The Oertel System

A more recent system for the dietetic treatment of obesity is that practised by Oertel and modified by Schweninger. The distinctive feature of the Oertel treatment is the attention which is paid to improving the condition of the circulation by strengthening the heart action, and this, he claims, so much improves the general condition of the patient that the fat once eliminated is not reformed. According to his theory, corpulent patients may be subdivided into two different classes, whose diet is regulated accordingly. They are:

" (a) Cases of fat accumulation in which the respiratory and circulatory apparatus have undergone no special derangement, and the patient is capable of muscular effort and locomotion. A much more serious form is that in which the condition of fatty heart is present, with consequent enfeeblement of circulation and visceral engorgement.

"(b) Cases in which, in consequence of advanced stasis and hydraemia (with deficiency of haemoglobin), the amount of oxygen taken up from the lungs is extremely reduced, and the slightest muscular efforts are enough to disturb the respiration and provoke dyspnoea".

For the first class his maximum allowance of fat is fifty grammes and of carbohydrates two hundred grammes, with a minimum of one hundred and fifty grammes of albumin. For the second class the maximum allowance of fat is twenty-five to thirty grammes, with one hundred grammes of carbohydrates, but the albumin must considerably exceed one hundred and fifty grammes. In this class especially the amount of fluids drunk must be curtailed. By withholding fluid, Oertel argues, blood pressure is reduced, venous stasis is lessened, the vessels of the body will adapt themselves to the reduced quantity of fluid, and to supply the glandular organs and muscles with their normal proportion fluid will be " drained away from places where the tissue changes are less energetic, and which are less favourably innervated. Such vessels are, above all, in the fatty tissues - vessels branching in the panniculus adiposus".

Nutritive changes ensue in the fatty tissues, the fat is disintegrated, conveyed away, and burned up.

This is certainly an ingenious, and withal very plausible theory which has many facts of clinical observation to recommend it.

Besides holding the view that the fluid in the body must be reduced before the accumulated fat can be diminished, Oertel says:

"Since the force required to raise the body through a great height entails the destruction of large quantities of fat, the above exertion [mountain climbing] will also lessen the fat accumulation, on condition only that we give less fat and carbohydrates in the food than are used up in the work done".

He gives some fat and carbohydrate food, but not very much, with proteids, for he believes that, anaemia being present, an exclusive meat diet would not be completely oxidised. It is better, therefore, to restrict all three classes of foods, but not to entirely exclude either, and the proteids must decidedly preponderate.

He also believes that anaemia has weakened the vascular tone through supplying a blood deficient in circulating albumin, and hence a diet rich in proteids is further indicated.

The Oertel system includes almost twice the quantity of animal food allowed in the Ebstein diet, and double the quantity of carbohydrates and less than half the quantity of fats. It is distinguished from the Banting system also by the greater preponderance of fats and starches. The following table from Yeo contrasts these different systems of diet. For comparison, the diet of Voit is added, which gives the proportion of the three chief varieties of foods upon which a man in health will decrease in weight. The figures represent grammes:

Daily Diet

Albuminates.

Fats.

Carbohydrates.

Moleschott, normal average

I30

84

404

Voit, " " ..............

140

44

165

Banting, " " ..............

170

10

80

Ebstein, " " ..............

100

85

50

Oertel, " " ..............

155-179

25-40

70-110

It will be observed that in all these diets the starches and sugars chiefly are proportionately much reduced, and the more liberal dietary of Oertel is particularly suitable for those classes of cases in which exercise can be joined with dietetic treatment. The combined effect of the diet with exercise results in the absorption and oxidation of the fat deposited between the muscular tissues and in the renewal of more vigorous action of the muscle fibres, which are shielded from waste by the liberal proportion of proteid food which is admitted. The whole treatment is aimed especially at increasing the vigour and force of the heart action, and in many cases it succeeds admirably. In the more serious type of obesity the deposition of fat around the base of the heart as well as between and within the heart muscle fibres enfeebles the strength of the cardiac systole and results in engorgement of the venous circulation. The heart is unable to propel the blood through the arteries and capillaries, and there is very little vis a tergo remaining for the blood in the veins. Lack of exercise also retards the venous circulation.

As a result, there is a constant venous congestion which is particularly noticeable in the viscera, and there may be dropsical accumulations in the different serous cavities or general anasarca.

Exercise

In the treatment of such cases Oertel withholds fluid from the diet as much as possible, and to assist the elimination of water from the body the patient is made to exercise by climbing carefully graded paths, which are measured and adapted with reference to use by patients of different strength. During muscular exertion the destruction of non-nitrogenous food stuffs is increased.

Palpitation and dyspnoea, which are so frequent accompaniments of excessive obesity, are not especially dreaded, and exercise is pushed until these symptoms occur - that is, the patients are made to climb the graduated ascents, walking slowly and systematically and covering a prescribed distance each day. As soon as they experience palpitation, or if shortness of breath appears, they are to stop and rest standing until the breath is regained. In this way it is believed by Oertel that the heart action is actually strengthened, and the fat is certainly reduced. Of course, due care must be observed to prevent exhaustion, and the patients must be warned against any sudden movement or overexertion which might occasion fatal heart strain. This exercise by climbing ascents is sometimes called the "terrain cure".

In case the patient is unable to take any exercise at all, the object is attained by massage and friction, and the promotion of perspiration is secured by baths of different sorts. In the treatment of such cases, among the solid ingredients of the food, the fats and starches are still further reduced.

Anaemia is believed to be counteracted by the use of albuminous food, and the following articles are allowed when this is a prominent symptom: Lean roast and boiled beef and veal, mutton, game, and eggs. Vegetables, spinach, and cabbage may be eaten. From four to six ounces of bread per diem are given, and fats and starches are restricted as much as possible, and sugars are withheld altogether. The fluid prescribed consists of a moderate cup (about six ounces) of coffee or tea or milk twice a day, with twelve ounces of wine with an equal quantity of water, which may be taken at dinner. If patients perspire very freely, a somewhat larger quantity may be given, and no other beverages of any kind are permitted.

The fluid allowed should not all be taken with the meals, but may be drunk at intervals between the times of eating to allay thirst. In the less serious type of cases, where the heart action is unimpaired, Oertel allows the fluid to be gradually increased, and he gives four to six ounces of wine at noon time, with a half bottle in the evening.

Bathing should be carried out systematically, and the patient may be packed with cloths dipped in hot water in order to promote perspiration. The baths are given at least twice a week through a period of a month or more.

A typical menu under the Oertel treatment is the following: