Obesity, or Excessive Corpulence: The Various Causes and the Rational Means of Cure

by J.-F. Dancel

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, 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 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 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. 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?