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

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.