M. De St. Germain achieved good results by combining judicious exercise with moderate alimentation, excluding wine and bread.

M. Dujardin Beaumetz, who professes to have given most close and careful study and attention to regimen for the obese, outlines the following, provided there is no evidence of fatty degeneration of heart.

Breakfast (at 8 a. m.)--Three-fourths of an ounce of bread "en flute"--that is abounding with crust; one and a half ounces of cold meat, ham or beef, six ounces weak black tea, sans sugar.

Lunch (at 1 p.m.)--An ounce and a half to two ounces of bread, or a ragout, or two eggs; three ounces green vegetables; one-half ounce of cheese; fruits at discretion.

Dinner (at 7 p.m.)--An ounce and a half to two ounces of bread; three to four ounces of meat, or ragout; ditto of green vegetables, salad, half an ounce of cheese, fruit ad libitum.

At meal times the patient may take only a "glass and a half" of liquid--approximately ten ounces--though a greater amount may be permitted if he abstains during the intervals.

Special alimentary regimen, however, does not constitute the sole treatment of obesity. Concurrently must be employed a number of practical adjuvants which are oftentimes of the utmost assistance. For one thing, exercise is indispensable; all authorities agree on this point. The exercise taken in the gymnasium is one of the best, notably the "wall exercise," which is more particularly suited to those afflicted with pendulous and protuberant abdomens as the result of feebleness of the hypogastric muscles, to accumulation of fat under the skin and in the omentum, and to dilation of the stomach and intestines. In the "wall exercise," the patient stands erect against an absolutely straight and plumb wall, lifts his hands (carrying a weight) straight over the head, and causes them to describe a semicircle forward. Zantz particularly insists upon arm and leg exercise for the obese, especially the former, since with the same amount of effort a larger amount of oxygen is consumed than is possible by the latter.

However, of whatever character, the exercise should be continued to the point of fatigue or dyspn#oelig;a--three thousand movements daily, gradually increased to twenty-five thousand, if the system can bear it; and under such conditions, not only is there consumption of hydrocarbons, but there is provided a veritable greed for air that augments waste. The experiments of Oertel indicate that loss of weight due to fatiguing exercise arises more particularly from dehydration, which is made good by absorption of the fluids employed as beverage; the fluids are claimed by Germain See to act as accelerants of oxidation.

During exercise there is obviously more abundant absorption of oxygen, and consequently greater elimination of carbonic acid, and as a consequence (as shown by researches of Voit), the reserve fat of the economy is attacked and diminished; in intense labor there is an average hourly consumption of about 8.2 percent. of fat. Further physical activity is useful in exercising the voluntary muscles, and thus opposing the invasion by interstitial fat of the muscle fibrils. Extreme exercise also, to a certain degree, exerts a favorable influence on the cardiac muscle, augmenting both its nutrition and its capacity for labor. With the anaemic obese, however, it is necessary to be most circumspect in prescribing forced exercise; also with the elderly obese possessed of enfeebled or fatty heart.

Hydrotherapy, especially in the form of cold douches, particularly when combined with massage, is often of considerable value in relieving obesity; the method of Harmman, of St. Germain, which has in many instances induced rapid loss of adipose, is of this class. Tepid saline baths and vapor baths have many advocates, and may afford material aid when the heart and circulation do not inhibit their employment. Hot baths elevate the temperature of the body and increase the organic exchanges, hence, as Bert and Reynard have pointed out, tend to the elimination of oxygen and carbonic acid; but when employed, the patient should be introduced while the temperature is below 130° F., when it may be gradually raised in the course of thirty or forty minutes to 140° F.

It has already been intimated, the chief feature of the treatment of obesity is acceleration of the exchanges; and this is in the main true, though it must also be borne in mind that, while there are obese who excrete little urea and have a depressed central nervous temperature, many may be azoturic, and besides eliminate phosphate in excess, when an oxidating treatment will not only fail, but prove positively injurious.

The bile throws out fat, therefore, to accelerate nutritive oxidations, the liver and nervous system must be acted upon, i.e., stimulated. Everything that tends to diminish the activity of the former, or depress the latter, must be avoided. Hence intellectual labor should be encouraged, or in lieu thereof, travel advised. Exercise should be taken chiefly while fasting; the limits of sleep confined to strict necessity, and siestas after meals and during the day strictly forbidden; the skin stimulated by hydro-therapeutic measures, including massage under cold affusions, during warm salt baths, etc.

To increase the activity of the liver, salicylate of soda may often be advantageously administered for its cholagogue effect; or resort may be had to saline purgatives such as are afforded by the springs of Marienbad, Kissengen, Homburg, Carlsbad, Brides, Hunyadi, or Chatel-Guyon; and it is somewhat remarkable that while undergoing a course of these waters, there is often no appreciable change in weight or obesity, though the decrease becomes most marked almost immediately upon cessation of treatment.

Everything tending to increased or fuller respiration is to be encouraged, for the fats are thus supplied with oxygen, hastening their disintegration and consumption.

Direct medicinal treatment presents no very wide scope. Bouchard imagines lime water may be useful by accelerating nutrition, but this is problematical, since fat in emulsion or in droplets does not burn. Nevertheless, alkalies in general, alkaline carbonates, liquor potassa, soaps, etc., aid in rendering fat more soluble, and consequently more susceptible to attack. The alkaline waters, however, are much less active in obesity than the saline mineral waters, unless, as sometimes happens, there is a complication of diabetes and obesity.

Purgatives are always more or less useful, and often required to be renewed with all the regularity of habit. Then too, the iodides, especially iodide of sodium or potassium, as recommended by M. Germain See, frequently prove of excellent service by aiding elimination and facilitating the mutations.

According to Kisch, the cold mineral waters containing an abundance of sulphate of soda, like Hunyadi and Marienbad, are to be preferred to the hot mineral waters, such as Carlsbad, because of their lesser irritant action on the vascular system, and because they strongly excite diuresis through their low temperature and contained carbonic acid; Carlsbad deserves preference only when obesity is combined with uric acid calculi, or with diabetes. For very anaemic persons, however, the weak alkaline and saline waters should be selected; or they should confine themselves to chalybeate waters containing an excess of sulphate of soda. Water containing sulphate of soda is also indicated as a beverage where there are troubles of the circulatory apparatus; it is contraindicated only in accentuated arterio-sclerosis.

As a matter of fact, I find the suggestion of M. Dujardin-Beaumetz, that the obese should be divided into two groups, a most practical one, for some are strong and vigorous--great eaters, perhaps even gluttons--while others, on the contrary, are feeble and debilitated, with flesh soft and flaccid; and upon the former may be imposed all the rigors of the reducing system, while the latter must be dealt with more carefully.

In general, it must be noted, the regimen prescribed for the obese is insufficient, as the following table prepared by M.C. Paul abundantly proves:

There is, therefore, as Dujardin-Beaumetz asserts, autophagia in the obese, and all these varieties of treatment have but one end, viz.: Reduction of the daily ration. But the quantity of nourishment should not be too greatly curtailed, for, manifestly, if the fat disappears the more surely, the muscles (rich in albumen) undergo too rapid modification. It is progressive action that should always be sought.

The quantity of aliment may be reduced either by imposing an always uniform regimen, which soon begets anorexia and disgust, or by withholding from the food a considerable quantity of fat, or, finally, by forbidding beverage during meals. Emaciation is obtained readily enough in either way, and demands only the constant exercise of will power on the part of the patient; but unhappily, severe regimen cannot always be prescribed. When the obese patient has passed the age of forty; when the heart suffers from degeneration; or when the heart is anaemic--in all, rigorous treatment will serve to still further enfeeble the central organ of circulation, and tend to precipitate accidents that, by all means, are to be avoided. In such cases, by not treating the obesity, the days of the patient will be prolonged. In degeneration of the heart, however, the method of Ebstein may be tried; and when there is renal calculi and gouty diathesis, that of Germain See may prove satisfactory.