CHAPTER III.
The human skin is capable of great extension. It may be distended to four times its size, yet is not endowed with much elasticity. On this account we may notice, in very fat persons, rolls of fat about the neck, back, buttocks, arms and pubis. The epidermis, which constitutes the external layer of the skin, is but slightly capable of extension. When distended beyond a certain point, it tears, and produces those white streaks which are to be seen on the abdomen of pregnant women, or of those who have borne children, and also of those who have laboured under severe dropsical ascites. These white streaks may be formed upon all parts of the body, when the skin is considerably distended: thus they have been seen in a young woman twenty-eight years of age, who weighed three hundred and four pounds. In her case these white streaks were to be seen upon the arms, the shoulders, the breasts, &c.
The skin of the abdomen would not be sufficient to retain the abdominal viscerain situ,were it not that between these organs and the integument there exists a fibrous or muscular layer, in some places double, consisting of a stronger and less extensible tissue than the skin, in order to strengthen the abdominal walls. It sometimes happens that this fleshy layer, having yielded to a certain amount of distension, occasioned by the volume of the intestines, and of their surrounding fat, and being thereby unduly stretched, permits the passing between its fibres of a certain portion of intestine or of fat, which, lying immediately under and pushing the skin before it, constitutes what is termed a hernia. Dropsy or pregnancy are frequently the primary cause of the various descriptions of hernia, termed inguinal, crural, &c. Umbilical hernia is that which is usually produced by a too great development of fatty tissue in the abdomen. The umbilicus is that part of the abdomen which is the least susceptible of dilatation. When the belly becomes enlarged to a moderate extent, the navel becomes depressed, shewing that this part does not easily yield to the pressure from within; but it is supported by the recti muscles, those two bands of fleshy fibres lying immediately beneath the skin, and passing from above downwards, on each side and close to the navel. In extreme development of the abdomen, these muscles are displaced from their normal position near the umbilicus, and no longer lend it support. The fibres of the umbilical ring are thus separated by the pressure exerted by the abdominal fat, and a portion passing through the fibres pushes the skin before it. A small protrusion takes place, which is not yet outwardly apparent, because the remaining fibres of the umbilical ring still afford considerable resistance, and retain the ring concealed in the deep hollow which is observable in the navel of fat persons. In order to determine the existence of umbilical hernia at this early stage, the patient should be placed in the recumbent position. On introducing the little finger into the navel depression, and directing the patient to cough, we feel an impulse against the finger which is not to be felt, under the same circumstances, over any other portion of the abdominal walls.
In some cases of hernia it is not absolutely necessary to place the person in the recumbent position, but in this case it is indispensable: unless we do so the impulse cannot be felt, since it cannot take place in the upright position.
In the year 1851, a lady consulted me. She was then very fat, and the abdomen was greatly enlarged. I said to her, "You have probably umbilical hernia." "I have long feared thatsuch was the case," she replied, "but happily I have not. Only a few days ago my own physician examined me, and he declared that I had not. He has advised me to wear an abdominal supporter." Noticing her great enlargement, I was not satisfied of the non-existence of hernia. I begged to be allowed an examination. Having obtained her consent, I immediately detected, by the means I have previously pointed out, a small hernia in the depth of the navel cavity. She had great confidence in her own physician, and told me positively that I was mistaken. I recommended her to see her own physician, and to be examined again by him in the same manner as I had examined her. There was no doubt in my mind but that he would detect it, and such was the case; but he said that it had occurred since his previous examination: possibly so. An umbilical truss was immediately adapted; for it is only in hernia at its early stage that we can hope for a cure by means of a truss, and by removing the cause, that is to say, by reducing the mass of fat existing in the abdomen.
If the development of a small hernia is not prevented, it gradually increases, and makes its appearance upon the walls of the abdomen. At first it is of the size of a small pear, a hen'segg; afterwards it increases to six, eight, ten, fifteen or twenty pounds weight. It then assumes more or less the shape of a mushroom, which is exceedingly troublesome, as it requires to be supported by means of a hollow truss, a species of box with springs. Umbilical hernia is to be met in more than one half the number of persons who measure fifty-five inches round the abdomen.
Such is the progress of medical science, that the following ideas as to the diseases which may be engendered by excessive corpulence, would have been deemed, twenty-five years ago, unworthy of a doctor of medicine: a hundred and fifty years ago they would have obtained the applause of the physicians of those days. At the present time I foresee—I am indeed sure, that the medical profession will acknowledge these same ideas to be founded upon reason and observation, two indispensable requisites in all that concerns the healing art.
When the system of medicine founded by Borelli was in vogue, called the "Iatro Mathematical," it would certainly have been acknowledged that a superabundance of fat, when developed in the human body, could interfere with the vital organs in the performance of their functions, and thus be the cause of much disturbance and of many diseases.But this would no longer have been admitted, when Broussais, the distinguished author of "Chronic Phlegmasia," in our own day, in harsh and severe language, and with an air of conviction, loudly proclaimed that all disease resulted from local irritation, whence it was irradiated throughout the organism, as in the case when a sharp instrument pierces the flesh. This theory was the very opposite to the teachings of the majority of medical men of a previous age, who maintained that local disease resulted from a general disturbance of the whole system.
Thus, if the stomach were affected, Broussais called the disease a gastritis (or inflammation of the stomach), which might induce disturbance of the system at large; while many of the old school would have said that if the stomach were especially diseased, it was because nature chose that channel in order to eliminate from the body the morbid principle which in the outset had attacked the entire system.
It belongs not to the subject on hand to endeavour to signalize all the errors of the old school, nor to set forth what truth there may be in the system; but I would ask one simple question. It has happened to every medical practitioner to be called in to see a person recently taken ill, and that he has said, "Thedisease is not yet well characterized; by-and-bye, or to-morrow, I shall be able to form an opinion, and say what the disease is." But until this "by-and-bye," until this "to-morrow," what happens to the patient? for it is evident that there is sickness, a general ailment. And when one particular portion of the body, an organ, is principally affected, when the disease has there manifested itself, as we say, shall we be far wrong in saying that it is a kind of crisis? It would be just what happens, only more evidently, in those fevers which terminate in a critical abscess.
Nor is it advisable that I should speak of the founder of physiological medicine. His vast labours are the result of great genius, and have long influenced the medical world with all the weight of a master mind. Having been his pupil for many years, I shall never cease to admire his life of scientific labour. Nevertheless, I cannot refrain from remarking how much he has done to lessen the spirit of medical enquiry. By localizing all diseases, and by his system of irritation, without taking into account the constitution as a whole, how greatly is the labour of the physician reduced! how little knowledge is necessary on his part to be deemed worthy of the title of Doctor of Medicine! Once upon the highway of localization, once engaged in this contracted study, there is no stop. It is no longer necessary to be acquainted with all the organs, both in a state of health and of disease; the extent of territory to be explored is reduced. The fashion at the present day is, that a physician of this school should know only how to treat the diseases of one particular organ, and rarely of two; that he should be, in fact, a specialist. But are not the principal organs of the body, for the most part, mutually dependent on each other, and all of them subject to a generalconsensus? What is the consequence of this medical specialism? Why, that every physician so engaged thinks, and most conscientiously, that the patient before him labours under that particular disease to which he particularly devotes his attention. This is perfectly natural. The mind of man is so formed, that it is narrowed, and loses its powers of comparison and of judgment, whenever it is concentrated and brought to bear solely upon one subject, one single object. Man is no longer capable of reasoning upon a science or an art, when he puts it out of sight as a whole, in order to devote himself entirely to one of its parts; but ends by making the subject of his study the principal point, the all-important one, whence flow, in his opinion, all the rest; andfinally assumes that a part is equal to the whole. When a patient complains of palpitation of the heart, he prescribes a bleeding, leeches, digitalis. If another complain of sense of weight or oppression, bleedings, softening syrups, troches, &c., are prescribed. If another complain of headache, dizziness, with threatening apoplexy, he is bled.
Everything is treated locally, without inquiring whether the evil be or be not the effect of some general cause.
Among a vast number of general causes, giving rise to disease, I purpose to treat of one, and that is excessive corpulence, termed obesity. In our recent medical works, no reference is made to this morbid predisposition, in regard to the diseases occasioned by it. I do not mean to say that superabundance of fat is the cause of all the ills that flesh is heir to; but I am persuaded and do affirm that it is often the primary cause of many diseases.
Thus, in cases of headache, there are assuredly many which are produced by superabundance of fat, because they commenced when that superabundance began to appear, and ceased on its being diminished. Frequent headache, becoming periodic, is constantly met with in fat people. Nothing is more common among such persons than dizziness. In thesecases, are not the blood-vessels oppressed with fat interfering with a free circulation of the blood, and is not fat therefore the cause of all these troubles?
But it may be said that the blood produces these affections, since, after loss of blood, the patients are relieved. I do not agree with this, and I say that the blood is not in such cases the cause of these ailments; because fat people, both men and women, have no more blood than thin persons: I maintain that they have even less. It is granted that loss of blood in cases of headache, vertigo, alleviate and even cure these affections; but only for a time; for eight days, or a month or two at the most, and then gradually reappear, and bleeding is again required.
This amelioration, these momentary cures, produced by blood-letting, are to be explained in such cases by saying that the quantity of blood, although not so great in fat as in thin people, is impeded in its circulation, and that loss of blood, by still further diminishing the quantity, facilitates for a while its passage through the blood-vessels.
This method is consequently only palliative; it does not attack the root of the evil. Bleeding takes away blood which is troublesome only in consequence of the excess of fat; for every physician is aware that repeatedbleedings tend to the development of fat in an extraordinary degree. Fat people insist upon being bled at more frequently recurring periods, because their corpulence continues to increase, and headaches and dizziness become more frequent. The seemingly useful remedy increases the cause of the trouble.
Notwithstanding the temporary relief, and apparent cure, corpulence finally produces such a disturbance of the brain, or of some other vital organ, as suddenly to produce death in the course of an hour or two, with every appearance of excess of health. Usually an attack of serous or sanguineous apoplexy is the cause of death in persons labouring under excessive corpulence.
It is an important fact, and one which I have noticed throughout twenty-five years of medical practice, that wherever I have been called to a case of apoplexy occurring in a fat person, death has ensued in spite of every care both on my part and of the other physicians summoned together with myself to attend the case. Bleedings, repeated three or four times in the course of twenty-four hours, leeches applied to the temples, mustard poultices, blisters—everything has failed to prevent a fatal termination. On the other hand, I can flatter myself that I have successfully treated, bymeans of bleeding, leeching, &c., persons of a spare habit of body, when seized with apoplexy, some having made a perfect recovery, and others retaining only a partial paralysis. I am persuaded that physicians, if they will reflect upon the results of their practice, will acknowledge that this is their experience also. In these cases an excess of fat is prejudicial, therefore, to life. The existence of an apoplectic tendency in certain persons is admitted by all physicians, that is, in the corpulent, with a short neck. Fat plays a most important part in such a constitution. Many persons have naturally a short bony framework of the neck; but these persons, on becoming fat, have scarcely any neck; and those in whom the neck is naturally long, on the supervention of fat about the shoulders, chest, and lower portion of the face, become short-necked. The much-dreaded predisposition to apoplexy is consequent upon the development of fat. It will be seen, on reading the remarks upon the cure of obesity, that in those cases where there has been a reduction in the amount of fat, this tendency to apoplexy and cerebral disturbance has disappeared.
Asthma, bronchitis, bronchorrhœa, pulmonary catarrh, in fat persons, both male and female, do they terminate favourably? If so,it is only for a while, to return, again to disappear, and finally to remain permanently, with a more or less constant cough, expectoration and oppression. In such cases, permanent cure becomes impossible, unless assisted by a reduction of fat. How are these phenomena to be explained? Some physicians will say that the lungs, being oppressed, and their movements constrained by neighbouring parts, and by the abdominal viscera, become obnoxious to inflammation; while others will maintain that these bronchial and pulmonary affections of fat people, are due to an afflux of humours to the part. Explain the presence of these affections in either way, I am persuaded that a reduced corpulency will be favourable to the restoration of health. The cases which I shall hereafter adduce will sustain my views. Let us enquire into the cause of those frequent palpitations and dull pains in the region of the heart so common in persons of excessive corpulency. Pharmacopœal remedies are for the most part unavailing in these cases. We shall find, further on, in our cases of recovery, that they have disappeared simultaneously with the undueembonpoint, a proof that they frequently arise from obstruction to the motion of the heart. The fat which overloads it and the neighbouring viscera, occupies too large a portion of the space necessary for the free execution of the heart's movements, and hence the spasms, sense of oppression, &c.
The fatty liver is well known to be a liver containing in its substance more than the normal amount of fat; a morbid condition intentionally induced in certain animals for the purpose of gain. In man the liver often becomes surcharged with fat, giving rise to obstruction of the liver. The term, obstruction, conveys an idea of the disease arising from this cause. The liver secretes bile, which, in order to reach the duodenum, flows through a small duct. If this duct be compressed, the flow of bile is impeded, and the result is uneasiness and disease. The liver is traversed by a vast number of arteries and veins, through which, in a condition of health, the blood finds a ready passage. If, however, an undue development of fat should take place in the tissue of the liver, these vessels become compressed. The inferior vena cava receives all the blood emerging from the liver, and conveys it to the right side of the heart, thence to be sent to the lungs, to undergo that aëration which, by changing it from venous to arterial blood, renders it fit for the nourishment of the various parts of the body. Any obstruction to the circulation through the liver must necessarily give rise to the most serious consequences; for the blood which it contains is in no wise fitted for nutrition.
In case of obstruction to the circulation through this organ there may arise swelling of the legs, thighs and of the abdomen. It is one of the recognized causes of abdominal dropsy,ascites; of dropsy of the lower extremities,anasarca. Hence arise those frequent swellings of the legs, with their attendant incurable ulcers, so often met with in fat people. And when we reflect that the venous circulation is carried on by means of a vital power which has to overcome the force of gravity, causing the blood to flow from below upwards, from the feet towards the heart, we can readily understand how easily any slight obstruction in the liver may give rise to serious consequences, while on the other hand it will be manifest, that the liver being freed from its excess of fat, the venous circulation will be re-established, and those troublesome affections alluded to, therewith got rid of.
However, every medical man does not see, or is not willing to see matters in this light. Many will insist that this hepatic obstruction is a chronic hepatitis, or chronic inflammation of the liver, which is to be subdued by the lancet, leeches, blue pill, Vichy water andvegetable diet. And what becomes of the patient? I know I shall always remember a circumstance which occurred in 1829. I was at that time a surgeon attached to the military hospital of the Val-de-Grâce, where Broussais, the illustrious founder of physiological medicine, was head physician. It was my duty to make thepost mortemexaminations, to record the several abnormal conditions found to exist, and which had been the cause of death. Upon one occasion, while thus engaged, Broussais entered the amphitheatre, saying, "Bring your instruments with you, we are going to hold apost mortemin the city." We went to the house. A statement was required to be put on record as to the organic lesions which had produced death in the case of a young woman, about 25 or 26 years of age, belonging to a wealthy and noble family. It was of importance to have such a document, because the mother of this young woman had died at an early age, and the family wished to be able to prove in a court of law that death had not occurred in consequence of any hereditary disease. Broussais and I entered the room where lay the body of the deceased. We met there two of the professors of the Faculty of Paris, another physician, and the usual medical attendant of the family. A few words passedin reference to the previous ailments of the deceased. The family physician, a young man imbued with the principles of Broussais, told us that he had been in attendance upon the deceased lady about a year before, for a disease other than that which had caused her death; that he had cured her by means of bleedings and leeches, and that after her recovery she had enjoyed the advantages of sea bathing; that in the illness which had just terminated fatally, he had made use of bleedings and an antiphlogistic regimen. The body of the deceased being removed from the bed and placed upon a table was remarkable for its excessive development of fat. The head having been opened, the brain was submitted to inspection and acknowledged to be healthy; and the same of the tongue, the œsophagus, the larynx, the bronchi, the lungs, the heart, the spleen, the kidneys, the bladder: the womb was somewhat engorged, and larger, heavier than normal, but without any trace of inflammation. All the principal joints were opened and found healthy; likewise glands, arteries, veins and lymphatics. The alimentary canal was carefully examined throughout, without discovering any organic lesion in the stomach or large intestine. A few reddish brown spots were, however, to be seen in the small intestine.Broussais upon this pronounced death to have been caused by enteritis. Several of the medical men, on the other hand, were unwilling to admit that these reddish brown spots could have caused death. The liver was then examined. On separating one of the lobes a layer of grease was left on the blade of the knife, as is the case always in cutting into a fatty liver, but which phenomenon is never manifested in the case of a healthy liver. Those gentlemen who had demurred to the reddish brown spots as being the cause of death were of opinion that the fatty liver, or which is the same thing, the obstruction to the hepatic circulation had produced death. Broussais could not agree with this opinion, but dwelt upon the importance of the testimony revealed by the reddish brown spots, and a warm discussion ensued. Thepost mortembeing over, I returned to the hospital, leaving these gentlemen in the midst of a discussion as to how the medico-legal statement accounting for the death should be drawn up. At this time I was scarcely able to arrive at a satisfactory conclusion, although I had already spent several years in the hospital as assistant to M. Fouquier, and had frequently listened to the teachings of Broussais, which explained all diseases as due to irritation dependent upon organic lesion; and alwaysended by shewing that the only rational treatment for every morbid affection consisted in blood-letting, leeching and low diet. It may be mentioned as somewhat remarkable that at thepost mortemheld upon the corpse of Broussais, no organic lesion sufficient to account for death was discoverable. In his own person, the greatest possible contradiction to his theory was thus presented. Since that time my attention has been particularly directed to this subject. In my own practice I have constantly observed that when any obstruction occurs in the liver no progress is ever made towards the cure of diseases arising from this cause, until the obstruction is overcome, and if not overcome, that death supervenes; and the cause of this death is to be found only in the liver, as in the case of the lady just mentioned. One of the earliest signs of obstruction of the liver, is swelling of the legs and ankles, appearing at first only towards evening, and not to be noticed on the following morning, but again appearing during the day. It disappears during the night, because the horizontal position favours the circulation in the lower extremities. In this position fluids have not to contend with the laws of gravity. It is highly important that this evil should be at once remedied. The treatment for the reduction ofembonpointwe shall find to be infallible in such cases.
It is indubitable that almost all fat women labour under some uterine affection. Some are troubled with engorgement of the organ, with a continual sensation of weight, and a dragging of the sides and back. Others suffer from falling of the womb and displacement. These disorders are frequently attended with granulations of the neck of the womb, menorrhagia, leucorrhea, &c. Pessaries were formerly the usual remedies in such cases, but latterly it has been well understood that in fat women these conditions are due to the fact that the womb, a body floating within the abdomen is depressed, displaced by the large mass of fat collected about the intestines. In order to prevent this intestinal mass of fat from pressing upon the womb, abdominal supporters have been contrived; but this intestinal mass cannot be so lifted as to set the uterus free, without making pressure upon the stomach and lungs, and so giving rise to a sense of oppression and suffocation; and even should such means afford some relief, it would prove but temporary: the cause of the trouble would be still persistent. In order to effect the replacement of the uterus, the mass of fat must be got rid of.
It is a well established fact that many fat persons are troubled with skin diseases, which resist every treatment, and a cure is effected only when, from some cause or other, the person has become thin. Would it be wrong to say that in such cases the disease of the skin is due to its over distension by fat, causing a partial stagnation of venous blood and serous fluid?
Among female patients who consult me in reference to their obesity, many complain of a general sense of uneasiness, with frequent pains in the stomach, kidneys, headache, &c., asserting that their excess of fat came on after a confinement and when they had not suckled the infant, and thence infer that their obesity is owing to a decomposition of milk within the system. I am not aware that this explanation has ever been accepted, yet I do not understand why it should not be received as valid, since it is well known that any deteriorated secretion may be absorbed and prove noxious to the general system. Pus from an inflamed vein may be thus re-absorbed, and the patient under such circumstances almost invariably dies. Why may not the secreted milk be likewise re-absorbed? I have met with many fat women from whose breasts milk constantly flowed, although they had not borne childrenfor the last ten years. A lady who has followed my method of treatment for obesity, says that she is certain that her excessive fat arose from her not suckling her last child, and that her milk turned into fat. She has had no children for the last eight years, and whenever she takes a child in her arms a peculiar feeling causes an abundant flow of milk from her breasts, which has all the properties of the healthy secretion.
It is now well understood that corpulency is the true cause of many diseases, yet it would be folly to assign obesity as a cause of every disease. To do so would be to detract from the value of the anti-obesic treatment. I feel called upon, however, to relate the following account given by one of my patients, the correctness of which was vouched for by several of her acquaintances. She had been subject for many years to a nervous affection, the attacks of which were so severe that she fell to the ground, foamed at the mouth and clenched her hands, but did not lose consciousness during the fit, which usually lasted from ten minutes to a quarter of an hour. Such are the symptoms of hysteria. Two years ago this lady went to the baths at Aix-la-Chapelle, where she heard of the anti-obesic treatment. Being very strong, she came to Paris andplaced herself for two or three months under my care. She had had several fits at Aix. I do not know whether she had any during the the first few days after her arrival in Paris, but at the end of a month she told me she had been perfectly free from them, and trusted that this change was due to my treatment. Such has really been the case; for since this lady has lost her corpulence, she has been free from hysterical seizure. I am aware that many thin women are hysterical. When, however, this disease is met with in a corpulent person, and that it disappears under the anti-obesic treatment, the cure may perhaps be fairly assigned to the treatment. Excessive corpulence is the cause of many affections which are often with difficulty characterized by physicians. The superintendent of a large manufactory at Belleville received a severe blow upon the left side, several years ago. Latterly he has become very corpulent, subject to dizziness and headache; moreover the left leg is swollen, and he suffers pain in the side which had been bruised. Professor Cloquet first recommended bleedings, then leeches, afterwards frictions and plaisters. The patient at length, wearied with the aggravation rather than the amelioration of his ailings, came to consult me in the month of April, 1853. In the course of two monthsunder my treatment he has lost his excessive corpulence, is free from pain in the side, his leg is no longer swollen; he is active, and has now no fear of being obliged to give up his business. This is another instance of disease due to obesity.
After reading the preceding remarks, some astonishment must be felt that medical writers have paid so little attention to the subject of corpulence. It has been said not to constitute a disease: that it is a normal condition: that it is a condition intermediate between health and disease: that a fat person is predisposed to disease.
For my part I cannot comprehend a condition between health and disease, with corpulence; and if such do exist it is attended with those infirmities and serious inconveniences already mentioned. Predisposition to disease and morbid tendency are, in the case of persons labouring under obesity, the precursors of serous or sanguineous apoplexy, obstructions, &c.
In fine, obesity is not always a disease, because it does not always cause suffering; but it ought, nevertheless, not to be neglected, because life cannot be of long duration under such circumstances, and may terminate suddenly at any moment.
In the midst of the various duties of a medical career, I flatter myself that I have not fallen into an error, too frequent with medical men, that of referring all diseases to one single cause. Suspicion may arise that I have fallen into such an error, because I speak here only of those diseases consequent upon excessive corpulence; but I pray the reader to remember that a vast number of diseases exist which are altogether independent and foreign to obesity. It was, however, necessary that I should point out those morbid phenomena which are due to an excessive development of fat in the system.