42 WILDER TILESTON 



measures, and leads after a period of many years to death from cardiovas- 

 cular disease or intercurrent infections, or occasionally from the effects 

 of a pituitary tumor. 



The Metabolism in Obesity 



(1) Exogenous Obesity. The basal metabolism has been found 

 normal by all observers. This fact was first demonstrated by Rubner, who 

 measured the gas exchange of a fat boy and his thin brother. The fat 

 boy had a lower metabolism per kilo body weight but when reckoned 

 according to surface area, there was no difference. Means, using the 

 latest methods for reckoning surface area, has come to similar results. 

 In a case of obesity with multiple nodular lipomata, recently studied by 

 the writer, the basal metabolism was normal, and the lipomata were not 

 affected by reduction of the body weight. 



Grafe and Koch report some interesting observations, which show that 

 overnutrition, if excessive, may actually increase the basal rate. Their 

 first case was an emaciated man on whom a gastro-enterostomy had been 

 performed for stenosis of the pylorus. When placed on a high calory diet 

 (up to 98 calories per kilo) the gain in weight was much less than that 

 expected. Metabolism experiments explained this deficiency. The basal 

 rate, recalculated according to the Du Bois height-weight formula, rose 

 from minus ten per cent to plus 27 per cent, and the total heat production 

 increased 80 per cent, though the weight rose only 50 per cent. The in- 

 crease in metabolism after taking food also rose from ten per cent of the 

 caloric intake on a maintenance diet to 30 per cent on a high calory diet, 

 the normal rise being about 14 per cent. Similar results were obtained 

 in the case of 'an asthmatic boy of 14 years who displayed a voracious 

 appetite. This boy showed a marked increase in the metabolic rate when 

 placed on a diet of 100 calories per kilo, but failed to gain weight. 



Similar results were obtained by Grafe and Graham (a) in overfeeding 

 experiments on a dog. 



The authors claim that heavy eaters usually have a higher metabolic 

 rate than light ones, and suggest the possibility that in obesity this assumed 

 normal response to overfeeding may be lacking. 



Attempts have been made to demonstrate lowering of the metabolism 

 in obesity by means of accurate estimations of the caloric value of the 

 food over prolonged periods, but they are not absolutely conclusive, owing 

 to the fact that retention of water may take place to a marked extent, 

 thus masking the loss of fat. For example, Grafe in his third case found 

 the weight constant for 22 days on a diet of 10 calories per kilo, 1000 

 calories in all ; this would ordinarily lead to the conclusion that the metab- 

 olism was much lowered. Examination showed however that the basal 

 metabolism was normal. The loss of body substance was masked by re- 



