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Obesity.

Problems:

Synonyms.—Lipomatosis Universalis; Polysarcia Adiposa.

Definition.—An excessive accumulation of fat, impairing the bodily functions, or rendering the patient uncomfortable.

It is difficult to draw the line between the normal and abnormal amount of adipose tissue, though we may be safe in classifying an individual as obese whenever the fat becomes burdensome, and as soon as the function of any part becomes impaired thereby, it becomes a disease.

Etiology.—In obesity, as in most diseases, there are a number of predisposing causes, among which may be mentioned, first:

Heredity.—From fifty to sixty per cent of obese people can trace the condition to parents or grandparents.

Age.—While we meet with obesity in children, the most favorable time for an increase of adipose tissue is after the age of forty. The menopause also favors the deposit of fat.

Sex.—Women are more prone to obesity than men.

Race.—Corpulency is found more frequently among the Germans and Hebrew races than among the English.

Disease.—Certain diseases predispose to obesity. Gout and diabetes, especially, may be named, and it is not uncommon to find this condition in chlorotic. girls. It frequently follows typhoid fever, and develops after castration and ovariotomies.

Habit.—Sedentary habits are prone to result in obesity, since oxidation is deficient in all cases of corpulency.

The existing causes of obesity are undoubtedly due to overeating and drinking, especially fat-producing foods, and the use of alcohol, beer, and sweet wines. While the carbohydrates and fats are more prone to produce obesity, even the albuminoids will give rise to the same condition when more is taken than is necessary for the daily waste. This is especially true when the patient leads an inactive life, since active muscular contractions lead to the decomposition of a large amount of fat. Strümpell says, in the daily ingestion of five or six glasses of beer, there is taken into the system, from this source alone, one-half the total amount of starch required by the system. The obesity of beer-drinkers is thus readily accounted for.

Pathology.—The subcutaneous cellular tissue is the first to receive the fatty deposits and the "panniculus adiposis" soon attains considerable thickness. The face becomes full, the neck enlarges, the double-chin develops, the chest broadens, and, in women, the breasts may become enormous, owing to fatty deposits. The abdomen becomes prominent, and as a result of overhanging portions, intertrigo of the groin, the under surface of the breasts, and between the nates, is common.

The internal organs also share in the general deposit. Thus, the mesentary, mediastinum, pericardium, and capsules of the kidney show the accumulation of fat. In more severe and serious cases, layers of fat are deposited about the heart, fatty overgrowth, and in the muscular structures fatty infiltration or degeneration occur. This is attended by impaired respiration and circulation, on slight exertion. Thus the breathing is rapid, the pulse small and feeble, or irregular. The same changes may take place in the liver and kidneys. We are not to understand, however, that these degenerations take place in all obese persons, for many fat people enjoy good health.

Symptoms.—For a time the only symptoms are those of inconvenience, and the increased fat may be somewhat burdensome; as the fat progressively increases, however, there is impairment in the respiratory and circulatory functions. On slight exertion, such as rapid walking, climbing a hill, or ascending stairs, the patient experiences difficulty in breathing, or as he may express it, "is winded." The pulse becomes feeble on such occasions, and not infrequently is quite irregular. At times there is severe palpitation.

The appetite is often impaired and digestion feeble. Constipation is a common condition. Catarrhal conditions of the respiratory apparatus often follow obesity. In some there is mental lethargy, the individual being tired and sleepy. The temperature is often subnormal.

Diagnosis.—The only care in the diagnosis is to distinguish the complications when they exist.

Prognosis.—This is favorable when the patient is willing to subscribe to the dietary prescribed by his attendant, and will pursue daily systematic exercise, followed by the graduated bath.

Treatment.—The most important part of the treatment consists in pursuing such methods as will bring about the oxidation of the fat already deposited, and prevent the formation of new supplies. The most efficient means at our command to bring this about is exercise and diet.

In restricting the quantity of fat-producing foods, we are to be careful and avoid the mistake of too rigid a diet, or we will do injury to the body itself. When the individual is weakened by diet, a more generous list must be furnished.

Various diet lists have been suggested for the reduction of adipose tissue, Banting's, Ebstein's, and Oertal's being the ones most commonly used. Each list has its defects, and one can usually get better results by selecting parts of each than by adhering strictly to one. Banting's diet list is largely nitrogenous, the fat and carbohydrates being reduced to a minimum, and is as follows:

Breakfast.—Meat or fish, excepting pork or salmon, four or five ounces; tea, without cream or sugar; toasted white bread, about one ounce.

Lunch.—Meat, five or six ounces; vegetables, exclusive of potatoes; toasted white bread, one ounce. No farinaceous dishes, no champagne, port-wine, or beer; red wine, or sherry if desired, two or three glasses.

Afternoon.—Fruit, two or three ounces; a little toast; tea.

Evening.—Meat or fish, three or four ounces; red wine, claret, water without limit.

Ebstein's diet allows twice the amount of fat, but restricts the carbo-hydrates, while Oertel favors less fat than Ebstein, but doubles the quantity of carbohydrates, and restricts fluids.

Banting's diet is, perhaps, theoretically the best, but unfortunately is not the most practical, for it is impossible for the body to maintain its metabolic equilibrium on an exclusive nitrogenous diet, and though the fat rapidly diminishes on such a diet, the patient grows weak, nervous, and sleepless. An exclusive nitrogenous diet also gives rise to gastro-intestinal disturbances, and various dyspeptic symptoms result. Although one can not prescribe the same diet for every obese person, a happy mean may be reached by combining portions of the three diet lists.

Thus, for breakfast an orange, a small bit of steak or fish, one ounce of toasted white bread, or shredded wheat biscuit, one cup of clear tea, no sugar or cream.

For lunch, steak or fish, four ounces; small piece of toast, or two rolls; green vegetables, fruit, and one cup of clear tea.

Dinner.—Steak, roast-beef, or fish, four to six ounces, or one or two eggs, green vegetables, fruit, and black coffee. Butter may be used moderately. Alcohol, beer, and wines should be prohibited, but water may be taken freely two hours after a meal. In some cases, water should be limited to one pint in twenty-four hours. Although the patient may be anxious for a rapid decrease in weight, the safer plan is to gauge the diet, so that the patient will lose from three to five pounds per week.

The patient should retire at 10 P. M., and arise at 6 A. M., eight hours being sufficient for fat people. He should take at least three baths a week, and, if robust, a daily bath. If the heart be good, cold baths are preferred; but when there is cardiac weakness, the hot bath should be recommended.

Exercise.—To increase oxidation, the patient must take daily exercise in the open air,—walking, horseback-riding, swimming, rowing, tennis; in fact, any exercise that will bring into play a large number of muscles and produce free perspiration. When there is cardiac feebleness, care must be taken that the exercise be not too long nor too severe. The medicinal treatment is not very satisfactory, though some reduction in weight may follow, usually, however, at the expense of the patient's strength; the most commonly used agents being the juice of the phytolacca berry, and thyroid extract.


The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.



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