SYMPTOMATOLOGY I57 



and consequences is typical of advanced obesity, especially of lipomatosis 

 universalis. 



We have already said that the other general " diseases of protoplasm based 

 on hereditary predisposition" (gout and diabetes mellitus), frequently com- 

 plicate the earlier stages of obesity, the enviable and the ludicrous stages. 

 These unfortunate complications should not be regarded as direct sequela of 

 obesity, but as diseases developed as the result of a pathologic condition of the 

 body cells. The three diseases need not accompany or follow one another, but 

 may arise independently. Hence we must infer that in each of them a sepa- 

 rate abnormality of protoplasm exists. That uratic calculi often occur in 

 the form of obesity which is commonly seen in combination with gout, and 

 that the stones are caused by the gout, has been taught me often enough by 

 my own experience. These stones rarely reach such a size that they cannot 

 be spontaneously voided with the urine. 



Atheromatous degeneration of the arteries, which is not infrequently noted 

 in combination with obesity, I should not so much refer to the obesity as to 

 the often coexisting gout, that is, to the uric acid diathesis. The obese, as a 

 rule, enjoy an excellent appetite. Almost invariably they eat more than nor- 

 mal persons under otherwise similar conditions. Special stress is to be laid 

 upon this in estimating the quantity of food which a corpulent individual 

 consumes. Naturally we must not depend upon his own reports. In my 

 experience obese individuals who are recognized as notorious gourmands, will, 

 if questioned, deny that they consume an immoderate amount of food. They 

 usually only say that their food agrees with them very well. Pat people often 

 have, as I have already pointed out, a tendency to obstinate constipation. 

 Hemorrhoids exist, or at least develop, very often. Upon the basis of the 

 composition of the urine, A. Eobin has difEerentiated two forms of obesity. 

 In the one form there is profuse, in the other very slight, excretion of urea 

 and phosphates. Eobin believes that in the former group obesity is the result 

 of increased, in the latter case of decreased, assimilation. He holds that this 

 division is of great importance, especially in measuring the amount of fluid 

 allowed in the dietetic treatment. That with the previously mentioned com- 

 plications the urine shows corresponding changes, need only be indicated here. 

 In advanced obesity there is usually a tendency to catarrhal conditions, espe- 

 cially of the pharynx and of the bronchial tree. 



Obesity, if left to itself (or improperly treated), and when no conditions 

 arise which produce emaciation — as, for example, severe acute or chronic 

 affections — ^becomes a protracted disease which, as a rule, shows a tendency to 

 progress. Yet I have not infrequently known persons who have become fat 

 in middle age to lose their fat as they grew older without an apparent reason. 

 Usually this is not the case. As regards longevity, obesity is a factor gener- 

 ally considered to shorten life. On this point we are indebted to the life 

 insurance companies for valuable conclusions. Especially worthy of note, 

 it appears to me, is what A. Hagler says in his book " On the Factors of Eesist- 

 ance and the Prognosis of the Duration of Life in Normal Individuals" 

 (Basel, 1896, page 47 et seq.) regarding the prognosis of obesity. All 

 cases are by no means to be judged by the same scale. Age, heredity, manner 



