If we desire to obtain a rise in bodily weight, we must introduce into the body larger amounts of food, and especially nutriments of a high caloric value. Practically we proceed as follows: We inquire minutely how the patient has recently lived; what kind of food and how much he has taken with every meal. If we find that his diet was one-sided, we must immediately change it; for a diet list excluding many important, foodstuffs is always deleterious in the long run. We will therefore permit as great a variety of food as is compatible with the condition of the case.

We then inquire as to the quantity of food ingested. Should the latter be insufficient it must be our aim to prescribe the food in somewhat larger quantities. If the normal amount is taken, we must make the beverages taken with the meals more nutritious. Coffee and tea, for instance, are given diluted one-half with milk and a small addition of cream as well as sugar, or, instead of coffee, a glass of milk is ordered.

In suitable eases two or three smaller meals, consisting of milk and buttered bread, may be given with advantage.

It is advisable to prescribe the daily amount of butter that should be taken: I usually order a quarter of a pound per day. Butter is a fat easily digested, and, on account of its high caloric value, especially suitable.

The success of treatment is practically assured, if it is possible to get the individual to take larger amounts of food. We often have to deal with persons whose appetite is very poor. Here, besides the usual remedies, we have to make use of the following dietetic means: Bread and vegetables, as well as milk and eggs, can usually be taken with relish, even if a marked antipathy for meat exists. The addition of olives, lettuce, horseradish, etc., sometimes aids in overcoming this. A glass of cold water stimulates the appetite while eating and induces a larger consumption of food. It is self-understood that we make use of all these measures, which besides their dietetic importance contribute to the patient's enjoyment of life, provided no serious contraindications are present.

Outdoor life and moderate exercise (walking, light gymnastics, bowling, etc.) are of great value. The latter stimulates the appetite, and by satisfying it the increased loss of heat through muscular work will not only be compensated, but probably an excess of food will be ingested without trouble. Exercise, furthermore, serves the purpose of stimulating muscular development and of strengthening the body.

By means of a suitable combination of food and exercise, we effect not only an increased formation of adipose, but also of muscular tissue, and a gain in strength.

III. The bodily weight should be reduced as soon as there is a surplus of fat, which is displeasing to the eye or mars the harmony of the body.

There are two ways of diminishing the bodily weight: first, diminution of the amount of food taken; secondly, increase of the amount of work performed, or a combination of both.

Karell,1 and after him S. Weir Mitchell,5 have tried to treat obesity by a restricted milk diet. S. Weir Mitchell says: "Karell has pointed out that on a cream-less milk diet fat people lose flesh.

"This can be done rapidly and with safety by the following means: The person whose weight we decide to lessen is placed on skimmed milk alone, with the usual precautions, or at once we give skimmed milk with the usual food, and in a week put aside all other diet save milk and all other fluids. When we find what quantity of milk will sustain the weight, we diminish the amount by degrees, until the patient is losing a half pound of weight each day, or less or more, as seems to be well borne. Meanwhile, during the first week or two, rest in bed is enjoined, and later, for a varying period, rest in bed Or on a lounge is insisted upon, while at the same time massage is used once or twice a day, and later in the case Swedish movement. At the same time the pulse and weight are observed with care, so that if there be too rapid loss or any sign of feebleness the diet may be increased. In many such cases I allowed daily a moderate amount of beef or chicken or oyster soup - more as a relief to the unpleasantness of a milk diet than for any other reason."

Banting's cure also is based upon a reduction of the amount of calories introduced with the food (nearly exclusively meat diet).

1 Philip Karell: "Milk in Cardiac Hypertrophy." Edinburgh Medical Journal, August, 1866.

2 S. Weir Mitchell; "Fat and Blood." Philadelphia, 1884.

Oertel1 was the first to call attention to the value of muscular exercise in the treatment of obesity. By a gradual slow increase of work it was found possible to accustom even a weakened heart to greater exertion. Oertel, as is known, recommended for this purpose the climbing of light grades.

Zuntz2 is of the same opinion, and advises in treating obesity to utilize muscular activity. In the treatment of obesity we must endeavor to free the body from superfluous fat, without impairing the amount of albuminoid substance (muscles). This can be most easily accomplished if with a moderate but sufficient diet the usual amount of work is slowly increased without augmenting the amount of food consumption. It is more difficult if at the same time that work is increased the amount of food is considerably decreased.

Practically we should proceed as follows: We must determine exactly under what dietary (this must be estimated quantitatively in an approximate manner) an individual will remain in a state of bodily equilibrium. If the person has not gained lately, we may take the amount of food that be has been in the habit of consuming as a standard. If, however, he has been gaining on this quantity, we ought to diminish it, allowing, for instance, only one slice of bread instead of two or three, leaving off intermediate meals, etc. The weight of the patient should be controlled every two or three days, or weekly, by the scales. As soon as the amount of food necessary to keep the body in equilibrium has been determined, we must begin slowly to increase his muscular work. He should walk one-half to three-quarters of an hour in addition to his usual work, or ride a wheel, or row or fence, or play billiards or golf, or hunt or fish. Gradually the time for exercise may be lengthened or the degree of work intensified; as, for instance, by traversing the same distance in shorter time, when walking, cycling, or rowing. This materially increases the consumption of calories. If we proceed slowly and carefully, we can soon obtain considerable work even from individuals that are weak.

1 Ocrtel: "Allgemeine Therapic der Kreislaufsstorungen," Leipsic, 1884

2 Zuntz: "Zeitschrift fur diatetische und physikalische Therapie," loc. cit.

In increasing the work never allow the patient to become exhausted. The accelerated heart action and respiration due to the exertion must return to normal ten minutes after beginning to rest. If this is not the case, the work must be reduced.

IV. We have seen that by means of suitable diet and muscular work the body weight may be increased or reduced at will. It is also gratifying to note that the increase or reduction of the body substance, if it is advantageous for the organism, will be distributed in a harmonious way, so as not to offend our aesthetic feelings. In a general way, we will be right if we maintain that beauty and health with regard to bodily shape go hand-in-hand. When an increase in body-weight is accompanied by increased beauty it will be found to be of hygienic value. In a similar manner, a decrease of weight bringing out a more harmonious appearance is certainly also advantageous to health.

The axiom that fat and muscular tissue are evenly distributed when an increase takes place is, however, subject to an exception in the interest of the organism. The deposition of fat is somewhat greater in places where the subjacent muscles are not called into frequent play, whereas the muscles increase to the largest extent in such places where they are called frequently into action. In reducing weight the opposite holds good. The greatest loss in fat occurs in places where the muscles are most exercised, and the greatest loss in muscular tissue where muscular activity is small. The advantage of this arrangement is that fat. is deposited in such places where it can cause the least harm, and muscles where they are of most value. In the disintegration of tissue, of course, the contrary obtains. Thus the organism watches that everything shall turn out to the best advantage, i.e., it makes use of everything (work and food) for its own benefit.

It is a grateful task for the physician to intervene where in consequence of a false mode of life (too much or too little food, too much or too little work) harm may result to the organism. At the same time we must feel great satisfaction in the knowledge that through simple means (diet and muscular work) we are able to effect an improvement or a cure of the harmful conditions present.