c. Slight Degrees of Obesity

(body weight about 5-15 kilo above the normal average). Cases of this character, provided the patients are otherwise healthy, do not call for reduction treatment; all they require, if their corpulence continues to increase, is treatment directed towards preventing a further increase of fat. Nevertheless many people, in particular women, seek the advice of a physician for the sake of reducing even these mild degrees of obesity; they want to lose weight and want to have more slender figures. As a rule vanity is the chief reason why these women want to undergo reduction treatment and not physical discomfort of any kind. Vanity plays a much more important rôle in these cases than in the more advanced degrees of obesity, for the patients of both sexes who are already pretty corpulent are usually accustomed to being obese and no longer indulge the hope of being able to regain the slender outlines that they possessed in more youthful years. Those who may be puritanically inclined might object that a physician should not lend himself to gratifying the whims of vanity; such an ideal standpoint is not justified, however, for it does not consider the actual exigencies of every day practical life; a physician who would refuse to treat a case of the kind described on such grounds would merely drive his client into the hands of some quack who could readily inflict serious damage. Many a physician will, in fact, welcome the opportunity of undertaking the treatment of such a case because in this way he gains control over the mode of life of his patients and may exercise a beneficial influence in many directions, particularly as there is usually much to correct; he may be able to advise greater moderation in eating and may regulate the time of eating and the use or abuse of alcoholic liquors; again he can give definite directions in regard to the amount of physical exercise that should be taken; if by dint of all this control and regulation of the mode of life the goal that both physician and patient are aiming at is finally attained, much more true benefit accrues to the patient than if a rapid reduction cure is undertaken. Particularly in the case of young persons should rapid reduction cures only be advised with great care and after due deliberation, especially as it will be found that such rapid methods of treatment are exceedingly popular. All that can be attained by this method of treatment is a transitory effect; unless the general mode of life is sensibly regulated at the same time it never prevents the gradual transition of mild forms of obesity into more advanced degrees. On the other hand it may be considered established that a careful avoidance of certain errors of living and of diet, as for instance a restriction of sweets, moderation in beer drinking, a plentiful amount of physical exercise, will be of infinite value in the reduction of incipient obesity and will at the same time prevent the subsequent development of excessive corpulency. If therefore we can use the vanity of our patients as a lever, so much the better; this sort of vanity is moreover to a certain extent excusable and is by no means so serious a vice as many of our puritanical friends would have us believe.

On the other hand, of course, we should exercise great care in humoring the peculiar whims and fancies that we occasionally encounter in our lady patients. In many women, particularly if they have given birth to numerous children, the distribution of fat does not occur regularly over the whole body but seems to favor the abdominal walls in particular. This is an evil that many women emphatically demand to have remedied and unfortunately it is by no means an easy matter to do this. Reduction cures can of course only be directed towards reducing the general fat-content of the body and as a rule - though not always - produce a loss of fat in other parts of the body than the abdomen (the neck, the shoulders, the breasts and the calves of the leg), while at the same time the fatty deposit in the mesentery and the abdominal walls persists with considerable obstinacy. This peculiar effect is seen particularly in rapid reduction cures, whereas in slow reduction cures the loss of fat is much more uniform and the loss of abdominal fat is consequently also greater in proportion. If the loss of fat can be maintained for some time an equalization of the different fat deposits occurs, in the sense namely, that the excess of fat contained in the abdomen is gradually transported to other portions of the body where there is less fat. This event is usually hailed with much delight particularly as it may follow within a few weeks after the institution of a reduction cure. But the loss of fat is by no means an unmixed good for in many cases these women begin to complain of a series of disturbances that can be directly attributed to the loss of abdominal fat; they begin to suffer from constipation, develop hernias, gastroptosis, dislocation of the kidneys and occasionally malposition of the uterus; the direct effects of the loss of fat are therefore in many cases more troublesome to bear than the mild degree of obesity that these patients were formerly afflicted with. Another sequence of reduction cures in many of these subjects is the development of attacks of gall-stone colic, a condition that may never have been noticed before or that had at least been dormant and that can as a rule be directly referred to the changes brought about in the arrangement and position of the intra-abdominal organs; while the patients were fat the adipose layer around the gall-bladder and the liver protected these organs from the pressure exercised by skirtbands, corsets, etc.; as soon as the fat was lost the liver was readily compressed and the flow of bile interfered with.

All these disadvantages of reduction cures are in my experience more frequent in mild cases of obesity than in more advanced degrees of corpulency. In cases of pronounced obesity reduction cures, if carried out sensibly, rarely produce so marked a loss of fat that serious changes of intra-abdominal pressure are brought about; enough fat is usually allowed to remain to protect the abdominal viscera and to prevent excessive external pressure on these organs.

Occasionally we are able to promote a more uniform loss of fat and a participation of the abdominal fat in the general reduction by instituting a course of abdominal massage together with the reduction cure. The efficacy of this mode of combined treatment is, however, greatly exaggerated. If many women actually have the abdomen massaged for a number of years, the long duration of this treatment alone speaks against its efficacy. In cases in which benefits are derived from this method we must assume that the intestine is favorably influenced, particularly in those cases in which a reduction of the abdominal circum ference is really brought about; we know that many cases of obesity suffer from intestinal atony and that this sluggish condition of the bowels moreover is particularly apt to follow reduction cures; massage of the abdomen undoubtedly relieves this condition much more than it reduces the abdominal fat; many massage cranks, of course, both among physicians and the laity, claim that the method of treatment exercises its primary and chief effect on the abdominal fat per se. I once attempted to determine the effect of local massage on local fat deposits and ordered daily massage of one arm in a stout lady; massage was given according to all the rules of the art for a period of six weeks, a treatment every day. The result was that the arm that was massaged gained one and a half centimeters in circumference while the other arm that was not massaged retained its old dimensions.

If we summarize all that has been said in this paragraph we arrive at the conclusion that reduction cures are not urgently indicated in mild degrees of obesity but are nevertheless desirable for a variety of external reasons and for the purpose chiefly of preventing the development of more advanced degrees of corpulency.

Of the different methods of reducing treatment that can be adopted, slow methods are unquestionably to be preferred, particularly in women with large fat deposits in the abdomen, and in young subjects.