THE HYGIENIC TREATMENT OF OBESITY.1

THE HYGIENIC TREATMENT OF OBESITY.¹

By Dr. Paul Cheron.

In order to properly regulate the regimen of the obese, it is first necessary to determine the source of the superfluous adipose of the organism, since either the albuminoids or the hydrocarbons may furnish fat.

Alimentary fat becomes fixed in the tissues, as has been proved by Lebede, who fed dogs, emaciated by long fast, with meat wholly deprived of fat, and substituted for the latter linseed oil, when he was able to recover the oil in each instance from the animal; parallel experiments with mutton fat, in lieu of oil, afforded like results.

Hoffman also deprived dogs of fat for a month, causing them to lose as high as twenty-two pounds weight, then began nourishing with bacon fat with but little lean; the quantity of fat formed in five days, in the dog that lost twenty-two pounds, was more than three pounds, which could have been derived only from the bacon fat.

It has been stated, however, that alimentary fat seems to preserve from destruction the fat of the organism which arises from other sources. Be this as it may, it is a fact that the pre-existence of fat furthers the accumulation of more adipose; or in other words, fat induces fattening!

That adipose may be formed through the transformation of albuminous matters (meat) is an extremely important corollary, one established beyond cavil by Pettinkofer and Voit, in an indirect way, by first estimating the nitrogen and carbon ingested, and second the amount eliminated. Giving a dog meat that was wholly deprived of fat, they found it impossible to recover more than a portion of the contained carbon; hence some must necessarily have been utilized in the organism, and this would be possible only by the transformation of the carbon into fat! It goes without saying, however, that the amount of adipose thus deposited is meager.

Other facts also plead in favor of the transformation of a portion of albumen into fat within the economy, notably the changing of a portion of dead organism into what is known as "cadaveric fat," and the very rapid fatty degeneration of organs that supervenes upon certain forms of poisoning, as by phosphorus.

The carbohydrates, or more properly speaking hydrocarbons, are regarded by all physiologists as specially capable of producing fat, and numerous alimentary experiments have been undertaken to prove this point. Chaniewski, Meissl, and Munk obtained results that evidenced, apparently, sugar and starch provide more fat than do the albuminoids. Voit, however, disapproves this, maintaining the greater part of the hydrocarbons is burned (furnishes fuel for the immediate evolution of force), and that fat cannot be stored up unless a due proportion of albuminoids is also administered. He believes the hydrocarbons exert a direct influence only; being more oxidizable than fats, they guard the latter from oxidation. This protective role of the hydrocarbons applies also to the albuminoids.

We may believe, then, that the three great classes of aliment yield fat, in some degree; that alimentary fat may be fixed in the tissues; and that hydrocarbons favor the deposition of adipose either directly or indirectly.

It is well understood that fat may disappear with great rapidity under certain conditions; many maladies are accompanied by speedy emaciation; therefore, as fat never passes into the secretions, at least not in appreciable quantities, it probably undergoes transformation, perhaps by oxidation or a form of fermentation, the final results of which are, directly or indirectly, water and cadaveric acid. It is certain the process of oxidation favors the destruction of adipose, and that everything which inhibits such destruction tends to fat accumulation.

Since the earliest period of history, there seems to have been an anxiety to secure some regimen of general application that would reduce or combat obesity. Thus Hippocrates says:

Fat people, and all those who would become lean, should perform laborious tasks while fasting, and eat while still breathless from fatigue, without rest, and after having drunk diluted wine not very cold. Their meats should be prepared with sesamum, with sweets, and other similar substances, and these dishes should be free from fat.

In this manner one will be satiated through eating less.

But, besides, one should take only one meal; take no bath; sleep on a hard bed; and walk as much as may be.

How much has medical science gained in this direction during the interval of more than two thousand years? Let us see:

First among moderns to seek to establish on a scientific basis a regimen for the obese, was Dancel, who forbade fats, starchy foods, etc., prescribed soups and aqueous aliment, and reduced the quantity of beverage to the lowest possible limit; at the same time he employed frequent and profuse purgation.

This regimen, which permits, at most, but seven to twelve ounces of fluid at each repast, is somewhat difficult to follow, though it may be obtained, gradually, with ease. Dr. Constantine Paul records a case in which this regimen, gradually induced, and followed for ten years, rewarded the patient with "moderate flesh and most excellent health."

In Great Britain, a mode of treatment instituted in one Banting, by Dr. Harvey, whereby the former was decreased in weight forty pounds, has obtained somewhat wide celebrity; and what is more remarkable, it is known as "Bantingism," taking its name from the patient instead of the physician who originated it. The dietary is as follows:

Breakfast.--Five to six ounces of lean meat, broiled fish, or smoked bacon--veal and pork interdicted; a cup of tea or coffee without milk or sugar; one ounce of toast or dry biscuit (crackers).

Dinner.--Five or six ounces of lean meat or fish--excluding eel, salmon, and herring; a small quantity of vegetables, but no potatoes, parsnips, carrots, beets, peas, or beans; one ounce of toast, fruit, or fowl; two glasses of red wine--beer, champagne, and port forbidden.

Tea.--Two or three ounces of fruit; one kind of pastry; one cup of tea.

Supper.--Three or four ounces of lean beef or fish; one or two glasses of red wine.

At bed-time.--Grog without sugar (whisky and water, or rum and water), and one or two glasses of sherry or Bordeaux.

"Bantingism," to be effective, must be most closely followed, when, unfortunately also, it proves extremely debilitating; it is suitable only for sturdy, hard riding gluttons of the Squire Western type. The patient rapidly loses strength as well as flesh, and speedily acquires an unconquerable repugnance to the dietary. Further, from a strictly physiological point of view, the quantity of meat is greatly in excess, while with the cessation of the regimen, the fat quickly reappears.

Next Ebstein formulated a dietary that is certainly much better tolerated than that of Harvey and Banting, and yields as good, or even better, results. He allows patients to take a definite quantity--two to two and a half ounces-of fat daily, in the form of bacon or butter which, theoretically at least, offers several advantages: It diminishes the sensations of hunger and thirst, and plays a special role with respect to the albuminoids; the latter may thus be assimilated by the economy without being resolved into fat, and thus the adipose of the organism at this period is drawn upon without subsequent renewal. The following is the outline:

Breakfast.--At 6 a.m. in summer; 7:30 in winter:--Eight ounces of black tea without either milk or sugar; two ounces of white bread or toast, with a copious layer of butter.

Dinner.--2 p.m.:--A modicum of beef marrow soup; four ounces of meat, preferably of fatty character; moderate quantity of vegetable, especially the legumines, but no potatoes or anything containing starch; raw fruits in season, and cooked fruits (stewed, without sugar); two or three glasses of light wine as a beverage, and after eating, a cup of black tea without sugar.

Supper.--7:30 p m.:--An egg, bit of fat roast, ham, or bacon; a slice of white bread well buttered; a large cup of black tea without milk or sugar; from time to time, cheese and fresh fruits.

Germain See suggests as a modification of this regimen, the abundant use of beverage, the addition of gelatins, and at times small doses of potassium iodide in twenty cases he claims constant and relatively prompt results.

Whatever may be urged for Ebstein's system--and it has afforded most excellent results to Unna and to Lube, as well as its author--it certainly exposes the patient to the terrors of dyspepsia, when the routine must needs be interrupted or modified; hence it is not always to be depended upon. As between dyspepsia and obesity, there are few, I fancy, who would not prefer the latter.

Another "system" that has acquired no little celebrity, and which has for its aim the reduction as far as possible of alimentary hydrocarbons while permitting a certain proportion of fat, is that, of Denneth, which necessarily follows somewhat closely the lines laid down by Ebstein.

Oertels' treatment, somewhat widely known, and not without due measure of fame, is based upon a series of measures having as object the withdrawal from both circulation and the economy at large, as much of the fluids as possible. It is especially adapted for the relief of those obese who are suffering fatty degeneration of the heart. The menu is as follows:

Breakfast.--Pour to five ounces of tea or coffee with a little milk; two to two and a half ounces bread.

Dinner.--Three or four ounces of roast or boiled meat, or moderately fat food; fish, slightly fat; salad and vegetables at pleasure; one and a half ounces of bread (in certain cases as much as three ounces of farinaceous food may be permitted); three to six ounces of fruit; at times a little pastry for dessert.--In summer, if fruit is not obtainable, six to eight ounces of light wine may be allowed.

Tea,--A cupful (four to five ounces) of tea or coffee, with a trifle of milk, as at breakfast; one and three-fourths ounces of bread; and exceptionally (and at most) six ounces of water.

Supper.--One to two soft boiled eggs; four or five ounces of meat; one and three fourths ounces of bread; a trifle of cheese, salad, or fruit; six to eight ounces of light wine diluted with an eighth volume of water. The quantity of beverage may be slightly augmented at each meal if necessary, especially if there is no morbid heart trouble.

Schwenninger (Bismarck's physician), who opened a large sanitarium near Berlin a few years since for the treatment of the obese, employs Oertel's treatment, modified in that an abundance of beverage is permitted, provided it is not indulged in at meals; it is forbidden until two hours after eating.

Both Oertel's and Schwenninger's methods have procured grave dyspepsias, and fatal albuminurias as well, according to Meyer and Rosenfield. It has been charged the allowance of beverage upon which Schwenninger lays so much stress in the treatment at his sanitarium has a pecuniary basis, in other words a commission upon the sale of wines.²

Thus, it will be observed that while some forbid beverage, others rather insist upon its employment in greater or less quantities. Under such circumstances, it would seem but rational, before undertaking to relieve obesity, to establish its exact nature, and also the role taken by fluids in the phenomena of nutrition.

Physiologists generally admit water facilitates nutritive exchanges, which is explained by the elimination of a large quantity of urine; the experiments of Genth and Robin in this direction appear conclusive.

Bischoff, Voit, and Hermann have shown that water increases, not alone the elimination of urine, but also of sodium chloride, phosphoric acid, etc. Grigoriantz observed augmentation of disintegration when the quantity of beverage exceeded forty-six to eighty ounces ("1,400 to 2,400 cubic centimeters") per diem. Oppenheim, Fraenkel, and Debove, while believing water has but little influence upon the exchanges, admit it certainly need not diminish the latter; and Debove and Flament, after administering water in quantities varying from two to eight pints per diem, concluded that urine was diminished below the former figure, while above the latter it increased somewhat, being dependent upon the amount ingested. It was on the strength of the foregoing that Lallemand declared water to have no influence upon the exchanges.

The results claimed by Oppenheim, Debove, et al. were immediately challenged--and it is now generally admitted, not without some justice--by Germain See. It seems certain, to say the least, that water taken during the repast does tend to augment the quantity and facilitate the elimination of urine. Abundance of beverage, moreover, presents other advantages, in that it facilitates digestion by reason of its diluent action, a fact well worth bearing in mind when treating the obese who are possessed of gouty diathesis, and whose kidneys are accordingly encumbered with uric and oxalic acids. The foregoing presents the ground upon which Germain See permits an abundance of beverage; but he also expresses strong reservation as regards beer and alcohol, either of which (more especially the former) tends to the production of adipose. In his opinion, the only beverage of the alcoholic class that is at all permissible, and then only for cases suffering from fatty heart, is a little liqueur or diluted wine. Coffee and tea he commends highly, and recommends the ingestion of large quantities at high temperature, both during the repasts and their intervals. Coffee in large doses is undoubtedly a means of de-nutrition, and so, too, in no less extent, is tea; both act vigorously owing to the contained alkaloids, though, to be sure, they sometimes, at first, tend to insomnia and palpitation, to which no attention need be paid, however. The treatment outlined by See is:

1. A physiological regimen comprising four to five ounces of nitrogenous principles as derived from eight to ten ounces animal muscle and albuminates; three to six ounces of fat; eight to ten ounces of hydrocarbons as yielded by ten to twelve ounces of sugar or starch food.

These proportions to be modified in such manner that the musculo-albuminates shall not sensibly exceed the normal ratio, for meat in excess itself furnishes fat during transformation. The fatty substances of easy digestion may, without inconvenience, be utilized in doses of two to three ounces. The hydrocarbons should be reduced to a minimum. As for the herbaceous elements, they contain nothing nutritive.

2. Beverage, far from being suppressed, should be augmented, in order to facilitate stomachal digestion and promote general nutrition, though alcoholic liquids must be inhibited; likewise mineral waters, except, perhaps, for occasional use. Both should be replaced by infusions of coffee or tea, taken as hot as can be drank.

Henrich Kisch insists that any method which promises rapid and marked decrease of adipose must, per se, be objectionable, even if not positively injurious, since it tends to provoke general troubles of nutrition. He suggests that first the fats and hydrocarbons be reduced as little as possible; that a moderate mixed regimen is required, containing a preponderance of albumen, small quantities of hydrocarbons and gelatinous matters, with but very little fat. Certain fatty meats, however, should be generally interdicted, such as pork sausage, smoked beef tongue, goose breast, smoked ham, fat salmon, and herring in any form. Eggs, however, may be partaken of in moderation, giving preference to the albumen over the yelk. Farinaceous foods, in the main, should be rejected, even bread being allowed only in small quantities, and then preferably in the form of toast. Cheese likewise contains too much fat; and mushrooms are so rich in hydrocarbons that they should be rejected. Condiments, water, vegetable acids (vinegars excepted) may be permitted; especially pernicious is vinegar where there is any tendency to gout or gravel. All fatty beverages--bouillon, unskimmed milk, chocolate, or cacao--and all alcoholics, are hurtful; breakfast tea is undoubtedly the best beverage, but, after a little, is advantageously replaced by light white wine diluted with water.

Kisch believes in a free and abundant use of water by the obese, especially where there is a tendency to plethora, since this fluid facilitates oxidation as the result of absorption; thus he advocates the inhibition of large quantities of cold water by all, save those presenting evidence of cardiac insufficiency. In short, his regimen is based upon the administration of a large quantity of albumen, like that of Harvey-Banting.

E. Munk recommends an almost identical dietary, save that he prefers great moderation in fluids employed as beverage.

M. Robin has sought to harmonize the opposing views regarding fluids, and therefore declares obesity arises from two distinct sources: 1. Augmentation of assimilation. 2. Reduced disassimilation. In the former, he insists water must be interdicted, while in the latter it may be allowed ad libitum.

Again, in order to recognize the exact variety of obesity, he divides his patients into three classes, each recognizable by the volume of urea excreted. In the first there is an increase above normal; in the second the volume of urea is stationary; in the third decreased, increased, or stationary.

When the urea is stationary, which is most frequently the case, it is necessary to calculate the coefficient of oxidation; that is, the relation existing between the solid matters of the urine and the urea. The elevation of the coefficient is prima facie evidence the obesity is due to excess of assimilation, while depression of the coefficient indicates default of assimilation. In the first case, water and liquids must be denied as far as possible, the same as if there was no augmentation of urea; in the second, the same as if there was diminution of urea, the patients may be permitted to imbibe fluids at pleasure.

For the obese from default of disassimilation, Robin recommends a regimen of green vegetables and bread chiefly--the latter in small quantities, however, and fluids as may be desired. By this means, on one occasion, he was able in the course of one month to diminish the weight of a female patient by twelve and a half pounds, her measurement around the waist at the same time decreasing 5.2 inches and across the stomach 4.8 inches.

M. De St. Germain achieved good results by combining judicious exercise with moderate alimentation, excluding wine and bread.

M. Dujardin Beaumetz, who professes to have given most close and careful study and attention to regimen for the obese, outlines the following, provided there is no evidence of fatty degeneration of heart.

Breakfast (at 8 a. m.)--Three-fourths of an ounce of bread "en flute"--that is abounding with crust; one and a half ounces of cold meat, ham or beef, six ounces weak black tea, sans sugar.

Lunch (at 1 p.m.)--An ounce and a half to two ounces of bread, or a ragout, or two eggs; three ounces green vegetables; one-half ounce of cheese; fruits at discretion.

Dinner (at 7 p.m.)--An ounce and a half to two ounces of bread; three to four ounces of meat, or ragout; ditto of green vegetables, salad, half an ounce of cheese, fruit ad libitum.

At meal times the patient may take only a "glass and a half" of liquid--approximately ten ounces--though a greater amount may be permitted if he abstains during the intervals.

Special alimentary regimen, however, does not constitute the sole treatment of obesity. Concurrently must be employed a number of practical adjuvants which are oftentimes of the utmost assistance. For one thing, exercise is indispensable; all authorities agree on this point. The exercise taken in the gymnasium is one of the best, notably the "wall exercise," which is more particularly suited to those afflicted with pendulous and protuberant abdomens as the result of feebleness of the hypogastric muscles, to accumulation of fat under the skin and in the omentum, and to dilation of the stomach and intestines. In the "wall exercise," the patient stands erect against an absolutely straight and plumb wall, lifts his hands (carrying a weight) straight over the head, and causes them to describe a semicircle forward. Zantz particularly insists upon arm and leg exercise for the obese, especially the former, since with the same amount of effort a larger amount of oxygen is consumed than is possible by the latter.

However, of whatever character, the exercise should be continued to the point of fatigue or dyspn#oelig;a--three thousand movements daily, gradually increased to twenty-five thousand, if the system can bear it; and under such conditions, not only is there consumption of hydrocarbons, but there is provided a veritable greed for air that augments waste. The experiments of Oertel indicate that loss of weight due to fatiguing exercise arises more particularly from dehydration, which is made good by absorption of the fluids employed as beverage; the fluids are claimed by Germain See to act as accelerants of oxidation.

During exercise there is obviously more abundant absorption of oxygen, and consequently greater elimination of carbonic acid, and as a consequence (as shown by researches of Voit), the reserve fat of the economy is attacked and diminished; in intense labor there is an average hourly consumption of about 8.2 percent. of fat. Further physical activity is useful in exercising the voluntary muscles, and thus opposing the invasion by interstitial fat of the muscle fibrils. Extreme exercise also, to a certain degree, exerts a favorable influence on the cardiac muscle, augmenting both its nutrition and its capacity for labor. With the anæmic obese, however, it is necessary to be most circumspect in prescribing forced exercise; also with the elderly obese possessed of enfeebled or fatty heart.

Hydrotherapy, especially in the form of cold douches, particularly when combined with massage, is often of considerable value in relieving obesity; the method of Harmman, of St. Germain, which has in many instances induced rapid loss of adipose, is of this class. Tepid saline baths and vapor baths have many advocates, and may afford material aid when the heart and circulation do not inhibit their employment. Hot baths elevate the temperature of the body and increase the organic exchanges, hence, as Bert and Reynard have pointed out, tend to the elimination of oxygen and carbonic acid; but when employed, the patient should be introduced while the temperature is below 130° F., when it may be gradually raised in the course of thirty or forty minutes to 140° F.

It has already been intimated, the chief feature of the treatment of obesity is acceleration of the exchanges; and this is in the main true, though it must also be borne in mind that, while there are obese who excrete little urea and have a depressed central nervous temperature, many may be azoturic, and besides eliminate phosphate in excess, when an oxidating treatment will not only fail, but prove positively injurious.

The bile throws out fat, therefore, to accelerate nutritive oxidations, the liver and nervous system must be acted upon, i.e., stimulated. Everything that tends to diminish the activity of the former, or depress the latter, must be avoided. Hence intellectual labor should be encouraged, or in lieu thereof, travel advised. Exercise should be taken chiefly while fasting; the limits of sleep confined to strict necessity, and siestas after meals and during the day strictly forbidden; the skin stimulated by hydro-therapeutic measures, including massage under cold affusions, during warm salt baths, etc.

To increase the activity of the liver, salicylate of soda may often be advantageously administered for its cholagogue effect; or resort may be had to saline purgatives such as are afforded by the springs of Marienbad, Kissengen, Homburg, Carlsbad, Brides, Hunyadi, or Chatel-Guyon; and it is somewhat remarkable that while undergoing a course of these waters, there is often no appreciable change in weight or obesity, though the decrease becomes most marked almost immediately upon cessation of treatment.

Everything tending to increased or fuller respiration is to be encouraged, for the fats are thus supplied with oxygen, hastening their disintegration and consumption.

Direct medicinal treatment presents no very wide scope. Bouchard imagines lime water may be useful by accelerating nutrition, but this is problematical, since fat in emulsion or in droplets does not burn. Nevertheless, alkalies in general, alkaline carbonates, liquor potassa, soaps, etc., aid in rendering fat more soluble, and consequently more susceptible to attack. The alkaline waters, however, are much less active in obesity than the saline mineral waters, unless, as sometimes happens, there is a complication of diabetes and obesity.

Purgatives are always more or less useful, and often required to be renewed with all the regularity of habit. Then too, the iodides, especially iodide of sodium or potassium, as recommended by M. Germain See, frequently prove of excellent service by aiding elimination and facilitating the mutations.

According to Kisch, the cold mineral waters containing an abundance of sulphate of soda, like Hunyadi and Marienbad, are to be preferred to the hot mineral waters, such as Carlsbad, because of their lesser irritant action on the vascular system, and because they strongly excite diuresis through their low temperature and contained carbonic acid; Carlsbad deserves preference only when obesity is combined with uric acid calculi, or with diabetes. For very anæmic persons, however, the weak alkaline and saline waters should be selected; or they should confine themselves to chalybeate waters containing an excess of sulphate of soda. Water containing sulphate of soda is also indicated as a beverage where there are troubles of the circulatory apparatus; it is contraindicated only in accentuated arterio-sclerosis.

As a matter of fact, I find the suggestion of M. Dujardin-Beaumetz, that the obese should be divided into two groups, a most practical one, for some are strong and vigorous--great eaters, perhaps even gluttons--while others, on the contrary, are feeble and debilitated, with flesh soft and flaccid; and upon the former may be imposed all the rigors of the reducing system, while the latter must be dealt with more carefully.

In general, it must be noted, the regimen prescribed for the obese is insufficient, as the following table prepared by M.C. Paul abundantly proves:

Author.Albuminous Matters.Fatty Matters.Hydrocarbons.

Voit.11840150

Harvey-Banting.1701080

Ebstein.1008550

Oertel.155-17925-4170-110

Kisch (plethoric).1601080

Kisch (anæmic).20012100

Normal ration.12455455

There is, therefore, as Dujardin-Beaumetz asserts, autophagia in the obese, and all these varieties of treatment have but one end, viz.: Reduction of the daily ration. But the quantity of nourishment should not be too greatly curtailed, for, manifestly, if the fat disappears the more surely, the muscles (rich in albumen) undergo too rapid modification. It is progressive action that should always be sought.

The quantity of aliment may be reduced either by imposing an always uniform regimen, which soon begets anorexia and disgust, or by withholding from the food a considerable quantity of fat, or, finally, by forbidding beverage during meals. Emaciation is obtained readily enough in either way, and demands only the constant exercise of will power on the part of the patient; but unhappily, severe regimen cannot always be prescribed. When the obese patient has passed the age of forty; when the heart suffers from degeneration; or when the heart is anæmic--in all, rigorous treatment will serve to still further enfeeble the central organ of circulation, and tend to precipitate accidents that, by all means, are to be avoided. In such cases, by not treating the obesity, the days of the patient will be prolonged. In degeneration of the heart, however, the method of Ebstein may be tried; and when there is renal calculi and gouty diathesis, that of Germain See may prove satisfactory.

Paris, France.

[1]

Translated by Mr. Jos. Helfman, Detroit, Mich.

[2]

The sanitarium is owned by a stock company, Schwenninger being merely Medical Director.--ED.