160 OBESITY 



and particularly over the crests of the ilium, great coUops of fat stand out. 

 An enormous size is often attained by the buttocks which are thickly cushioned 

 with fat. These, however, do not appear rounded but assume a somewhat 

 triangular form since the masses of fat hang downward and deviate laterally. 

 Over the fold of the buttocks there is, therefore, a thick, shapeless mass formed 

 by the superficial subcutaneous fatty tissue, which projects considerably beyond 

 the lateral line of the thighs. In other eases the fat accumulates particularly 

 in the sacral and lumbar regions. The remarkably great development at the 

 fold of the buttock continues downward into the upper portion of the thigh, 

 where the subcutaneous fatty tissue shows an increase that is scarcely less con- 

 spicuous. In very corpulent persons the subcutaneous fatty tissue upon the 

 legs also forms prominent tumors. Of course, it is only at the autopsy of the 

 obese that we can recognize the full extent of the enormous masses of fat which 

 pack the internal cavities of the body, the mediastinal fat, the fat upon the 

 pleura, the great accumulations of epicardial fat, the often excessive accu- 

 mulation of fat in the omentum and mesentery, as well in the folds of the 

 synovial membranes, etc. 



J. P. Frank mentions a man observed by Boerhaave who, as the result of 

 over-indulgence in food and drink, became so fat that the abdomen had to be 

 carried in a sling which reached down from the shoulders, and the table at 

 which he was accustomed to sit had to be cut away in a semicircle. His 

 mesentery alone weighed 33 pounds. 



Such fat people are generally looked upon as unsightly. Among the 

 Moors, however, obesity in women is regarded as a great mark of beauty, and 

 among the Kelowi in Central Africa a faultless odalisk must have the weight 

 and circumference of a young camel, a circumference which she attempts to 

 secure by a fattening process carried out with great perseverance. De gustihus 

 non est disputandum ! 



I have already mentioned the conclusions of the Basel Life Insurance 

 Company in regard to the proportion between size and body-weight as a factor 

 in prognosis. In the diagnosis, however, we must determine not only that 

 the individual in question is obese but also the degree of his obesity; we must 

 recognize probable complications and the patient's capacity for work ; we must 

 decide to what extent he is anemic, etc. All these questions miist be accu- 

 rately determined before treatment is begun, and careful examination of the 

 urine must be made in every ease if gross errors are to be avoided. 



TREATMENT 



The treatment by which a patient is freed from his fat is often designated 

 antifat treatment. Of course, the individual is not to be rid of all his fat 

 and reduced to absolute leanness, but he is to have the surplus fat removed. 

 In such an antifat treatment, it must never be forgotten that adipose tissue 

 is a normal constituent of the body, and that its complete absence is not only 

 unbecoming but a decided menace to the health of the person in question. 

 There are people whose occupation necessitates that they be thin and remain 

 so, guarding themselves against the over-accumulation of fat from any cause. 



