Water should not be drunk at meal-times, as with it a larger quantity of food can be eaten than without it and the food is more perfectly absorbed - and assimilated. But between meals patients should drink at least from 1200 to 1500 c.c. (40 to 45 ounces) daily, gouty individuals requiring even more than this amount. A small cup of tea or coffee may be taken with the meals, but it should not be sweetened with sugar, although saccharin may be used instead. Skimmed milk may also be taken in moderate amounts by those who wish it, for a liter produces only 396 calories, while the same amount of rich milk produces 675 calories. Alcoholic beverages should be forbidden for the reasons already given.

The diet just outlined can be stated more tersely as follows: Each day a patient may be permitted about 200 grams of bread, or approximately half a loaf; 350 grams of lean meat or other protein food, which could be an egg at breakfast, a French chop or its equivalent in size of other meat at noon, and a slice of cold meat of the same dimensions at night; 250 grams of vegetables and salads, which are equivalent to a baked potato, and a small saucer of peas, and a few leaves of lettuce or slices of tomato; 250 grams of fresh fruit, which 2 or 3 apples will equal; and 1500 c.c. of water, or approximately five glasses. Tea or coffee may be substituted for part of this water if desired. Such a diet will produce from 1300 to 1400 calories.

Necessary as it is to reduce the amount of food eaten, equally necessary is it to consume, by work, some of the surplus fat of the obese body. A starvation diet will result in the disappearance of a portion of the stored fat to maintain the temperature of the body and the energy of the tissues. The fat will, however, be used faster if muscular work is done. When muscles have been made partly useless by obesity or have undergone atrophy, they can be restored to normal strength only by use.

If the heart is weak, as is often the case, exercise must be taken with caution. The best results in the excessively stout are always gotten by carefully graded exercise. Active exercise is preferable to massage. The latter may at first be employed when active exercise is distressing or distasteful. The masseur should, however, introduce into his treatment numerous resistance exercises. The degree of resistance made should be increased little by little. As soon as possible the obese patient should be led to take active exercise, and for this to be effective, it must be sufficiently severe to cause perspiration. Oertel especially insists upon the need of exercise and its utility in reducing flesh. It insures a better circulation of blood, a better oxygenation of it because of deeper breathing, and therefore more perfect metabolism, and stronger muscles, a more rapid consumption of fat, and a more rapid elimination of water by the skin and lungs. Of all forms of exercise, he thinks hill climbing is the best. Such exercise is easily graded by prescribing the distance to be walked and the time during which the walk is to be taken. In this way exercise may be adapted to weak hearts as well as to strong ones. Hill climbing insures the elimination of larger quantities of fluid than any other exercise commonly used. This elimination in itself reduces weight. Even if a portion of the lost fluid be replaced, the new fluid will come to the tissues ready to take into solution, and in turn to eliminate from them, larger amounts of waste. Those patients who are strong, and especially those whose hearts are strong, should be encouraged to take gradually longer and more rapid walks and finally trots. A run upon a level, with a sweater on, will produce almost the same results as climbing steep and long hills.

Hot baths, either tub, Turkish, or Russian baths, are sometimes employed to produce free elimination by the skin. They do not, however, produce effects comparable to those that can be obtained from exercise.

The alkaline mineral waters are often given for their effect upon general nutrition. Undoubtedly they do benefit those afflicted with gout. Drinking water copiously, especially alkaline water, stimulates more rapid and perfect metabolism. Bouchard claims that alkaline sulphur waters act upon the liver and promote greater elimination of fat. Purgative waters are also useful, especially for those with enormous abdomens.

Various drugs have been used to influence general nutrition and to hasten the loss of flesh. But most of these produce no positive effect. Desiccated thyroid may be used with advantage as an adjuvant to diet and exercise for it undoubtedly causes a reduction in body weight. If given in large doses, however, it will lessen appetite, and cause nausea, rapid action of the heart, and loss of strength and endurance. It is safest to begin with moderate doses - one and one-half or two grains, but these doses may be gradually increased. Watch should be kept over the effect of the drug upon the heart, as it may cause distressing cardiac weakness. I have many times given strophanthus or digitalis with thyroid extract when I desired to get the fullest effect of the latter, in order to counteract the quickening and weakening action of the drug upon the heart.

Thyroid should be used only when there is no organic disease of the heart or of the great vessels and should not be used long.

Not all cases of obesity can be treated alike. The general principles of treatment that I have described must be applied to each with discrimination.

Obesity in childhood rarely requires treatment for it is outgrown in almost all cases. After middle life a rapid reduction in weight should not be attempted or only in those who are especially vigorous, but a slow or intermittent reduction is possible and will greatly benefit them. The effect of treatment upon the heart's strength and upon the activity and health of the kidneys must be watched closely.

The treatment outlined above is applicable to the obese who are florid and strong. However, there are a large number of fat persons who are anemic and who cannot be given so restricted a diet and so much exercise. These cases are often helped by the treatment advised by Weir Mitchell, which is as follows: The patient should rest in bed for two weeks; during the next two weeks he may walk about a little, but should still spend much time upon the lounge. Massage once or twice daily, later combined with more active, Swedish movements, should be given. During the first five or six days of treatment the patient's ordinary diet is gradually changed until he is gotten upon an exclusive skimmed milk ration. If drinking milk only becomes very monotonous, it is varied by permitting a little of beef, chicken, oysters, or clam soup. Upon skimmed milk, patients often lose half a pound or more a day. Care must be taken, if the heart grows too quick and weak because of rapid depletion, to feed more generously. Meats, fish, and eggs constitute the first change from the skimmed milk to an ordinary diet. While upon this diet anemic patients must be given iron. Rest in bed with only passive exercise at first will enable many feeble patients to bear a rapid loss of flesh that they could not stand if they were up and taking active exercise.