Percussion shows the area of cardiac dulness enlarged, according to the stage of the fatty heart, first in length, later also in width. A larger portion of the heart adjoins the thoracic wall, the impulse is diffuse and lacks force, and the apex beat is usually displaced out ward, possesses slight resistance, and often cannot be felt.
On auscultation the heart sounds are clear when no complication is present; when the hypertrophy and dilatation are still confined mainly to the left heart they are loud and distinct, frequently with accentuation of the second aortic sound. But when the signs of in sufficiency of the left ventricle become more marked and the right ventricle has likewise undergone dilatation and hypertrophy, then the heart sounds diminish in intensity, they become muffled with ever- more distinct accentuation of the second pulmonic sound. A reduplicated sound may also be observed in systole owing to the equal contraction of the ventricles.
The pulse in the majority of cases is slow (pulsus tardus), espe cially when the obesity is great and plethora exists. In other cases it becomes frequent and may lose in quality with the progress of the circulatory' disturbances, until it finally is dicrotic or subdicrotic.
At the same time with the increasing weakness of the heart the impeded circulation becomes perceptible by reason of regurgitation of the blood in the venous apparatus, and dilatation of the smaller cu taneous veins; we see this, for instance, in the circle of ectatic veins and capillaries which start from the eusiform process and extend along the lower margin of the ribs toward both sides, also by the for mation of varices on the extremities and dilatation of the rectal veins which are most apt to exhibit the influence of gravity and the slight propulsive and aspirating force of the heart. The rectal veins are not only dependent in every normal position of the body, but the efflux of the blood is besides frequently impeded by fmcal accumu lations at the upper part of the rectum, due to the excessive and im proper nutrition.
The symptoms of the patient will be intensified more or less rapidly according to the increase of the circulatory disturbances, which are compensated less and less completely by the fatty heart; embarrassed respiration, shortness of breath, and palpitation will occur even on moderate exertion such as a quick walk and stair-climb ing, and will reach a distressing height with more violent efforts. Not rarely there may be frequent attacks of dyspnoea and vertigo.
When the obesity has attained a high degree the patients are nearly always forced, after a short walk or ascent, often after every few steps, to stop and breathe with open mouth and distended nostrils, to gasp for air. At the same time the excitement of the heart has risen to a violent palpitation, and the storm is allayed, the respira tion becoming freer and deeper, only when the patient remains stand ing and keeps perfectly quiet. Any at all active muscular exertion, movement of the arms, turning of the head, stooping or sitting down, during which the abdominal viscera are crowded upward and the respiratory space is contracted, immediately increases the dyspuoea and palpitation, and forces the patient to rise. Often prolonged ab solute rest is necessary before normal respiration and cardiac action are restored.
Respiratory Apparatus.—The respiratory symptoms of such pa tients are due not only to the insufficiency of the heart muscle and the overfilling of the lungs by reason of the regurgitation of the blood, but they are also increased by the mechanical influence of the masses of fat accumulated in the body. The large abdominal de posits of fat crowd the diaphragm far up into the thoracic space and diminish its capacity, while the enlarged and not rarely great volume of the fatty heart and the fat accumulated in the mediastinum lessen it still more. Moreover the fat on the surface of the thorax, which is not rarely enormous, influences the respiratory space, since the weak, fatty, impotent muscles are unable to lift and distend the tho racic walls, with their heavy load, in a normal manner; and on the other hand the diaphragm cannot force down, as under ordinary con ditions, the elevated abdominal viscera, enlarged as they are by fatty infiltration and deposition, into the abdomen which is likewise bur dened with thick, almost unyielding deposits of fat. Hence the respiratory capacity of the lungs and their inspiratory distention are considerably restricted from two sides. This explains why even at this stage, without further pathological alterations in the heart and lungs, the patients quickly become short of breath at night, espe cially when low down in the bed, as the abdominal viscera then gravi tate farther into the thorax; or why they lose breath when the stom ach is greatly distended; or finally why the d,yspuceic symptoms, which may assume the character of asthmatic attacks, wake the patient and cause him to sit up or jump out of bed.