Still another factor is of importance in the symptomatology of the anaemic corpulent persons, namely, the water. Early in this condition water accumulates in the blood and the tissues owing to the insufficiency of the heart muscle and the circulatory disturbances resulting from it. The rapid occurrence of palpitation in such pa tients has been already repeatedly mentioned. Even in moderate degrees of anaemic obesity palpitation of the heart, subjectively and objectively, is never absent. Vigorous, perfect contractions are lack ing and are replaced by weak and rapid movements. The heart is usually dilated, and the systolic murmurs often audible over the vari ous valves indicate the relative insufficiency, as the accentuated second pulmonary sound shows the increased pressure in the right heart and the venous apparatus. In other cases a venous hum is audible over the bulb of the internal jugular vein. At the same time the arteries are slightly filled; the pulse is small, soft, weak, and dicrotic.
The slight afflux of blood to the kidneys, and the lessened pres sure of the blood in them, in their turn again influence the excretion of urine and give rise to increased tension in the other water-excret ing organs, to augmented sensible and insensible perspiration, and when these are no longer sufficient, to an accumulation of water in the blood and tissues. The excretion of urine diminishes more and more. Not only is the total amount of urine small, but its excre cretion occurs also at. irregular intervals; a considerable time may elapse after the ingestion of fluids before urination takes place, and then the quantity may be rather large. But finally even this irregu lar polyuria ceases. The water ingested within twenty-four hours in the beverages is incompletely excreted by the kidneys, leaving a very large surplus of water which can no longer be expelled from the body by the sensible and insensible perspiration. The best information on this point is gained by the determination of the differences which we shall presently discuss at greater length. These patients soon develop, beside the anaemic quality of the blood, an accumulation of water in the latter and in the tissues, hydrfemia and oedemas which manifest themselves first in the lower extremities, around the ankles.
Through the cc-operation of these circumstances the anemic form of obesity passes much more rapidly into the hydrcemic than does the plethoric, in which the disease may assume several phases and persist many years before the heart muscle reaches such a condition and the force of the heart sinks to the same point as it may in a few years in the anemic form.
Sequelce of the avanic Ch«nges.
With the development of these changes in the various vital organs by excessive deposition of fat, conditions may result which early en danger the life of the patient, should intercurrent processes bring about additional diseases and organic changes.
The first to suffer is the muscular power, as the fat surrounds and penetrates the muscles which in part undergo fatty degeneration from the pressure and the nutritive disturbances. The strength is consid erably impaired when the blood is anaemic either from the start as in the anemic form of obesity or becomes so in the further course, so that the muscle is not supplied with sufficient oxygen.
These injurious influences gain particular importance in the heart which, as stated above, is rapidly weakened. But with the slowly increasing insufficiency of the heart muscle the general resisting power of the body, especially against intercurrent febrile diseases, sinks likewise. Observations to this effect were made even by
Hippocrates, Celsus, and Galen, and in more recent times Wuncler lich and Liebermeister have called special attention to the fact. The power of the heart which even in the afebrile state was able to main tain the circulation only with difficulty, is still more impaired by the fever so that the arteries are but imperfectly filled with blood; the pulse becomes small, weak, dicrotic, and irregular; and the fever as sumes the adynamic character, to use the earlier term for the results of this sinking of the heart action. But in the febrile condition of such patients a further dangerous factor is superadded, to which Liebermeister has called attention. The small surface of the body of the obese as compared with his weight, in conjunction with the thick subcutaneous layer of fat, interferes with the dissipation of heat so that the temperature in the interior of the body soon reaches a high degree which damages the functions and acts deleteriously upon the heart. Hence it is not necessary to assume that the febrile diseases—typhoid fever, pneumonia, the exanthemata, etc.—in the obese are associated with an absolute higher temperature, with in creased ox illation, but the greater heat in the viscera is fully explained by the retention of heat. For the same reasons—the smaller surface of the body and the enormous panniculns adiposns—it is more difficult to reduce the temperature by direct abstraction of heat, by cold baths, in the obese than in the lean ; while on the other hand also the inter nal antipyretic drugs—antipyrin, quinine, etc.•—are usually badly borne and even in moderate doses may cause a serious collapse. Corpulent persons, therefore, who are attacked by the above-named diseases are always exposed to the danger that the greater or lesser insufficiency of the heart will rapidly increase under the fever and that a sudden collapse may terminate fatally.
Convalescence after febrile diseases in the obese also runs a slower, often an unfavorable course. Not only in pre-existing ameinia, but also in the plethoric form of obesity the luemoglobiu contents of the blood sink remarkably during the fever and the regen eration of the red corpuscles is effected with difficulty. Owing to these causes on the one hand, and on the other hand to the plentiful diet, the forced nutrition during convalescence, and the rest combined with it, there is again more fat than muscle formed, and the decom position products of the albumin are less completely burned up and instead are changed into fat which is likewise deposited. Therefore the disturbances in the course of convalescence dependent upon cardi ac weakness and anmmia will not only be greater than before, but also the corpulence will be apt to increase.
Grave dangers threaten the life of the corpulent, moreover, by the anomalies of metabolism resulting from the accumulation of fat in the body, partly by complicating diseases which either are due to the same cause as the increased fat-formation or are induced by it : uric acid diathesis and gout, functional disturbances and diseases of the kidneys, arteriosclerosis, diabetes mellitus, carcinosis. We encoun ter them sooner or later in the further course of the disease. tinder their baleful influence the symptomatology changes, the existing symptoms are aggravated, additional ones appear, and they deter mine the extent of the complicating processes which modify the ter mination of the disease according to their nature.