156 OBESITY 



not give rise to any inconvenience, and so long as the affected individuals 

 maintain good muscular power no attempt should be made to remove or reduce 

 the accumulation of fat. A certain amount of fat is a good reserve fund in 

 time of need, for, not infrequently, even in this stage of corpulence, such 

 unwelcome complications as gout and diabetes mellitus appear. Therefore, in 

 this stage of obesity the condition is not to be combated, but any increase of 

 it must be prevented. 



The conditions are naturally different when the obese individual becomes 

 a ludicrous figure. Such persons suffer from the ridicule of their companions, 

 and form an excellent subject for the gibes of artists and poets. The portly 

 Silenus has already been mentioned. The fat Falstaff, the popular repre- 

 sentative of low comedy, has been glorified and immortalized by no less a one 

 than Shakespeare. Kot equal to bodily exercise on account of their great 

 weight, obese persons in this second stage have difficulty in dragging them- 

 selves along even upon a level, and upon the slightest bodily exertion they not 

 only sweat profusely, but, as a rule, they must soon moderate or altogether give 

 up their exercise on account of dyspnea. So far, however, the dyspnea, though 

 it occurs upon slight bodily movement, is usually still of the "functional" 

 type, i. e., it is not due to irreparable changes of the thoracic organs or to other 

 gross organic lesions. The difficulty in breathing is due rather to dispro- 

 portionate development of the abdominal cavity in which the enormous dis- 

 tention of the intestines by feces and gases due to atony of the bowel plays 

 no insignificant role. Owing to this abdominal distention the thoracic space 

 is decidedly narrowed. The diaphragm is forced up and its free excursion hin- 

 dered, while the thoracic organs suffer a more or less decided compression lim- 

 iting their function. Such obese persons, despite their difficulty in moving, 

 show considerable fondness for all kinds of sport (hunting, horseback riding, 

 etc.), particularly as they hope thereby to regain their health. But their 

 motions and their whole appearance, which has so frequently been described 

 and put into song, are so ludicrous that they provoke laughter. Yet we must 

 not forget that even at this stage the complications and results of the immod- 

 erate accumulation of body fat often become alarming. 



In the THIRD STAGE of obcsity all the severe sequelae develop which make 

 the patient, pitiable, and, in fact, he is commiserated. At this stage we meet 

 especially the symptoms of severe disease of the heart, which I have Just 

 referred to, as a frequent accompaniment of obesity. This gives rise to dysp- 

 nea due to severe anatomical chang-es in the heart, and thus differing from the 

 functional form above described. Besides this, a constant accompaniment of 

 every case of marked obesity is a steadily increasing anemia. Prominent 

 observers have contrasted the anemic form of obesity with a plethoric variety, 

 but appearances are deceptive. I need only mention the obese chlorotics from 

 the country with their very red cheeks. Even if we admit the possibility of 

 plethora vera seu sanguinea (which in fact is a greatly disputed condition), 

 we must specifically deny that any plethora occurs in well-developed obesity. 

 Plethora could only happen in those forms of corpulence which belong to 

 the first stage of the disease, i. e., that in which the muscular system is 

 still in a normal condition. In general, anemia with all of its symptoms 



