172 OBESITY 



painfully thin, and began to menstruate at eleven years of age. She was apparently 

 anemic, but otherwise strong and without any symptoms of importance. She married 

 at nineteen, aborted after eight weeks, and within a few months became stout and 

 remained so for almost nine months. During this time her husband died. As a 

 widow she again became as thin as when she was a girl and remained so during 

 her widowhood (seven years), during which time she was occasionally very ane- 

 mic. After her second marriage, the patient soon became pregnant. After the birth 

 of a girl (autumn, 1890) the patient became very stout, again lost some flesh in 

 the next few years, but in 1893, after a serious miscarriage, she again became very 

 stout and under the influence of an injudicious mode of life she remained so up to March, 



1898, when she consulted me for the first time. After this miscarriage an exudate 

 formed in the pelvis, and she has since then suffered from obstinate constipation ; it was 

 on this account that she desired treatment. Besides this, the patient suffered from 

 gout which had appeared for the first time in 1886, and was localized in the fingers, 

 being diagnosticated by Professor Liicke in Strassburg. On this account Professor 

 Liicke ordered a course of Vichy water at the Springs. At this time a difficulty in 

 hearing appeared for the first time and gradually increased. In January, 1898, an 

 acute attack of gout occurred in the great toe of the right foot, and lasted eight days. 

 For some years cramps had occurred in the calves and feet, mostly at night when the 

 patient went to bed, but also during the night, and they recurred almost every night, 

 especially in the right leg. Early in March, 1898, severe pains were suddenly felt in 

 the great toe of the right foot. The toe swelled somewhat and became red. In about 

 ten days, during which period the patient was unable to stand upon the foot for several 

 days, the attack subsided. From the 14th to the 25th of April, 1898, the patient suffered 

 from an attack of influenza, during the course of which the temperature rose to 102.2° F., 

 and she was much debilitated. About the 9th of May of the same year, suddenly and 

 during her menstrual period, an attack of gout supervened. This was localized in the 

 little finger of the left hand, and ran a typical course in a very short time. Upon the 

 12th of the same month, the redness of the affected area had disappeared. At the begin- 

 ning of June the patient complained of decided gouty pains in the feet. The first 

 metatarsophalangeal joints of both feet were very sensitive to pressure. No typical 

 attack developed, however. When the patient stopped treatment upon the 23d of June, 

 she was able to walk quite a, distance without difficulty. 



In this case the treatment was first directed against the obesity, gout, and also 

 particularly the stubborn constipation. For evacuation of the bowels, large enemata 

 of oil were used with good effect. A diet was instituted according to the principles 

 laid down by me, and, in so far as gout permitted, walking was ordered for active bodily 

 exercise, which was supplemented by massage of the body. As a drug, the prolonged 

 use of 0.5 (7J grains) urotropin in a quarter of a liter of alkaline water to be taken 

 twice daily was prescribed. Her weight fell during this time from 199 pounds to 187 

 pounds. This success was evidently not due to the diet alone, which under the circum- 

 stances could not be strictly carried out. During this time a, severe influenza occurred 

 from which the patient slowly recovered, also quite severe gout which of course also 

 decreased the body-weight. When I saw the patient again in October of the same year, 

 the constipation had been relieved by the continuance of the enemata, the gouty difli- 

 culties had not recurred, but there was a decided psychical depression which was 

 increased by various external conditions. The weight had again risen to 194.5 pounds, 

 and the patient had resumed her former manner of living, which was conducive to the 

 accumulation of fat. The weight, when she decided to renew her treatment, had risen 

 to 203 pounds. Treatment began at my private hospital upon the 28th of August, 



1899, and ended upon the 5th of December, 1899. This time the treatment was not 

 hindered by disturbing intermediate maladies such as the attack of influenza and the 

 two attacks of gout during the first period of treatment. The function of the intestine 

 had been greatly improved. Of course, it was decidedly retarded by a very pendulous 

 abdomen. The gouty pains had by no means completely disappeared. The use of 

 urotropin was continued, besides the diet which was regulated according to my princi- 

 ples. The weight of the patient was as follows : Weight upon the 28th of August, 203.86 



