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 anæmic 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:

Author.Albuminous Matters.Fatty Matters.Hydrocarbons.
Voit.11840150
Harvey-Banting.1701080
Ebstein.1008550
Oertel.155-17925-4170-110
Kisch (plethoric).1601080
Kisch (anæmic).20012100
Normal ration.12455455

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.