Chapter 2. Gain Or Loss Of Weight Clinically Considered

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_ CHAPTER II. GAIN OR LOSS OF WEIGHT CLINICALLY CONSIDERED

The gentlemen who have done me the honor to follow my clinical service at the State Infirmary for Diseases of the Nervous System[2] are well aware how much care is there given to learn whether or not the patient is losing or has lost flesh, is by habit thin or fat. This question is one of the utmost moment in every point of view, and deserves a larger share of attention than it receives. In this hospital it is the custom to weigh our cases when they enter and at intervals. The mere loss of fat is probably of small moment in itself when the amount of restorative food is sufficient for every-day expenditure, and when the organs are in condition to keep up the supply of fat which we not only require for constant use but probably need to change continually. The steady or rapid lessening of the deposits of hydro-carbons stored away in the areolae of the tissues is of importance, as indicating their excessive use or a failure of supply; and when either condition is to be suspected it becomes our duty to learn the reasons for this striking symptom. Loss of flesh has also a collateral value of great import, because it is almost an invariable rule that rapid thinning is accompanied soon or late with more or less anaemia, and it is uncommon to see a person steadily gaining fat after any pathological reduction of weight without a corresponding gain in amount and quality of blood. We too rarely reflect that the blood thins with the decrease of the tissues and enriches as they increase.

[Footnote 2: The Pennsylvania Orthopaedic Hospital and Infirmary for Diseases of the Nervous System.]

Before entering into this question further, I shall ask attention to some points connected with the normal fat of the human body; and, taking for granted, here and elsewhere, that my readers are well enough aware of the physiological value and uses of the adipose tissues, I shall continue to look at the matter chiefly from a clinical point of view.

When in any individual the weight varies rapidly or slowly, it is nearly always due, for the most part, to a change in the amount of adipose tissue stored away in the meshes of the areolar tissue. Almost any grave change for the worse in health is at once betrayed in most people by a diminution of fat, and this is readily seen in the altered forms of the face, which, because it is the always visible and in outline the most irregular part of the body, shows first and most plainly the loss or gain of tissue. Fatty matter is therefore that constituent of the body which goes and comes most easily. Why there is in nearly every one a normal limit to its accumulation we cannot say, nor yet why this limit should vary as life goes on. Even in health the weight of men, and still more of women, is by no means constant, but, as a rule, when we are holding our own with that share of stored-up fat which belongs to the individual we are usually in a condition of nutritive prosperity, and when after any strain or trial which has lessened weight we are slowly repairing mischief and laying by fat we are equally in a state of health. The loss of fat which is not due to change of diet or to exercise, especially its rapid or steady loss, nearly always goes along with conditions which impoverish the blood, and, on the other hand, the gain of fat up to a certain point seems to go hand in hand with a rise in all other essentials of health, and notably with an improvement in the color and amount of the red corpuscles.

The quantity of fat which is healthy for the individual varies with the sex, the climate, the habits, the season, the time of life, the race, and the breed. Quetelet[3] has shown that before puberty the weight of the male is for equal ages above that of the female, but that towards puberty the proportional weight of the female, due chiefly to gain in fat, increases, so that at twelve the two sexes are alike in this respect. During the child-bearing time there is an absolute lessening on the part of the female, but after this time the weight of the woman increases, and the maximum is attained at about the age of fifty.

[Footnote 3: Sur l'Homme, p. 47, et seq.]

Dr. Henry I. Bowditch[4] reaches somewhat similar conclusions, and shows from much more numerous measurements of Boston children that growing boys are heavier in proportion to their height than girls until they reach fifty-eight inches, which is attained about the fourteenth year. Then the girl passes the boy in weight, which Dr. Bowditch thinks is due to the accumulation of adipose tissue at puberty. After two or three years more the male again acquires and retains superiority in weight and height.

[Footnote 4: Growth of Children, p. 31.]

Yet as life advances there are peculiarities which belong to individuals and to families. One group thins as life goes on past forty; another group as surely takes on flesh; and the same traits are often inherited, and are to be regarded when the question of fattening becomes of clinical or diagnostic moment. Men, as a rule, preserve their nutritive status more equably than women. Every physician must have been struck with this. In fact, many women lose or acquire large amounts of adipose matter without any corresponding loss or gain in vigor, and this fact perhaps is related in some way to the enormous outside demands made by their peculiar physiological processes. Such gain in weight is a common accompaniment of child-bearing, while nursing in some women involves considerable gain in flesh, and in a larger number enormous falling away, and its cessation as speedy a renewal of fat. I have also found that in many women who are not perfectly well there is a notable loss of weight at every menstrual period, and a marked gain between these times.

I was disappointed not to find this matter dealt with fully in Mrs. Jacobi's able essay on menstruation, nor can I discover elsewhere any observations in regard to loss or gain of weight at menstrual periods in the healthy woman.

How much influence the seasons have, is not as yet well understood, but in our own climate, with its great extremes, there are some interesting facts in this connection. The upper classes are with us in summer placed in the best conditions for increase in flesh, not only because it is their season of least work, mental and physical, but also because they are then for the most part living in the country under circumstances favorable to appetite, to exercise, and to freedom from care. Owing to these fortunate facts, members of the class in question are apt to gain weight in summer, although many such persons, as I know, follow the more general rule and lose weight. But if we deal with the mass of men who are hard worked, physically, and unable to leave the towns, we shall probably find that they nearly always lose weight in hot weather. Some support is given to this idea by the following very curious facts. Very many years ago I was engaged for certain purposes in determining the weight, height, and girth of all the members of our city police force. The examination was made in April and repeated in the beginning of October. Every care was taken to avoid errors, but to my surprise I found that a large majority of the men had lost weight during the summer. The sum total of loss was enormous. As I have mislaid some of the sheets, I am unable to give it accurately, but I found that three out of every five had lessened in weight. It would be interesting to know if such a change occurs in convicts confined in penitentiaries.

I am acquainted with some persons who lose weight in winter, and with more who fail in flesh in the spring, which is our season of greatest depression in health,--the season when with us choreas are apt to originate[5] or to recur, and when habitual epileptic fits become more frequent in such as are the victims of that disease.

[Footnote 5: See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci., 1876. Also Lectures on Diseases of the Nervous System, especially in Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven hundred and seventeen cases of chorea as to the months of onset (Trans. Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).]

Climate has a good deal to do with a tendency to take on fat, and I think the first thing which strikes an American in England is the number of inordinately fat middle-aged people, and especially of fat women.

This excess of flesh we usually associate in idea with slothfulness, but English women exercise more than ours, and live in a land where few days forbid it, so that probably such a tendency to obesity is due chiefly to climatic causes. To these latter also we may no doubt ascribe the habits of the English as to food. They are larger feeders than we, and both sexes consume strong beer in a manner which would in this country be destructive of health. These habits aid, I suspect, in producing the more general fatness in middle and later life, and those enormous occasional growths which so amaze an American when first he sets foot in London. But, whatever be the cause, it is probable that members of the prosperous classes of English, over forty, would outweigh the average American of equal height of that period, and this must make, I should think, some difference in their relative liability to certain forms of disease, because the overweight of our trans-Atlantic cousins is plainly due to excess of fat.

I have sought in vain for English tables giving the weight of men and women of various heights at like ages. The material for such a study of men in America is given in Gould's researches published by the United States Sanitary Commission, and in Baxter's admirable report,[6] but is lacking for women. A comparison of these points as between English and Americans of both sexes would be of great interest.

[Footnote 6: Statistics (Anthropological) Surgeon-General's Bureau--1875.]

I doubt whether in this country as notable a growth in bulk as multitudes of English attain would be either healthy or desirable in point of comfort, owing to the distress which stout people feel in our hot summer weather. Certainly "Banting" is with us a rarely-needed process, and, as a rule, we have much more frequent occasion to fatten than to thin our patients. The climatic peculiarities which have changed our voices, sharpened our features, and made small the American hand and foot, have also made us, in middle and advanced life, a thinner and more sallow race, and, possibly, adapted us better to the region in which we live. The same changes in form are in like manner showing themselves in the English race in Australia.[7]

[Footnote 7: This excess of corpulence in the English is attained chiefly after forty, as I have said. The average American is taller than the average Englishman, and is fully as well built in proportion to his height, as Gould has shown. The child of either sex in New England is both taller and heavier than the English child of corresponding class and age, as Dr. H.I. Bowditch has lately made clear; while the English of the manufacturing and agricultural classes are miserably inferior to the members of a similar class in America.]

Some gain in flesh as life goes on is a frequent thing here as elsewhere, and usually has no unwholesome meaning. Occasionally we see people past the age of sixty suddenly taking on fat and becoming at once unwieldy and feeble, the fat collecting in masses about the belly and around the joints. Such an increase is sometimes accompanied with fatty degeneration of the heart and muscles, and with a certain watery flabbiness in the limbs, which, however, do not pit on pressure.

Alcoholism also gives rise in some people to a vast increase of adipose tissue, and the sodden, unwholesome fatness of the hard drinker is a sufficiently well known and unpleasant spectacle. The overgrowth of inert people who do not exercise enough to use up a healthy amount of overfed tissues is common enough as an individual peculiarity, but there are also two other conditions in which fat is apt to be accumulated to an uncomfortable extent. Thus, in some cases of hysteria where the patient lies abed owing to her belief that she is unable to move about, she is apt in time to become enormously stout. This seems to me also to be favored by the large use of morphia to which such women are prone, so that I should say that long rest, the hysterical constitution, and the accompanying resort to morphia make up a group of conditions highly favorable to increase of fat.

Lastly, there is the class of fat anaemic people, usually women. This double peculiarity is rather uncommon, but, as the mass of thin-blooded persons are as a rule thin or losing flesh, there must be something unusual in that anaemia which goes with gain in flesh.

Bauer[8] thinks that lessened number of blood-corpuscles gives rise to storing of fat, owing to lessened tissue-combustion. At all events, the absorption of oxygen diminishes after bleeding, and it used to be well known that some people grew fat when bled at intervals. Also, it is said that cattle-breeders in some localities--certainly not in this country--bleed their cattle to cause increase of fat in the tissues, or of fat secreted as butter in the milk. These explanations aid us but little to comprehend what, after all, is only met with in certain persons, and must therefore involve conditions not common to every one who is anaemic. Meanwhile, the group of fat anaemics is of the utmost clinical interest, as I shall by and by point out more distinctly.

[Footnote 8: Zeitschrift fuer Biol., 1872. Phila. Med. Times, vol. iii., page 115.]

There is a popular idea, which has probably passed from the agriculturist into the common mind of the community, to the effect that human fat varies,--that some fat is wholesome and some unwholesome, that there are good fats and bad fats. I remember well an old nurse who assured me when I was a student that "some fats is fast and some is fickle, but cod-oil fat is easy squandered."

There are more facts in favor of some such idea than I have place for, but as yet we have no distinct chemical knowledge as to whether the fats put on under alcohol or morphia, or rapidly by the use of oils, or pathologically in fatty degenerations, or in anaemia, vary in their constituents. It is not at all unlikely that such is the case, and that, for example, the fat of an obese anaemic person may differ from that of a fat and florid person. The flabby, relaxed state of many fat people is possibly due not alone to peculiarities of the fat, but also to want of tone and tension in the areolar tissues, which, from all that we now know of them, may be capable of undergoing changes as marked as those of muscles.

That, however, animals may take on fat which varies in character is well known to breeders of cattle. "The art of breeding and feeding stock," says Dr. Letheby,[9] "is to overcome excessive tendency to accumulation of either surface fat or visceral fat, and at the same time to produce a fat which will not melt or boil away in cooking. Oily foods have a tendency to make soft fats which will not bear cooking." Such differences are also seen between English and American bacon, the former being much more solid; and we know, also, that the fat of different animals varies remarkably, and that some, as the fat of hay-fed horses, is readily worked off. Such facts as these may reasonably be held to sustain the popular creed as to there being bad fats and good fats, and they teach us the lesson that in man, as in animals, there may be a difference in the value of the fats we acquire, according as they are gained by one means or by another.

[Footnote 9: Letheby on Food, pp. 39, 40, 41.]

The recent researches of L. Langer have certainly shown that the fatty tissues of man vary at different ages, in the proportion of the fatty acids they contain.

I have had occasion, of late years, to watch with interest the process of somewhat rapid but quite wholesome gain in flesh in persons subjected to the treatment which I shall by and by describe. Most of these persons were treated by massage, and I have been accustomed to question the masseur or masseuse as to the manner in which the change takes place. Usually it is first seen in the face and neck, then it is noticed in the back and flanks, next in the belly, and finally in the limbs, the legs coming last in the order of gain, and sometimes remaining comparatively thin long after other parts have made remarkable and visible gain. These observations have been checked by careful measurements, so that I am sure of their correctness for people who fatten while at rest in bed. The order of increase might be different in people who fatten while afoot.

Facts of this nature suggest that the putting on of fat must be due to very generalized conditions, and be less under the control of local causes than is the nutrition of muscles, for, while it is true that in wasting from nerve-lesions the muscular and fatty tissues alike lessen, it is possible to cause by exercise rapid increase in the bulk of muscle in a limb or a part of a limb, but not in any way to cause direct and limited local increment of fat.

Looking back over the whole subject, it will be well for the physician to remember that increase of fat, to be a wholesome condition, should be accompanied by gain in quantity and quality of blood, and that while increase of flesh after illness is desirable, and a good test of successful recovery, it should always go along with improvement in color. Obesity with thin blood is one of the most unmanageable conditions I know of.

The exact relations of fatty tissue to the states of health are not as yet well understood; but, since on great exertion or prolonged mental or moral strain or in low fevers we lose fat rapidly, it may be taken for granted that each individual should possess a certain surplus of this readily-lost material. It is the one portion of our body which comes and goes in large amount. Even thin people have it in some quantity always ready, and, despite the fluctuations, every one has a standard share, which varies at different times of life. The mechanism which limits the storing away of an excess is almost unknown, and we are only aware that some foods and lack of exertion favor growth in fat, while action and lessened diet diminish it; but also we know that while any one can be made to lose weight, there are some persons who cannot be made to gain a pound by any possible device, so that in this, as in other things, to spend is easier than to get; although it is clear that the very thin must certainly live, so to speak, from hand to mouth, and have little for emergencies. Whether fat people possess greater power of resistance as against the fatal wasting of certain maladies or not, does not seem to be known, and I fancy that the popular medical belief is rather opposed to a belief in the vital endurance of those who are unusually fat.

That I am not pushing too far this idea of the indicative value of gain of weight may be further seen in persons who suffer from some incurable chronic malady, but who are in other respects well. The relief from their disease, even if temporary, is apt to be signalled by abrupt gain in weight. A remarkable illustration is to be found in those who suffer periodically from severe pain. Cessation of these attacks for a time is sure to result in the putting on of flesh. The case of Captain Catlin[10] is a good example. Owing to an accident of war, he lost a leg, and ever since has had severe neuralgic pain referred to the lost leg. These attacks depend almost altogether on storms. In years of fewest storms they are least numerous, and the bodily weight, which is never insufficient, rises. With their increase it lowers to a certain amount, beneath which it does not fall. His weight is, therefore, indirectly dependent upon the number of storms to the influence of which he is exposed.

[Footnote 10: Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883; Phil. Med. News, April, 1883.]

At present, however, we have to do most largely with the means of attaining that moderate share of stored-away fat which seems to indicate a state of nutritive prosperity and to be essential to those physical needs, such as protection and padding, which fat subserves, no less than to its aesthetic value, as rounding the curves of the human form.

The study of the amount of the different forms of diet which is needed by people at rest, and by those who are active, is valuable only to enable us to construct dietaries with care for masses of men and where economy is an object. In dealing with cases such as I shall describe, it is needful usually to give and to have digested a surplus of food, so that we are more concerned now to know the forms of food which thin or fatten, and the means which aid us to digest temporarily an excess.

As to quantity, it suffices to say that while by lessening food we may easily and surely make people lose weight, we cannot be sure to fatten by merely increasing the amount of food given; something more is wanted in the way of digestives or tonics to enable the patient to prepare and appropriate what is given, and but too often we fail miserably in all our means of giving capacity to assimilate food. As I have said before, and wish to repeat, to gain in fat is, in the feeble, nearly always to gain in blood; and I hope to point out in these pages some of the means by which these ends can be attained.

_Note_.--The statements made on page 21 and the following paragraphs about obesity in England and with us are no longer exact, but have been allowed to stand in the text as recording facts true at the time of writing them, in 1877. At the present a medical observer familiar with both countries must note several decided changes: more fat people, more people even enormously stout, are seen with us than formerly, and fewer of the "inordinately fat middle-aged people" in England than used to be encountered. With us the over-fat are chiefly to be found among the women of the well-to-do classes of the cities, and from thirty years old onward. They persecute the medical men to reduce their weight, and the vast number of advertisements of quack and proprietary remedies against obesity indicate how wide-spread the tendency must be.

Among women somewhat younger, as indeed among men, the American observer whose recollection takes him back twenty-five years must note a more hopeful change, a very decided average increase of stature, not merely in height but in general development. This change is to be seen throughout the whole country, and must be taken first as a sign of improved conditions of food and manner of life, and next, if not more largely, of the new interest and partnership of girls in the wholesome activities of field and wood. _

Read next: Chapter 3. On The Selection Of Cases For Treatment

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