Obesity - Further Course of the Disease Complications and Termination

heart, blood, urine, pressure, arteries, excretion, body, water, fluids and rarely

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(.brcliac the insufficiency- of the heart muscle is neither total nor constant, but is partial and temporary, confined to the left heart while the right ventricle is still capable of relatively vigorous contractions, we meet with grave paroxysmal and circulatory disturbances—cardiac asthma. The attacks usually occur at night, when the respiration during sleep has become more superficial, the rima glottidis narrower, and the tension of the oxygen in the lungs and blood has greatly decreased. The contractions of the left ventricle become progressively weaker and more incomplete, less and less blood flows into the arteries, while the right heart still pumps its contents into the lungs. The latter are more and more filled with blood, they lose their elasticity, grow rigid, the respira tory expansion and contraction become ever more incomplete, the insufficiency extends equally to inspiration and expiration. The patient awakes with oppression and pain in the chest, gasps for air, is forced to sit up or leave the bed, lips and cheeks are cyanotic, cold sweat bedews face and chest, and respiration is labored, all the auxil iary respiratory muscles being called in play. Despite the insuffi ciency of the heart muscle the blood pressure may rise in the arteries owing to the dyspncea and the vascular spasm dependent upon it, and will sink only in grave eases in which the insufficiency of the heart is greater than the irritability of the vasomotor nerves.

The expectoration in such cases is always scanty. According to the condition of the bronchial mucosa, small, tough, dirty-gray or more yellowish masses, rarely mixed with blood, are coughed up, while numerous small vesicular miles are heard scattered over the chest, and along with them partly vesicular, partly rough and obscure breathing. The attacks of cardiac asthma may occur, though rarely, in the early stage of corpulence, are always a symptom of marked weakness of the heart, and appear chiefly and reach a most painful and serious character when more or less extensive degenerative pro cesses have been established in the heart and the arteries, or when the arterial sclerosis is latent and can be inferred only from the high blood pressure.

With the gradual weakening of the heart muscle and the fall of the pressure in the aortic system, the excretion of water by the kid neys will also undergo increasing changes which manifest themselves by scanty and irregular, or again by profuse, secretion of urine.

On comparing the quantities of water ingested in drinks and other wise, which are usually exceedingly great, with the excretion of urine during twenty-four hours, preventing as far as possible all perspira tion, we find a great deficit, 40 to 60 per cent., not rarely 1,000 to 1,500 c.c., so that, making allowance for the water contained in the solid food, it can no longer be completely removed from the body by the sensible and insensible perspiration. A portion of the in gested water remains in the body, and the tissues, rendering them succulent and watery, and imparts to the patient the bloated, flaccid appearance which strikes one all the more because of the amemic pallor and cyanosis, and contrasts strongly with the earlier elastic firm ness of the body. Marked partial dropsies and (edemas do not occur at first, as the accumulated water can still escape by the occasional polyurias. If the ingestion of fluids in such a patient is restricted to

750 or 1,000 or 1,200 c.c., according to the hulk of the body and the quantity of liquids previously consumed, the excretion of urine is materially increased so that not only much more urine is passed than the amount of fluids ingested, but often enough the quantity of urine is absolutely greater than that excreted under ample or abundant con sumption of fluids. As a rule the excretion of urine remains for a long time inversely proportional to the ingestion of fluids, and alto gether more urine is passed than the amount of fluids consumed. The secretion of urine is greater, and in this case the excess, when the body can furnish no more fluid, is accounted for by the diminu tion of the excretion through the skin, which gradually becomes very much less.

Ayterioscleyosis. —A frequent and grave complication of obesity, which occurs sooner or later, is the decrease in the elasticity of the vascular walls and the lessening of the contractility of their smooth muscular fibres, with increase in the thickness of the walls—sclerosis of the arteries, especially of the coronary arteries of the heart.

It is not positively proved that the obesity causes the arterial sclerosis (Tranbe and Huchard) especially through the high blood pressure, which is kept up by the impeded circulation in the abdom inal vessels and the portal system, although persistent high blood pressure does impair the elasticity of the vascular walls and give rise to sclerosing processes. The same causes which lead to obesity—the excessive nutrition, the ingestion of large quantities of food and drink, especially the abuse of alcohol—will also favor the occurrence of sclerosis; and mental strain and emotions, sexual excesses, the abuse of tobacco, rheumatism, gout, and the climacteric constitute _Slditional etiological factors.

Arteriosclerosis manifests itself at an early period clinically by remarkably high tension of the pulse. The blood pressure in the radial artery, whose wall possibly shows as yet no anatomical altera tions, frequently reaches 150 mm. of mercury and may exceed it; rarely it remains below this figure. Subjective symptoms may at that time be lacking. Later on difficult respiration and slight dysp uwa occur after insignificant muscular exertion, stair-climbing, stooping, etc. No changes are as yet to be noticed in the heart. The area of cardiac dulness is enlarged, the apex beat, whether pal pable or not, is lower down and displaced within the mammillary the heart sounds are more or less muffled, or clear, and only the second aortic sound is accentuated. The pulse tracing shows no changes ex cept high pressure. Subsequently, under the increasing pressure, the arteries become elongated and serpentine, their walls thicken and grow rigid. When the fat on the arm is thick these alterations are not distinctly perceptible in the radial artery. The temporal artery like wise, when imbedded in fat, may escape simple observation, but pro jects at once above the level of the temple and the forehead when these parts are rubbed with the finger, a piece of chamois or glove leather, or a handkerchief, and clearly shows its elongation and ser pentine course.

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