundance of beverage; but he also expresses strong reservation as regards beer and alcohol, either of which (more especially the former) tends to the production of adipose. In his opinion, the only beverage of the alcoholic class that is at all permissible, and then only for cases suffering from fatty heart, is a little liqueur or diluted wine. Coffee and tea he commends highly, and recommends the ingestion of large quantities at high temperature, both during the repasts and their intervals. Coffee in large doses is undoubtedly a means of de-nutrition, and so, too, in no less extent, is tea; both act vigorously owing to the contained alkaloids, though, to be sure, they sometimes, at first, tend to insomnia and palpitation, to which no attention need be paid, however. The treatment outlined by See is:

1. A physiological regimen comprising four to five ounces of nitrogenous principles as derived from eight to ten ounces animal muscle and albuminates; three to six ounces of fat; eight to ten ounces of hydrocarbons as yielded by ten to twelve ounces of sugar or starch food.

These proportions to be modified in such manner that the musculo-albuminates shall not sensibly exceed the normal ratio, for meat in excess itself furnishes fat during transformation. The fatty substances of easy digestion may, without inconvenience, be utilized in doses of two to three ounces. The hydrocarbons should be reduced to a minimum. As for the herbaceous elements, they contain nothing nutritive.

2. Beverage, far from being suppressed, should be augmented, in order to facilitate stomachal digestion and promote general nutrition, though alcoholic liquids must be inhibited; likewise mineral waters, except, perhaps, for occasional use. Both should be replaced by infusions of coffee or tea, taken as hot as can be drank.

Henrich Kisch insists that any method which promises rapid and marked decrease of adipose must, per se, be objectionable, even if not positively injurious, since it tends to provoke general troubles of nutrition. He suggests that first the fats and hydrocarbons be reduced as little as possible; that a moderate mixed regimen is required, containing a preponderance of albumen, small quantities of hydrocarbons and gelatinous matters, with but very little fat. Certain fatty meats, however, should be generally interdicted, such as pork sausage, smoked beef tongue, goose breast, smoked ham, fat salmon, and herring in any form. Eggs, however, may be partaken of in moderation, giving preference to the albumen over the yelk. Farinaceous foods, in the main, should be rejected, even bread being allowed only in small quantities, and then preferably in the form of toast. Cheese likewise contains too much fat; and mushrooms are so rich in hydrocarbons that they should be rejected. Condiments, water, vegetable acids (vinegars excepted) may be permitted; especially pernicious is vinegar where there is any tendency to gout or gravel.

All fatty beverages--bouillon, unskimmed milk, chocolate, or cacao--and all alcoholics, are hurtful; breakfast tea is undoubtedly the best beverage, but, after a little, is advantageously replaced by light white wine diluted with water.

Kisch believes in a free and abundant use of water by the obese, especially where there is a tendency to plethora, since this fluid facilitates oxidation as the result of absorption; thus he advocates the inhibition of large quantities of cold water by all, save those presenting evidence of cardiac insufficiency. In short, his regimen is based upon the administration of a large quantity of albumen, like that of Harvey-Banting.

E. Munk recommends an almost identical dietary, save that he prefers great moderation in fluids employed as beverage.

M. Robin has sought to harmonize the opposing views regarding fluids, and therefore declares obesity arises from two distinct sources: 1. Augmentation of assimilation. 2. Reduced disassimilation. In the former, he insists water must be interdicted, while in the latter it may be allowed ad libitum.

Again, in order to recognize the exact variety of obesity, he divides his patients into three classes, each recognizable by the volume of urea excreted. In the first there is an increase above normal; in the second the volume of urea is stationary; in the third decreased, increased, or stationary.

When the urea is stationary, which is most frequently the case, it is necessary to calculate the coefficient of oxidation; that is, the relation existing between the solid matters of the urine and the urea. The elevation of the coefficient is prima facie evidence the obesity is due to excess of assimilation, while depression of the coefficient indicates default of assimilation. In the first case, water and liquids must be denied as far as possible, the same as if there was no augmentation of urea; in the second, the same as if there was diminution of urea, the patients may be permitted to imbibe fluids at pleasure.

For the obese from default of disassimilation, Robin recommends a regimen of green vegetables and bread chiefly--the latter in small quantities, however, and fluids as may be desired. By this means, on one occasion, he was able in the course of one month to diminish the weight of a female patient by twelve and a half pounds, her measurement around the waist at the same time decreasing 5.2 inches and across the stomach 4.8 inches.