OBESITY - DISTRIBUTION OF WORK.
The work is distributed according to the force of the heart, the state of nutrition and strength of the patient, the character of the affection, whether of the anemic, plethoric, or hydrcemic form, and the complications.
1. If the force of the heart is sufficient and a plethoric condition is present the patient may be allowed from the beginning to take walks of the first and second varieties, viz., those having an incline of 5 to 15 degrees, and he may be permitted to pass over six to eight units of distance, the return course not being reckoned in, and the exercise may be distributed over the morning and afternoon hours according to circumstances.
Taking normal walking time as a standard, this work of six to eight distance-units would require, including going and coming, three to four hours. The patient himself can employ as much time as necessary for this, and his attention should be called to the point that it does not matter how long he takes to cover the distance, say, of six units. The main point is that the work is done. Later on the work is increased or, according to circumstances, decreased, from time to time. Days of rest may be interspersed in order to pro tect against over-exertion.
Paths of the fourth order up to 20 degrees can only be made use of from time to time, in case the heart is perfectly strong and the gen eral condition has been so far brought back to the normal that it insures the preservation of the heart's force. The patient must be impressed, no matter what curative walking exercise he takes, not to hold the breath, but to breathe in and out deeply and quietly. If he gets short of breath during the walk he is to adapt his gait according to the capacity of his lungs, a step being counted to each inspiration and expiration. It is also admissible for the patient to breathe dur ing a short time, say for five minutes, when he is walking on paths of the second or third order, in an interrupted (staccato) way; that is, to follow an inspiration by two expirations in such a way that, for in stance, two steps coincide with one inspiration and two steps with two expirations ; in this broken manner of breathing perfect expiration is secured and also thorough inspiration. At the same time the two expiratory efforts, if they are somewhat intensified, exercise a certain slight pressure effect over the heart's surface, which, received and collected by the heart action, has the effect, as it were, of an invig orating massage to the heart muscle.
2. If the heart action has become more or less impaired, as is the case in the anemic and still more in the hydrfflinic form, it is best to begin with paths of the first and second order and to prescribe accord ing to the general conditions present four to five lengths of distance, more on the level and less on the incline, and slowly to increase the work in proportion to the strength gained, up to six and eight dis tance-units. In these cases, more than in those previously discussed,
the greatest attention must be paid to the manner of breathing. If air is not freely enough admitted through the nose, thus doing away with the frequent difficulty of respiration often coming on sud denly, the patient must breathe with open mouth and bring the efforts at breathing into rhythmical relation with the pace. One to two steps must correspond to the inspiration and the same number to the expi ration, or, if interrupted breathing is for a time resorted to, with two expirations, and the latter must be performed with a little more force. Only after a longer period, two to three weeks, according to the severity of the case, and under the condition that the heart muscle is sufficiently accustomed to the exercise and properly strengthened, the paths of the third order (up to incline) are to be chosen. The paths of the fourth' order will either not come into requisi tion at all or will be used only in exceptional cases where the patient is to be considered as iu perfect health. After a year or so these paths may be used more frequently by those who were formerly under treatment, and these patients may also try moun tain climbing. Here, more so than in the previous class of cases, muscular work must be regulated so as to be spread over a more ex tended period and to correspond with the patient's strength, being gradually increased. Aside from an increased burning up of the fat there must be an increase in the albumin in order to enhance the de velopment of blood and muscles, and to favor the processes of nutrition and growth. This is done not alone by augmenting the albuminous food, but rather by strengthening the muscles and making their ac tion more effective. The strengthening of the heart and the develop ment of all the other muscles of the body take place in the same manner by reduction of the fat deposited upon and interspersed between their fibres. These changes in nutrition finally result in a clearly demonstrable decrease in the dilatation of the heart. The percussion dulness of the heart may also be diminished by atrophy of the fat and by more powerful contraction of the strengthened heart muscle.