4

o'clock.-A cup of weak tea with milk and toast.

7 o'clock. Broth or some farinacous pudding as at lunch. IO P.M.-A cupful of thin gruel or of arrowroot.

Hot Water and Diluents.-He should sip half a pint of hot water twice or thrice daily between meals, and barleywater or toast-water may also be allowed. After the acute symptoms have subsided, boiled fish or a little bit of chicken may be given once a day, and the amount of nourishment otherwise very carefully and gradually increased.

Asthenic Cases. In old or feeble and debilitated persons, the diets, as already pointed out, although kept on the same lines, must be more supporting, and therefore the broths, &c., given may be stronger, and beef-tea, chicken-tea, or an egg beaten up in milk may be added once a day to the list. Alcohol will also be necessary, under the restrictions already mentioned.

Protracted Cases. If the attack is a long one, the patient becoming reduced and the pulse feeble, it will be necessary to relax the rules still further, and to allow a somewhat more nutritious diet, including fish, soups, and white meats, as well as the allowance of brandy or whisky.

CHAPTER X.

OBESITY.

MANY persons who are decidedly very stout are yet apparently healthy, and it is a difficult matter to say at what point obesity becomes a morbid condition, though that it does so in a certain proportion of cases cannot be denied.

Whilst a certain plumpness of body is desirable, yet an excess of fat, besides being unsightly, is a burden to its possessor, and many plans for reducing the superfluous fat have at different times been suggested.

Causes. (a.) Excess of Food.-Obesity may be due to excessive indulgence in food, but this alone is probably not a common cause, and, moreover, thin persons are often much larger eaters than those who are stout.

(b.) Alcoholic Beverages, especially malt liquors and sweet wines, have a decidedly fattening effect in the case of many persons, and corpulent people are often large consumers of fluids.

(c) Sex and Heredity.-Women more commonly than men become very stout, and heredity is to be looked upon as an important element in the clinical history of a case. Stoutness is to be found prevailing in some families, while others are lean, and cannot be fattened by any means.

(d.) Want of Exercise.-The want of sufficient exercise, by diminishing tissue change, favours obesity, and the stouter a person grows, the more difficult does the taking of exercise become.

(e.) Gouty Diathesis.-Excessive fatness is also at times

associated with the gouty diathesis, and to be effectual in such cases, treatment must be directed against that state.

(f.) Anomia.-In anæmia, also, there is often a tendency to unnatural stoutness, which likewise yields to appropriate treatment.

It is rarely found that very stout people live to a good old age, but instances are on record of persons who having been very stout, have been able to reduce their corpulence, and have lived on many years in the enjoyment of excellent health. If any plan or treatment for the reduction of corpulence be adopted, it should be commenced very gradually and carried out with great caution.

Sudden Change Hurtful.-Evil results have often followed sudden changes in diet, especially a great increase in the nitrogenous materials of the dietary, to the exclusion of the carbo-hydrates, by persons desirous of rapidly losing their superfluous fat. No sudden change in the mode of life should be rashly undertaken, and all extreme measures should be avoided.

Fatty Degeneration. It is not to be forgotten that the heart and blood vessels in these patients frequently undergo fatty change, and also that the kidneys, if not actually diseased, are often quite inadequate to the strain thrown upon them by a diet from which sugar and starches are almost entirely excluded, and which, therefore, consists very largely of nitrogenous materials. Upon such a diet, however, Mr. Banting reduced his weight by over three stones in a year, and, moreover, a return to ordinary diet was not followed by an increase of weight. The chief objection to the plan called after Mr. Banting is that the diet consists too largely of nitrogenous substances, and for many stout people it is dangerous to throw so much extra work upon the liver, and more especially upon the kidneys.

"Banting."—Mr. Banting, in advocating his plan, forbids sugar and starches; milk and butter; salmon, herrings, and eels; veal and pork; potatoes, parsnips, beetroot, turnip,

and carrot; bread, except when toasted; pastry and puddings; beer and stout, champagne and port. He limited the quantity of liquids as well as of solids, and in reality a comparison of diets will show that his is not more than sufficient to maintain life in a state of inactivity.

His diet was as follows:—

Breakfast.-Fish, bacon, beef, or mutton; one breakfast cupful of tea or coffee without milk or sugar, and one small hard biscuit, or one ounce of dry toast.

Dinner. Fresh white fish, beef, mutton, lamb, game or poultry; green vegetables; a slice of dry toast; cooked fruit without sugar; two to three glasses of claret or of sherry.

Tea.—A cup of tea without milk or sugar; a biscuit or a rusk; two to three ounces of cooked fruit.

Supper.-Meat or fish, with toast, and a couple of glasses of claret or of sherry in water.

The amount of meat allowed at breakfast was five to six ounces, a like quantity was permitted at dinner, and about half as much at supper.

Preponderance of Proteids.-A glance at this dietary shows the large preponderance of nitrogenous materials over the carbo-hydrates, and also the fact that the diet is a very spare one.

Ebstein's Diet.-Another plan, and one which has the recommendation of more variety, while it is also free from some at least of the objections of that followed by Mr. Banting, has been proposed by Professor Ebstein of Göttingen. He excludes carbo-hydrates, sugar, all sweets, and potatoes. Bread is limited to about three ounces a day.

Besides potatoes, he excludes carrots, turnips, parsnips, and beetroot; but allows asparagus, spinach, cabbage, and the leguminose vegetables freely. No sort of meat is prohibited, and he allows the fat as well as the lean to be eaten.

Professor Ebstein does not set strict limits to the quantity of liquid consumed, and he believes that the rules are better kept in the main, and in the most important points, if some articles of diet which strictly would be forbidden-for example, potatoes-are allowed in very moderate quantities. The diet is thus kept from being so irksome, and the patient is able to persevere longer with it than he could otherwise do. It will be observed that in this plan, while the fats are not excluded, the rule against the carbo-hydrates is very strict.

Gradual Change. In most cases it will be well not to be too rigid, for the reasons already mentioned, and it cannot be too strongly insisted upon that the change of diet should be made gradually. Sugar, sweets, puddings, pastry, cakes, cream, sweet wines, stout and beer, should all be cut off. All farinaceous articles should be gradually reduced. Brown bread and toast in limited quantities should be substituted for ordinary bread, or its place may be partially taken by gluten bread. Lean meats, including poultry and game, also eggs, should be taken in moderation. Fish may

enter largely into the dietary, and all green vegetables, salads, and cooked fruits may also be allowed.

As already

said, all malt liquors and sweet wines must be excluded. Hock, claret, or other light wine may be allowed to the extent of three or four glasses a day, or a small quantity of spirits in water may be permitted; but the total quantity of liquid taken in the twenty-four hours should not exceed two and a half or three pints.

The corpulent should be encouraged to take exercise, and especially exercise in the open air; but any violent exertion is most undesirable, from the strain it would put on the heart and blood vessels.