158 OBESITY 



of life and occupation must be carefully considered. Moreover, we should 

 ascertain the patient's power of reaction against external influences, especially 

 mountain climbing and other bodily exercise. Hagler requires that obese 

 persons with an apoplectic or a diabetic family predisposition, with irregular 

 pulse, with decided bradycardia, those who live in an improper manner, and 

 those who are addicted to the use of alcohol, should be excluded from life 

 insurance. ISTo absolute norm for a maximal or minimal body-weight exists, 

 but the rules laid down by Hagler are nevertheless noteworthy: "The insur- 

 ance company at Basel is very cautious in its dealing with individuals of less 

 than 340 grams, or more than 530 grams of weight per centimeter of body- 

 height, and such are usually rejected. We have, however, reached the con- 

 clusion that in certain regions, especially among the very large, often giant- 

 sized, land owners and farmers of East Friesland, a higher body-weight is 

 compatible with a normal duration of life." In my professional activity I 

 have come across such persons, and in general may confirm this statement. 

 But however true this may be, the risk of the obese person is to be estimated 

 with caution. Even the enviable stage of obesity I look upon with suspicion, 

 for it happens now and then that, without the ludicrous intervening, the 

 pitiable stage arises, and. this is especially frequent, in my experience, in the 

 cases in which obesity is associated with diabetes mellitus. Primary arthritic 

 gout, even when it runs a severe course, produces, as I have seen, far less dele- 

 terious effects. Frequently the obese are threatened by lesions of the heart 

 and the vascular system. In the heart itself in consequence of fatty deposits 

 dilatation at first develops; sooner or later, when compensation for the dam- 

 age to the cardiac muscle is no longer possible, the symptoms of muscular 

 insufficiency supervene. The vascular disturiances are scarcely dependent 

 upon obesity, but are to be referred to the uric acid diathesis, usually a factor 

 in such cases. The arterial diseases of the obese usually cause effusions of 

 blood into the brain, to which many fat persons succumb. It is of great 

 practical importance in prognosis that persons who suffer from obesity, as is 

 proved by experience, readily succumb to any infectious disease that attacks 

 them. Among other factors which render the prognosis more serious in 

 obesity, I must particularly emphasize the fact that as it progresses it makes 

 the affected individual more and more sedentary, a habit to which the foot 

 affections arising as the result of obesity also -furnish their share. Flat-foot 

 very often develops in the young, particularly in individuals hereditarily pre- 

 disposed to obesity, when the body-weight increases. This usually affects 

 those belonging to the higher classes of society, men as well as women. I 

 should like to add here that I have observed such cases of flat-foot, mostly in 

 those with a gouty predisposition. This is particularly worthy of note because 

 such a deformity of the foot cannot be cured without considering gout as 

 an etiologic factor. A sufficient amount of active muscular exercise is quite 

 impossible on account of the affection of the joints of the foot and the result- 

 ing pain. But if the superfluous fat is removed by suitable dietetic regimen, 

 with the slighter weight the diseased feet will also show a corresponding 

 improvement. 



At this point some remarks on the influence of increasing obesity upon 



