I mentioned in a previous chapter that there are cases of obesity due not to eating an extraordinarily abundant diet of a fattening character nor to performing an exceptionally small amount of muscular exercise, but to reduced oxydative energy. As far as we know to-day the cause of this reduction must be looked for in a decrease of the specific function of the thyroid gland. This may be due to a primarily deficient or disordered thyroid function or to the effect of stimuli emanating from other organs and affecting the thyroid function secondarily in such a way that the latter becomes depressed or inhibited. In either case one can speak of hypothyroidism. It is by no means easy to correctly interpret conditions of this character. There is only one form in regard to which we have exact knowledge and that we can diagnose without difficulty, namely, the form that is dependent on disease of the hypophysis cerebri (degeneratio adiposo-genitalis). Cases, too, that are associated with myxedema can hardly be misinterpreted (see Vol. VIII).

Frequently, however, the correct state of affairs is not recognized until certain peculiar experiences with reduction cures are made. Patients afflicted in this way may not react favorably to a reduction diet that would otherwise produce the desired effect; increased muscular exercise also produces only slight results. And cases that after the institution of especially rigorous means actually do lose fat and weight, frequently will be found to have become very much weakened and to recover very slowly from the effect of the treatment, while at the same time the loss of weight is rapidly regained. Whenever an experience of this kind is encountered, one should suspect hypothyroidism. Here a thoroughly justified etiologic method of treatment can be advised, namely, the administration of thyroid preparations that act as a bellows for the combustion processes of the organism. I place particular emphasis upon this point, because I have always most energetically opposed the use of thyroid preparation in ordinary obesity due to over feeding or lack of exercise. In the latter category of cases the benefits accruing from thyroid medication are merely transitory, and it is, of course, impossible to order these patients to eat thyroid substance indefinitely. As soon as the administration of thyroid is stopped the patient's weight increases again, simply because the originally underlying cause of the obesity persists. Such patients do not learn during their treatment how they must live in order to prevent a reformation of fat.

In cases of hypothyroidism it is permissible to administer thyroid preparations permanently or at least for many months at a time with short intermissions. Here the diet should not fall below the maintenance diet, and this is very agreeable to patients who previously were ordered to live on a reduced diet for years and decades. Particularly important is the administration of rather abundant quantities of albumen, immaterial whether this albumen is incorporated in meat or in other proteid foods. I agree with Rheinboldt in regard to the correctness of the rule that abundant albumen should be administered in this category of cases, even though certain other authors do not occupy this stand. The observations that I have made in my own patients and in patients of other physicians teach me to insist on the administration of large quantities of albumen when thyroid preparations are given. I am not prepared to say that very much depends upon the kind of thyroid preparation that is given. My personal experience is practically limited to E.

Merck's Thyreoidinum siccatum, of which 0.1 to 0.3 g. are administered daily. In some of the cases this preparation was given for two years uninterruptedly without producing the slightest disagreeable effects. I have abandoned the use of iodothyrin, that I formerly employed quite extensively, because it did not seem to be sufficiently effective in the customary doses (about 1.0 g. daily). As soon as I administered larger quantities (2.0 to 3.0 gm.) that exercised a definite effect upon the body weight, I would sooner or later hear complaints in regard to considerable irritation of the heart. The dose of any thyroid preparation is to be regulated in such a way that not more than 500 to 800 g. of body weight are sacrificed in one week.