The condition of the patient becomes more and more deplorable. The congestion in the abdominal vessels, especially the portal system when the liver has undergone cirrhotic degeneration, leads to effusion of water into the abdominal cavity—ascites—with progressive reduc tion of space and crowding up of the diaphragm and further inter ference with respiration. Water also exudes from the vessels into the pleura and pericardium, causing hydrothorax and hydropericardium. The congested, nearly inelastic lungs, whose alveoli have already been much constricted by the ectasia of the capillaries resulting from the stasis of the blood, are compressed and their expansion during inspi ration is more and more limited. On the other hand the transuda tion in the pericardium, aside from its effect on the lungs, exerts more or less pressure upon the surface of the heart and hinders its diastole and at the same time the passage of the blood limn the over filled rigid lungs into the heart. The respiratory and circulatory disturbances reach the highest degree. The patient can no longer lie down. He passes day and night sitting upright in bed or outside of it. The swollen, painful feet interfere with spontaneous move ment. Suffering frown continual dyspmea he struggles laboriously for breath. Long-standing congestive catarrhs in the bronchi with the formation of abundant, tenacious, mucous or masses keep up the tormenting, painful cough and add to the dysp ncea. Owing to the weakness of the heart hemorrhagic infarctions and thromboses may form in larger or smaller pulmonary arteries. Blood in greater or lesser amount appears in the expectoration and renders it more difficult. Moreover, breathing is still more restricted by the shutting off of the region of the lung supplied by the throrn hosed artery. The patient may die rapidly in consequence of the pneumonia and pulmonary cedema resulting from the injury, or if the infarcted region is small he may recover from it and continue his miserable existence.
If the patient is fortunate the last terrors of the disease may be preceded by a serous effusion into the brain—cerebral (edema. Sopor ensues and death follows before the patient regains conscious ness. In other cases painful hours are still in store for him. The congestive catarrh involves additional bronchi in which the exudation grows more and more profuse while expectoration becomes more difficult, the dyspnoeft has become extreme, the weakening heart can no longer overcome the weight of the blood, hypostatic pueumonias develop or the patient perishes without them from the slowly form ing pulmonary oedema, after hours of stertorous breathing, pulseless, and covered with cold sweat.
The disease may terminate earlier by the alterations of the vascu lar walls due to the arteriosclerosis and atheroma, by their rupture through friability, by detachment of emboli and their deposition in some cerebral artery, by hemorrhage of the brain, and by embolism and thrombosis.
In obesity, especially the plethoric form, cerebral hypergemia is a frequent symptom and finds particular expression also in the external appearance, in the flushed face, the distinctly pulsating carotids, the thick-set figure, the broad chest, the short neck, i.e., the apoplectic habit. The patients complain of vertigo, headache, tinuitus aurium, muscoe volitantes, from which they are sometimes relieved by epis taxis. But even without the presence of true plethora, in hydmmia and serous plethora, the abnormally high vascular tension resulting from arterial sclerosis may lead to rupture of a vessel. It is gener
ally caused by an increased pressure in the cerebral vessels, a psychi cal excitement, a hearty meal, sexual excitement, or great muscular exertion. Besides, an increase of venous pressure by straining at stool, by sneezing, screaming, or laughing may indirectly raise the arterial pressure and be followed by rupture of a vessel.
Prodromes may precede the attack and manifest themselves chiefly after hearty meals and iu the presence of constipation by a marked feeling of heaviness and sluggishness, rush of blood to the head, flushing of the face even after slight physical and psychical excite went, while the extremities feel cold and cause sensations of stiff ness, numbness, and formication. Associated with them are the other symptoms of congestion, dizziness, tinnitus muscu voli tantes, general irritability, and restless sleep interrupted by alarming dreams, etc.
If an apoplectic attack has occurred the prognosis in general is always unfavorable. In most cases death ensues immediately or soon after the injury. When the location and size of the hemorrhage do not determine a fatal result and the patient recovers, fresh and more profuse hemorrhages soon follow and end in death. Only a small minority of the patients live for any length of time after the attack.
Glycosuria.—A grave complication of excessive accumulations of fat in the body is the excretion of sugar in the urine—lipogenous dia betes mellitus, glycosuria.
As regards the causes of this disease of the corpulent we are not yet fully informed. ,The capacity of the cells of the body for burn ing up sugar may be impaired by various causes, and of these differ ent causes oue perhaps is associated with a simultaneous protoplasm poisoning and pathological disintegration of albumin, while another is not. Numerous attempts at explanation are to be found in the litera ture. The inactive mode of life, the sedentary habit, the slight mus cular labor may favor the accumulation of sugar iu the blood as they do the deposition of fat. In the course of obesity the power of de composition by the muscular elements is still more impaired by the facts that the fibrilla-3 of the muscles are crowded apart by fat, partly undergo fatty degeneration, and that the energy of their contractions is reduced by the slight restitution of the inogen re sulting from the diminished supply of oxygen by the blood which is deficient in hfemoglobin, thus lessening the functional activity of the muscle in general. It is certain that the factors here enumerated may exert a restricting influence upon the decomposition of the car bohydrates; but we cannot consider them as the true cause of the diabetes, since they occur far more frequently and markedly in cases free from glycosuria. A better though still incomplete explanation of the etiology of diabetes in obesity has been furnished by the ex perimental investigations of Minkowski and von :Hering who were able to produce an intense diabetes in clogs after extirpation of the pancreas. When the latter was only partially removed and the rest with its vessels left in the abdominal cavity, the diabetes failed to occur. When the remnant of the organ was subsequently extir pated the disease developed. But if only about one-tenth of the pail CreaS is left in the body a slight form of diabetes ensues in which the gly•osnri I is dependent solely upon the ingestion of carbohydrates.