b. Medium Degrees of Obesity

(body weight about 15-25 kilo above the average for the particular age, sex and size of the subject). Cases of this kind are the most frequent ones encountered and lend themselves most readily to treatment by reduction cures; they are satisfactory cases to treat. In many of these subjects the small excess of fat can be borne with impunity and in some instances it may be as well to refrain from all attempts to reduce it; at the same time even the small excess may cause much discomfort and it can hardly be denied that intercurrent diseases (infectious diseases, heart lesions, pulmonary trouble, renal disease, arthritic manifestations, etc.), or over-exertion (by over-straining the heart), may all be frought with more serious consequences in these cases than if the fat content were reduced to normal.

Here, too, the age of the subject must be included in the calculation, and here, too, we must adhere strictly to the rule that reduction cures should be omitted in the aged and should be instituted only with the greatest care and very slowly in children and in adolescents.

The majority of subjects of this kind are about thirty years old or still more frequently between forty and sixty. The physician should carefully study the history of these cases and should make an accurate physical examination; if he finds cause to fear the development of serious complications later on he should most emphatically advise a reduction cure. In cases in which all the organs are found to be healthy the rapidity should be determined with which the fatty deposit grows; if the fat deposit is increasing rapidly or even if it is increasing slowly but steadily and progressively a mode of life should be arranged that will favor arrest of this development; in this way the incidence of degrees of obesity that are directly dangerous and that offer a less favorable prognosis and less chance of success from treatment may be prevented with great profit to the patient. In cases again in which the degree of obesity remains more or less stationary the external circumstances of the patient should be considered before it is decided whether or not to institute reduction treatment. If the patients are apt to indulge in severe bodily exercise, if they are exposed to the dangers of alcoholism or of other deleterious influences from excesses in living, if, finally, the character and morals of the patient seem to indicate that they will not exercise moderation in work and are apt to over-indulge in the good things of life, in all these conditions, the fact must be taken into serious consideration that obesity must needs be deleterious; here a reduction cure should be instituted even though the patients are not actually suffering any direct inconvenience from their obesity. All the eventualities that we are considering are more apt to occur in younger subjects between the age of thirty and forty, that is at the period, of greatest activity and greatest physical and mental exertion, than in later years of life; in men, moreover, these deleterious consequences are more liable for obvious reasons to appear during this period than in women. In all of these cases the success of a reduction cure will depend essentially on the length of time during which reducing measures are persevered in and on the method of reduction that is employed. There is of course no serious objection to inaugurating the course of reducing treatment with an energetic system of dietary and mechanical meas ures intended to cause a quick loss of weight amounting to about ten or fifteen pounds; in fact it may be desirable to cause such a rapid loss of flesh, and no bad effects have ever been known to follow this procedure. The root of the matter is not, however, reached by these rapid courses of reduction treatment; it is much more important, in order to obtain permanent and lasting results, to induce the patient to follow certain sensible rules at home and to persevere in the mode of life that is arranged to suit the peculiarities of each case and the external circumstances in which the patient happens to be living; only in this way can an increase of the fat layers be prevented and can a slow but steady reduction of the excessive adiposity be attained. Unfortunately the majority of patients are quite willing to undergo a rapid reduction cure but rarely willing or able to persevere in long lasting dietetic and mechanical restrictions that alone can lead to the desired goal. Nothing can be more foolish or more senseless than to expect lasting benefits from a short course of treatment every summer in some watering place as Marienbad, Kissingen or Homburg, especially if the patient is allowed in the meantime, that is, during the remainder of the year to live in the customary manner and free from all restraint in regard to diet, exercise, etc.; the benefits derived from the short summer treatment, lasting perhaps a month or so, do not determine the fate of the patient but the results of his régime during the remaining eleven months of the year. Unless the physician is so fortunate as to secure control of the patient during this longer period he will as a rule find that the period of involuntary martyrdom imposed upon him during the short period of one month each summer is altogether devoid of lasting good results; within a few weeks after the termination of the cure and after the patient by dint of rigid restrictions in food and drink, of violent purging and of mountain climbing and forced gymnastics has succeeded, painfully I may say, in getting rid of a few kilos of flesh, he will find to his chagrin that the old condition of obesity with all the discomfort that it entails will soon become re-established and that his vital energies continue to fail as before.

In subjects who are perfectly healthy and who are not exposed to particularly strenuous and exhausting conditions in the course of their daily routine the physician may proceed somewhat differently. This class of patients is found chiefly among men of somewhat advanced years particularly among the wealthier class and among professional people and office workers, also to a large extent among women. In all of these cases there is really no urgent indication for the removal of moderate degrees of obesity. People of this character who are suffering from a slight excess of flesh rarely resign themselves to the irksome task of giving up some of their favorite habits and of changing their mode of life for the sake of getting rid of a few pounds of flesh; they do not care to undergo all these hardships, to take exercise and to deny themselves many things in order to insure permanent re suits; here, therefore, the sacrifice is too great and the disadvantages and discomforts accruing from such a course of treatment are altogether out of proportion to the benefits to be derived from the permanent loss of five or ten kilos of fat. For all these reasons we frequently find that the efforts of these people to reduce their corpulency at home and with the aid of household measures are essentially abortive; a brave attempt may be made to carry out the measures recommended but the patients soon fall from grace and give up their original intention of persevering with the treatment. Many of these people would, I believe, be quite willing to undergo a short course of this kind of treatment even if it were very arduous and trying, provided they could be assured that the loss of weight attained in this way would be permanent and that the weapons could be laid aside for all time as soon as the fight were once won; but we know only too well that in order to obtain permanent results this petty war with one's own desires, tastes and inclinations must be carried on daily and indefinitely; very few people possess a sufficient degree of patience and energy to persist in this effort; as a rule few restrictions, that the physician may have advised, are conscientiously carried out, unless of course certain distressing symptoms warn the patient continuously not to stop in the treatment or unless the physician has uttered some serious warning in regard to life and health; the majority of people however content themselves with some one-sided restriction that is not particularly inconveni ent, they stop drinking water during meals, lor instance, or eliminate soup from the bill of fare, or eat only bread crust and none of the inside of the loaf; others take an occasional sweat bath or a cold rub or go to a gymnasium for half an hour's or an hour's exercise every few days, or employ a masseur, etc. All these measures, though only sham weapons, nevertheless enjoy a great reputation with the general public. Good results are, of course, never obtained from such halfway measures. Some five years ago thyroid preparations were recommended for the reduction of fat and it is characteristic for the class of people I have described, (and I may add that they are chiefly women who lack the energy and perseverance to carry out a systematic reduction cure,) that they embraced this method of treatment with enthusiasm because they believed it to be a simple and convenient method of getting rid of fat without any exertion on their own part.

The best method of treatment to adopt in this class of cases and the one that has been employed for a long time is to institute short courses of treatment lasting some four or five weeks at varying intervals; the result of these interrupted courses is a loss of weight of a few kilos (usually between three and eight kilos); during this period, that is after this small loss of flesh has been brought about, the patients should be induced to take advantage of their comparative leanness and to strengthen the muscles by systematic exercises and at the same time also to strengthen the skin by appropriate measures. As a rule this good effect is brought about by a trip to some watering place but there is really no reason why the same results should not be accomplished at home. In the latter case, of course, we cannot count so positively on favorable results as in the former; if they are sent to a watering place in fact we may be almost sure of a good result. In the interval between these short courses we will have to content ourselves, and are moreover probably justified in contenting ourselves, with eliminating some of the most deleterious habits and with regulating the general mode of life of these patients in such a manner that the increase of fat is not too rapid; in this way a return to the former state of corpulence may at least be retarded.

I am very much in favor of sanitarium treatment for both classes of cases that I have described, viz., for sufferers from obesity presenting urgent indications for a reduction cure and for those who do not; in the cases of medium degree a course of treatment in a closed institution is usually followed by excellent results. The educational influence exercised by careful and skilled physicians on patients afflicted in this way is very considerable; many patients who once undergo such a systematic course of sanitarium treatment maintain their reduced weight, for the reason chiefly that they have learned to fully understand and appreciate what they must do; this applies even to those cases who live under external circumstances that would ordinarily favor bad habits and would necessarily lead to a gain of flesh from neglect of the necessary precautions.

If ordinary drinking or bathing cures are taken this permanent effect is not as a rule witnessed; such cures, far from educating patients in the right direction, are more apt to influence them unfavorably. How else could we explain the fact that thousands and thousands of these people are forced to undergo a course of treatment not once or twice but for ten or even fifteen or twenty years in succession; these are the people whom we find making an annual pilgrimage to Marienbad or Karlsbad.

To judge from my personal experience in the treatment of these cases I should say that with rare exceptions the relapses that are so frequent after ordinary drinking or bathing cures do not occur if the patients undergo a systematic course of dietetic treatment in a sanitarium - either together with a drinking cure or without it.