moisture and taxing the respiratory capacity much more promptly and completely and is more capable of regulation than any other form of exertion, at least any which would be admissible. It is only possible for people relatively young or strong to begin in this way. Our subject is polysarcia in people of advancing years, and hence greater caution must be exercised in outlining activities than for younger folk. The general principles of exercises given at the end of this paper need not be repeated here, but should be read in connection with the measures now to be outlined. In over-stoutness of late middle life, accompanied by good health, it is essential to use first fairly active increasing extensor movements with elasticizing measures, active and passive stretchings, loosening up of the hip joints particularly, and above all, thorough drill in regaining proper attitudes. This should be followed by systematic, accurate training in breathing till a normal capacity is attained, almost never found in stout people unless acquired through teaching. In a paper elsewhere I have elaborated these thoughts (Internat. Med. Magazine, July, 1901).
When we have to do with the fat anemic person vastly more care must be used. The heart in these cases is likely to be infiltrated by fat and the muscular fibers clogged and inelastic, and must be taught slowly to regain their contractile vigor. At first, climbing stairs under direction is about as much as can be attempted, and any house will serve, merely regulating the number of steps walked up and down (both being of benefit) and the rate of speed carefully specified. Tall office buildings serve admirably for the purpose. Polysarcia is such a disabling condition that it is well worth prolonged remedial efforts. Success is possible, and indeed always probable, within limitations. The unaided efforts of the patient can readily lead to harm, sometimes calamity. There is one essential rule in dealing with the cases under consideration, and that is the time for treatment can not be measured by weeks, should not be measured by months and can only safely and satisfactorily be measured by years. One instance will help to illustrate my point. I had a gentleman under my care of sixty-one years of age, who had learned to ride a bicycle before meeting me and found it impossible to use this much because of the distress it produced in breathing. I saw him only rarely at intervals of months, and advised him by letter chiefly in connection with his own physician. He was advised to adopt the rule of riding regularly but briefly on the level roads of his own country place. After some months these short excursions produced no distress. In a year's time he was able to start out upon the open roads, but was compelled to dismount at every small rise of grade. In another year he was able to ride up moderate grades on a good road. At the end of the second year he was riding with comfort and pleasure. At the end
