The toxic (or gouty) form, in which the vital functions have not suffered, may be remedied by massage, and the main objective in treatment should be to assist the vascular system, particular attention being paid to the portal circulation.1 Gentle, rhythmical kneading, combined with deep stroking, should be applied to the four limbs, and general abdominal massage should follow. Breathing exercises - the simpler the better - complete the seance. As "tone" returns a gradually increasing amount of exercise may be prescribed. The importance of breathing exercises will be better realised when we consider that it is not uncommon to find, post-mortem, that unduly stout subjects often have a comparatively small lung capacity, while in thin subjects it is comparatively large.

Though massage may render valuable assistance to these sufferers, it can in no way compete with exercise as a remedial agent, since the cause of the condition is chiefly lack of it. But, usually owing to heart involvement, the victim is unable to indulge in the natural cure, and so artificial means are necessary. Much as massage may assist, the benefit is bestowed far more rapidly and efficiently by the use of general rhythmical faradisation on the Bergonie chair. By this means every muscle in the body can be exercised freely, not only without straining the heart, but while actually saving it from labour. As Sir Lauder Brunton has said, "at each relaxation of a muscle it tends to cause a vacuum within its surrounding fascia, into which the lymph flows from the muscular structures. At each contraction the muscle presses lymph out, and these alternate muscular movements really act as a subsidiary heart." By use of the chair every muscle in the body is thus transformed into a "subsidiary heart," and that, too, without involving any strain, or even effort, on the part of the nervous system. Sometimes patients actually fall asleep under treatment. Local troubles, such as fibrositis, which may co-exist with the obesity, call for additional treatment by massage.

For the non-toxic type of obesity the Bergonie chair is practically useless, whereas massage may often be of great service. To be effective the treatment must be thorough. An old-fashioned remedy for the undue deposit of fat about the hips of women - almost in itself a separate type of obesity - is to roll on the bare floor night and morning for a few minutes. Several patients have borne witness to the efficacy of the remedy. The problem is to transfer the fat globules to the lymph channels, and to effect this end some form of emulsifica-tion has to be performed. In some positions, such as under the chin, rolling between finger and thumb will prove efficacious. On the abdomen, picking up of the whole of the subcutaneous tissues of the abdominal wall will prove satisfactory, while elsewhere a combination of this and of kneading will prove to be the best technique. General abdominal massage should be included, though it is not so essentially a part of treatment as in the toxic variety. All treatment must be vigorous.

1 The technique of applying massage to assist the portal circulation is described in the next chapter (see p. 395).

Almost every patient who is under treatment for obesity has been put on a strict diet by the medical man. The masseur should have nothing whatever to do with this part of the treatment, except to report if he has reason to believe that the prescription is not strictly observed.

A well-known mot runs that "no man need have the gout who can afford to keep a slave," and doubtless it is true as regards the acute attacks that follow gross errors of dietary - if the "slave" be an expert masseur. Though regarded with levity by that portion of the public which does not suffer from it, this horrible complaint is not only a cause of acute suffering or intense discomfort, but also may lead to permanent crippling and even hasten the approach of death. Let us remember, too, that, though many patients have brought the curse upon themselves, there are many others who suffer as the victims of circumstances. Osier states that hereditary influences can be traced in 50 per cent. to 60 per cent. of all cases. In addition to joint changes, the patient usually suffers from chronic nephritis, arterio-sclerosis is common, and the heart is often hypertrophied. Emphysema is frequent in old-standing cases.

Whether obesity is present or not, treatment should be administered in the same manner as was advocated for that of the toxic variety of the complaint. The nodular points, which called for frictions, are here replaced by the deposits around the joints in chronic cases. In acute cases the whole of the area of inflammation should, of course, be given a wide berth. With this reservation massage is not only permissible, it is appropriate. General massage (especially abdominal) should open the seance, the limb containing the inflamed joint being left till the last. Supposing, as is usual, that the great-toe joint is affected, the whole limb should receive a dose of surface stroking from the mid-tibial region to the hip. Deep stroking is gradually substituted, and then the thigh should be kneaded gently. Stroking terminates the seance, which should have afforded the greatest possible relief to the sufferer, if technique has been efficient. The attack over, the patient should be given a table of exercises to be used as a prophylactic. The tendency to emphysema renders it necessary that respiratory exercises should take a prominent part, and the cardiac hypertrophy warns us to begin cautiously, increase gradually, and at all times to avoid strain. It is probable that regular doses of massage, or of Bergonie treatment, can serve as a permanent prophylactic against acute attacks, and that either can retard the progress of the disease and of its co-incident evils. It is thus possible, by ensuring the more efficient elimination of urates, that even life itself may be prolonged for "gouty" patients.