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
viscera _in 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 that such 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's egg; 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, "The disease 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 general _consensus_? 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; and finally 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
these cases, 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
repeated bleedings 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, by means 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, bronchorrhoea, 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.
Pharmacopoeal 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 undue _embonpoint_, 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 and
vegetable 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 the _post mortem_ examinations,
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 a _post mortem_ in 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 passed in 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 oesophagus, 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. The _post mortem_ being
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 always ended
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 the _post mortem_ held 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
of _embonpoint_ we 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 children for 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 and placed 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 months under 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.