An interesting feature of the HCG method is that, regardless of how fat a patient is, the greatest circumference — abdomen or hips as the case may be is reduced at a constant rate which is extraordinarily close to 1 cm. per kilogram of weight lost. At the beginning of treatment the change in measurements is somewhat greater than this, but at the end of a course it is almost invariably found that the girth is as many centimeters less as the number of kilograms by which the weight has been reduced. I have never seen this clear cut relationship in patients that try to reduce by dieting only.

Preparing the Solution
Human chorionic gonadotrophin comes on the market as a highly soluble powder which is the pure substance extracted from the urine of pregnant women. Such preparations are carefully standardized, and any brand made by a reliable pharmaceutical company is probably as good as any other. The substance should be extracted from the urine and not from the placenta, and it must of course be of human and not of animal origin. The powder is sealed in ampoules or in rubber-capped bottles in varying amounts which are stated in International Units. In this form HCG is stable; however, only such preparations should be used that have the date of manufacture and the date of expiry clearly stated on the label or package. A suitable solvent is always supplied in a separate ampoule in the same package.

Once HCG is in solution it is far less stable. It may be kept at room-temperature for two to three days, but if the solution must be kept longer it should always be refrigerated. When treating only one or two cases simultaneously, vials containing a small number of units say 1000 I.U. should be used. The 10 cc. of solvent which is supplied by the manufacturer is injected into the rubber- capped bottle containing the HCG, and the powder must dissolve instantly. Of this solution 1 .25 cc. are withdrawn for each injection. One such bottle of 1000 I.U. therefore furnishes 8 injections. When more than one patient is being treated, they should not each have their own bottle but rather all be injected from the same vial and a fresh solution made when this is empty.

As we are usually treating a fair number of patients at the same time, we prefer to use vials containing 5000 units. With these the manufactures also supply 10 cc. of solvent. Of such a solution 0.25 cc. contain the 125 I.U., which is the standard dose for all cases and which should never be exceeded. This small amount is awkward to handle accurately (it requires an insulin syringe) and is wasteful, because there is a loss of solution in the nozzle of the syringe and in the needle. We therefore prefer a higher dilution, which we prepare in the following way: The solvent supplied is injected into the rubbercapped bottle containing the 5000 I.U . As these bottles are too small to hold more solvent, we withdraw 5 cc., inject it into an empty rubber-capped bottle and add 5 cc. of normal saline to each bottle. This gives us 10 cc. of solution in each bottle, and of this solution 0.5 cc. contains 125 I.U. This amount is convenient to inject with an ordinary syringe.

HCG produces little or no tissue-reaction, it is completely painless and in the many thousands of injections we have given we have never seen an inflammatory or suppurative reaction at the site of the injection.

One should avoid leaving a vacuum in the bottle after preparing the solution or after withdrawal of the amount required for the injections as otherwise alcohol used for sterilizing a frequently perforated rubber cap might be drawn into the solution. When sharp needles are used, it sometimes happens that a little bit of rubber is punched out of the rubber cap and can be seen as a small black speck floating in the solution. As these bits of rubber are heavier than the solution they rapidly settle out, and it is thus easy to avoid drawing them into the syringe.

We use very fine needles that are two inches long and inject deep intragluteally in the outer upper quadrant of the buttocks. The injection should if possible not be given into the superficial fat layers, which in very obese patients must be compressed so as to enable the needle to reach the muscle. It is also important that the daily injection should be given at intervals as close to 24 hours as possible. Any attempt to economize in time by giving larger doses at longer intervals is doomed to produce less satisfactory results.

There are hardly any contraindications to the HCG method. Treatment can be continued in the presence of abscesses, suppuration, large infected wounds and major fractures. Surgery and general anesthesia are no reason to stop and we have given treatment during a severe attack of malaria. Acne or boils are no contraindication, the former usually clears up, and furunculosis comes to an end. Thrombophlebitis is no contraindication, and we have treated several obese patients with HCG and the 500-calorie diet while suffering from this condition. Our impression has been that in obese patients the phlebitis does rather better and certainly no worse than under the usual treatment alone. This also applies to patients suffering from varicose ulcers which tend to heal rapidly.

While uterine fibroids seem to be in no way affected by HCG in the doses we use, we have found that very large, externally palpable uterine myomas are apt to give trouble. We are convinced that this is entirely due to the rather sudden disappearance of fat from the pelvic bed upon which they rest and that it is the weight of the tumor pressing on the underlying tissues which accounts for the discomfort or pain which may arise during treatment. While we disregard even fair-sized or multiple myomas, we insist that very large ones be operated before treatment. We have had patients present themselves for reducing fat from their abdomen who showed no signs of obesity, but had a large abdominal tumor.

Small stones in the gall bladder may in patients who have recently had typical colics cause more frequent colics under treatment with HCG. This may be due to the almost complete absence of fat from the diet, which prevents the normal emptying of the gall bladder. Before undertaking treatment we explain to such patients that there is a risk of more frequent and possibly severe symptoms and that it may become necessary to operate. If they are prepared to take this risk and provided they agree to undergo an operation if we consider this imperative, we proceed with treatment, as after weight reduction with HCG the operative risk is considerably reduced in an obese patient. In such cases we always give a drug which stimulates the flow of bile, and in the majority of cases nothing untoward happens. On the other hand, we have looked for and not found any evidence to suggest that the HCG treatment leads to the formation of gallstones as pregnancy sometimes does.

The Heart
Disorders of the heart are not as a rule contraindications. In fact, the removal of abnormal fat – particularly from the heart-muscle and from the surrounding of the coronary arteries – can only be beneficial in cases of myocardial weakness, and many such patients are referred to us by cardiologists. Within the first week of treatment all patients – not only heart cases – remark that they have lost much of their breathlessness

Coronary Occlusion
In obese patients who have recently survived a coronary occlusion, we adopt the following procedure in collaboration with the cardiologist. We wait until no further electrocardiographic changes have occurred for a period of three months. Routine treatment is then started under careful control and it is usual to find a further electrocardiographic improvement of a condition which was previously stationary.

In the thousands of cases we have treated we have not once seen any sort of coronary incident occur during or shortly after treatment. The same applies to cerebral vascular accidents. Nor have we ever seen a case of thrombosis of any sort develop during treatment, even though a high blood pressure is rapidly lowered. In this respect, too, the HCG treatment resembles pregnancy.

Teeth and Vitamins
Patients whose teeth are in poor repair sometimes get more trouble under prolonged treatment, just as may occur in pregnancy. In such cases we do allow calcium and vitamin D, though not in an oily solution. The only other vitamin we permit is vitamin C, which we use in large doses combined with an antihistamine at the onset of a common cold. There is no objection to the use of an antibiotic if this is required, for instance by the dentist. In cases of bronchial asthma and hay fever we have occasionally resorted to cortisone during treatment and find that triamcinolone is the least likely to interfere with the loss of weight, but many asthmatics improve with HCG alone.

Obese heavy drinkers, even those bordering on alcoholism, often do surprisingly well under HCG and it is exceptional for them to take a drink while under treatment. When they do, they find that a relatively small quantity of alcohol produces intoxication. Such patients say that they do not feel the need to drink This may in part be due to the euphoria which the treatment produces and in part to the complete absence of the need for quick sustenance from which most obese patients suffer.

Though we have had a few cases that have continued abstinence long after treatment, others relapse as soon as they are back on a normal diet. We have a few “regular customers” who, having once been reduced to their normal weight, start to drink again though watching their weight. Then after some months they purposely overeat in order to gain sufficient weight for another course of HCG which temporarily gets them out of their drinking routine. We do not particularly welcome such cases, but we see no reason for refusing their request.

It is interesting that obese patients suffering from inactive pulmonary tuberculosis can be safely treated. We have under very careful control treated patients as early as three months after they were pronounced inactive and have never seen a relapse occur during or shortly after treatment. In fact, we only have one case on our records in which active tuberculosis developed in a young man about one year after a treatment which had lasted three weeks. Earlier X-rays showed a calcified spot from a childhood infection which had not produced clinical symptoms. There was a family history of tuberculosis, and his illness started under adverse conditions which certainly had nothing to do with the treatment. Residual calcifications from an early infection are exceedingly common, and we never consider them a contraindication to treatment.