We do not understand the cause of the great variation in the amount of fat present in different individuals; to my knowledge no comparative investigation has been made between naturally thin and naturally fat people, and with regard to the various foods which supply the required amount of calories, water and salts per kilogram of body weight in twenty-four hours. But we know for a fact that with people of about the same body weight the normal weight may vary considerably, i.e., that each individual has a normal weight at which he feels at his best.

In estimating obesity it is necessary to remember not merely the correlation between the height and body weight * of the patient, but also the general condition of the patient, of his heart, nerves and muscles, and the amount of exercise he can take, as well as the presence or absence of other factors which may influence the amount of fat deposited.

Excessive corpulence may be checked in two ways : (1) By appropriate exercise; and (2) by diminished food. We may remember that it is better to increase the amount of work the patient does than to limit his food supply, i.e., loss of weight is better obtained by increased output than by diminished intake. Our aim is not the patient's reduction to a certain weight, but rather the reduction to such a weight as can be obtained by vigorous exercise without excessive fatigue combined with suitable limitation of diet.

Neither must we diminish the body weight too rapidly. The rate and amount of reduction in body weight to be aimed at depends on the obesity and age of the patient as well as on the strength of his heart, nerves, and muscles. Among the number of patients I have treated the following examples may be cited : - A man of thirty years of age, well built and weighing 130 kilos., lost 20 kilos in forty days, which represents a very rapid decrease. The following weights for eight consecutive weeks were recorded in the case of a very small woman of fifty-three years of age weighing 96.55 kilos: - (1) 94.8, (2) 94.5, (3) 93.1, (4) 89.7, (5) 89.6, (6) 87.7, (7) 86.1, (8) 84.7. This irregular curve differs from most others in that its greatest fall occurs at the end of the treatment, probably because of chronic double-sided rheumatoid arthritis in the knees. which I massaged for eight weeks, and which allowed the patient to take much longer walks during the latter part of the time than at first. I myself at the age of fifty-eight, my height being then 175 cm., and neither nerves nor heart being very strong, underwent the terrain and diet cure for seventy days with strict abstinence and a great deal of hard exercise up and down hill, in the course of which my weight decreased from 104.3 to 93.0 kilos. I did not consider a further reduction in weight advisable. In all the above-mentioned cases, especially in the first, I have found rapid diminution of weight accompanied only by good results. It is impossible to give definite figures as to the decrease in weight to be aimed at, since, as above mentioned, it varies so much in individuals. It may be suggested as a general rule that people of middle age or of less than average strength should not continue the cure with decreased diet for more than two months, nor should their average decrease in weight exceed 10 per cent. of the normal body weight. Generally the greatest decrease is at the beginning of the treatment. Care must be taken to prevent over-fatigue and loss of energy on the part of the patient, or inability to perform the mechanical routine of his daily life; he must not feel palpitations; his pulse must not be irregular or too slow; his sleep must not be worse; nor must there be any other neurasthenic symptoms, and treatment must immediately be stopped if any of these warning signs appear.

* See Table on next page.

We may cite from a German medical calendar of average relative heights and weights the following table: -

If after two months the patient's weight is still excessive, it is advisable to lay down certain restrictions in diet for at least six months longer. This is difficult, depending as it does on the intelligence and will-power of the patient.

What effect has massage on the treatment of obesity? Very little in comparison with the effect of systematic physical exercise. Muscle massage produces, by means of local muscle contractions, some effect on the increased breaking down of fat into Co2 and water, but such effect is nothing to the effect of active muscle work. On the other hand, without doubt the movable pressure in massage has some effect on the absorption of fat locally. If a patient with diminished food and increased exercise becomes thin, his store of fat diminishes most in those parts which can be most easily reached by massage. Massage is commonly used in obesity for aesthetic purposes, and mostly by women who desire to get rid of a superabundance of tissue on the hips and abdomen. The same result can be obtained by decreased diet and the use of elastic bands which press on the parts affected.

With regard to dietetic treatment, all authorities are agreed that it must be effected by limitation of fat and carbohydrates. The four best-known systems of diet for obesity are : -

In the section on the Diseases of the Heart I have already spoken of the danger of an excessive decrease in the supply of water. Even if there is some reason for limitation of fluid in failure of compensation of the heart, there is certainly no reason for it in uncomplicated cases of obesity. There is always a certain amount of risk in limitation of fluid. In cases of pure obesity it is quite unnecessary, as the desired result can be obtained without it, especially if the patient can walk.

No definite law can be stated as to the exact weight of the various foods to be supplied, nor is it necessary to do so. This may be decided according to what has been said above.

Any amount of protein may be taken, all kinds of lean meat, fish, and fowl; but patients must not take fat meat, cheese, milk, butter, and olive oil. The amount of bread must be regulated, e.g., 100 grm. of Graham's bread * can be taken daily (= 40 grm. of starchy food), and in addition small quantities of vegetables, lettuce, spinach, French beans, tomatoes, cucumbers, asparagus, various kinds of cabbage, mushrooms, and other vegetables with a somewhat similar carbohydrate content. Sugar, sweets, chocolate, sweet preserved fruits, rice, macaroni, potatoes, haricot beans, peas, carrots, and other roots are strictly forbidden.

After a long experience I have come to the conclusion that in order to avoid digestive trouble, too rapid emaciation, etc., it is unwise, in uncomplicated cases of obesity, to diminish the daily portion of carbohydrates below 70 grm. Fatty food, on the contrary, may be reduced to a minimum.

In regard to drink, all kinds of malt drinks, wine, spirits, milk, cream should be given up as soon as possible. The patient may drink water and mineral waters, coffee and tea without sugar, and in some cases cocoa, but never chocolate.

With such a regime, together with two long walks a day, the decrease in weight desirable for the patient's health may be obtained.