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Obesity - Plethoric Form

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OBESITY - PLETHORIC FORM.

The first signs of increased fat formation and deposition in the plethoric form manifest themselves often in youth or in early man hood when the body is in the full vigor of development, and shape, carriage, and color correspond to perfect health.

With the first deposition of the excess of fat in the subcutaneous cellular tissue the limbs become rounded, gradually increase in cir cumference without damaging the symmetry of form; the skin every where is filled out by a cushion of fat and appears smooth and un wrinkled. But since with the ample or excessive nutrition and good health not only the amount of fat but also that of albumin is in creased, the muscles are powerfully developed, voluminous, and capa ble of function as is the heart muscle; the blood generally reaches the maximum in contained albumin and hiemoglobin, and its quantity may frequently exceed the normal by a considerable degree. The external appearance of the patient fully corresponds to the state of nutrition : his face and the mucous membranes are vivid red, slightly congested; his bearing, unless the phlegmatic temperament is con genitally present or has been acquired, is self-confident and elastic ; while the size and endurance of his muscles equal the normal, rarely exceed it, but more frequently are below it after the corpulence has existed a greater length of time.

In Munich there is abundant opportuni:,y for observing such persons : the sons of rich citizens with few hours of work, who set a good table not only for the chief repasts bu it various times during the clay, and consume beer in large amounts, usually eight to ten litres per day, or fat-forming substances to the extent of 360-450 gin. of carbohydrates, which alone would cover or exceed their daily requirements.

On examining such patients we find in the early years a full strong pulse which later on becomes weaker, of moderate frequency, 68-72, sometimes sinking to 50-60 per minute. The area of cardiac dulness is enlarged, often considerably; the impulse is felt indis tinctly, owing both to a loss of power of the heart muscle and to a greater deposit of fat on the thorax, through which the apex beat is less easily perceived. The heart sounds, at first clear and distinctly audible, subsequently lose force and are weakened by the large amounts of fat over the cardiac region. Respiration is normal. The large quantity of water ingested with the beverages is ' often suffi ciently excreted in the urine; but not rarely several hundred cubic centimetres remain behind in the body and must be passed off in the sweat and the insensible perspiration.

At first the patients, so long as they still feel strong and are able to put forth considerable bodily power, are proud of their cor pulence and imposing figure, looking clown with disdain upon other less well-nourished and thin individuals, and not rarely they are the object of envy to many, not alone lean persons. Thus the person may remain for years. Later on the patient's condition changes more and more both in his external appearance and in his subjective sensations, either gradually or rapidly. The masses of fat in the subcutaneous cellular tissue become excessive. The plumpness of the body, which before was not quite beyond the limits of symmetry, soon exceeds them, and the man who not long ago resembled a beau tiful young Bacchus in shape becomes a Silenus or a Falstaff, an ob ject of mockery.

More and more fat is deposited, obliterating the folds and fur rows; the face loses its mimic expression owing to the covering and nutritive disturbances of the facial muscles by the thick layers of fat. There are persons, says Lichtenberg, who are so fat in the face that they can laugh beneath the deposit so that the greatest physiognomic expert is unable to discover it, while we poor thin creatures, whose soul lies immediately 'under the epidermis, are forced to speak the language of truth.

The neck appears shortened by the double chin and the fat cush ions of the upper clavicular region; often an additional mass of fat in several rolls lies between the head and trunk. The chest gains in

circumference, the mammary region harbors large masses of fat, and as the tenser, short-fibred connective tissue along the sternum pre vents the development of the panniculus adiposus, the lateral portions in men present the appearance of female breasts, while iu women the mannum often attain an enormous bulk and finally extend down to the umbilical region as almost bag-like formations. But the largest bulk is presented by the abdomen; this is due not only to the thick exter nal deposits but also to the interior enlargement following the disten tion of the internal organs, the stomach and intestinal canal, increase of volume of the liver, the mesentery, and omentum with enormous masses of fat. Thus the abdomen may attain a truly monstrous form and proportion. Its dimensions increase steadily. In thick trans verse ridges, usually three, the abdomen hangs down over the thighs and covers the pubic region, while the umbilical region is drawn in in a funnel shape, and the stretching of the abdominal wall gives rise to umbilical hernia. As the weight of the abdomen brings the centre of gravity for the upright position of the body farther forward, the patients usually straddle in their walk, with legs turned outward, the head held high, the body drawn back, and with slow, careful steps like pregnant women. They also complain of pain iu the back, caused by the straining of the dorsal muscles to maintain the equi librium in walking. In the recumbent position, however, the dia phragm is pushed uncommonly high by the masses of fat accu mulated in the abdomen and the enlargement of the organs by fatty infiltration, thus compressing the thoracic space which is already crowded by the enlarged fatty heart and the masses of fat in the mecliastinum, oppressing the lungs and heart and causing dyspnoa so that the patients are forced to place the head and trunk high and even to assume an almost sitting position in bed.

In the upper and lower extremities, too, the fatty deposits grad ually reduce the nutrition, development, and activity of the muscles and distort the outlines. On the arm and forearm the furrows and lines limiting the muscles are filled up with fat and obliterated, the arms themselves are changed thereby into tumid cylinders the tense skin of which can no longer be lifted into folds. The thighs have still more markedly increasal in bulk, especially at their upper parts, around the hips and the buttocks. At times the greatly distended cushions of fat over the tuber ischii (steatopyga of the Bushman and Hottentot women) may attain enormous proportions. On the thighs the masses of fat form several transverse ridges, while the knees exhibit but little fatty deposit and the legs again are increased in bulk by abundant adipose tissue. The deposition of fat occurs last in the hands and feet, which are often remarkably small in obesity.

After a prolonged duration of corpulence and of the various, not necessarily very pronounced, circulatory and respiratory troubles, but before the disease itself has reached its height, death may occur suddenly by paralysis of the heart. At the autopsy of such cases the terminal fatty degeneration of the heart muscle may often be absent, and the fatal issue can thus far only by the assumption of a paralysis of the cardiac nerves which for the present must be called functional, until an anatomical lesion can be discovered (Bol linger). The fatigue of the heart muscle and the paralysis of the cardiac nervous system then would be due mainly to the inordinate quantity of blood and the intensity of the intracardial pressure— a fact to which I first called attention. Added to this is the in fluence of the lack of oxygen and the accumulation of carbonic acid in the blood which weaken the energy of cardiac activity and favor the occurrence of the paralysis.