and, even if they can be induced to follow out a strict diet, it is often useful to be able to cut off very rapidly a large amount of weight, and so shorten the period of strict regimen, or at least put over-fat persons in a condition to exercise with a freedom which had become difficult, and thus to provide them with a healthful means of preventing an accumulation of adipose matter.  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 movements.  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 allow 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.

When the weight has been sufficiently lowered, we add to the diet beef, mutton, oysters, etc., and finally arrange a full diet list to include but a moderate amount of hydro-carbons.  Meanwhile, the milk remains as a large part of the food, and the active Swedish movements are still kept up as a habit, the patient being directed by degrees to add the usual forms of exercise.

If we attempt to make so speedy a change in weight while the patient is afoot, the loss is apt to be gravely felt; but with the precautions here advised it is interesting and pleasant to see how great a reduction may be made in a reasonable time without annoyance and with no obvious result except a gain in health and comfort.

Cases of anaemia in women with excess of flesh have to be managed in a somewhat similar fashion, but with the utmost care.  In such persons we have a loss of red blood-globules, perhaps lessened haemoglobin, weak heart, rapid pulse, and general feebleness, with too much fat, but not, or at least rarely, extreme obesity.  The milder cases may profit by iron, with rest and very vigorous massage, but in old cases of this kind—­they are, happily, rare—­the best plan is to put the patient at rest, to use massage, restrict the diet to skimmed milk, or to milk and broths free from fat, and with them, when the weight has been sufficiently lowered, to give iron freely, and by degrees a good general diet, under which the globules rise in number, so that even with a new gain in flesh there comes an equal gain in strength and comfort.  The massage must be very thoroughly done to be of service, and it is often difficult to get operators to perform it properly, as the manipulation of very fat people is excessively hard work.  As to other details, the management should be much the same as that which I shall presently describe in connection with cases of another kind.