obesity during youth, as in adult life, depending entirely upon amount and quality of nourishment and the degree of oxidation in the organism, naturally varies greatly in individual cases. It may amount to 15 or 25 per cent., but it may be increased to 50 per cent., and even more. While metabolic obesity may exist during any or all periods of life, transitory obesity of adolescence is a specific condition whose occurrence is limited to the latter stage. It must be understood, however, that similar ætiological factors which are productive of adiposis during youth may also occur at other periods of life, particularly at such times when constitutional changes take place. There is little doubt that transitory obesity of adolescence is caused by certain metamorphotic anomalies incidental to pubescence and disappearing before or at the completion of systemic development. Such anomalies are also apt to occur at the climacteric age of women, and after orchidectomy and oöphorectomy; in short, as the consequence of pronounced alterations in the organism. The anomalies produce various disorders and abnormal conditions, among which adiposis interests us most at this moment. Thus, faulty activity of the same organ or organs may be at the bottom of lipomatosis during various phases of life; as, however, the obesity in adult persons or in those advanced in years is more a manifestation of decline of functional activity, while in the adolescent it is but a developmental disturbance, the transitory form of obesity of adolescence may well be designated as a specific type. The greater frequency of the specific form among girls explains itself by the fact that the changes occurring at the period of puberty are much more decisive in the female than in the male organism. Superalimentation does not play any part in the production of the specific type. On the contrary, I know of instances where the caloric value of the nourishment generally partaken of was unusually small. Moreover, anorexia is not infrequently met with. The appetite is often capricious. While, in the majority of instances, the heat- and fat-producing ingesta are given preference by the adolescent individual affected with this type of obesity, this is not always the case, and I remember some instances where even an aversion existed for carbohydrates or hydrocarbons or for both. Again, as superalimentation is not a causative factor of specific obesity of adolescence, this must be due to diminished intraorganic oxidation. One of the anomalies underlying the latter we are quite justified in seeking in a retarded or otherwise perverted function of the thyreoids (or parathyreoids, or of both?). My reasons for ascribing the catabolic disorders to faulty thyreoid (or parathyreoid) activity, are: first, disappearance of the thymus gland and marked development of the thyreoids at the period of puberty; second, the more frequent occurrence of thyreoid affections in girls than in boys, which fact tends to explain the analogue, greater frequency of transitory obesity of adolescence among the pubescent female; and, third, our physiological and clinical experience as regards increase in protoplasm oxidation after administration of thyreoid gland or its preparations. Most cases of transitory obesity run an uneventful course. Anorexia, chlorosis, constipation, headache, and dull pains in back and loins are often present; a sense of rigidity in the joints and sacrolumbar region, giving rise to ungraceful and awkward motions, is not uncommon; circulatory disturbances synchronously produced with transitory obesity or appearing during the course of the latter, are not very frequent and seem comparatively slight; however, preexisting anomalies of the circulatory apparatus may occasionally become decidedly aggravated after abnormal fat deposition. In severe cases we may meet with pronounced anæmia or leucocytosis; and in rare instances with vertigo and cardiac dyspnoea. The specific gravity of the blood and consequently that of the body are not pathognomonic of the condition. That is, they do not as a general rule differ materially from those in metabolic obesity of adolescence. Some cases tend to what I have described as hydroplasmic obesity, a condition of lipomatosis characterized by low blood density and lesser volume weight of the organism. Typical cases of hydroplasmic obesity are the result of a decided systemic deterioration, and are, therefore, of but exceptional occurrence during adolescence. There may be instances in which a specific type of polysarcia has apparently lost its transitory character. This may occur after an intercurrent disease, as enteric fever, or after an accident or affection favoring or provoking metabolic or hydroplasmic obesity. Thus, if a case of the latter type of adiposis is said to have originated during adolescence, I am of the opinion that it is almost always an instance of transformation from the metabolic to the hydroplasmic form, or that its occurrence was preceded by transitory obesity of adolescence, with which condition it does not stand in any true relationship.* The excess in absolute weight in transitory obesity of adolescence amounts on the average to about 25 or 30 per cent. It may, however, vary a good deal in different cases. A patient of mine affected with the condition, a girl thirteen years of age, weighed over 200 pounds. It occurs to me that in this form of obesity deposition of fat is more frequent upon the chest, breasts, and extremities, while, in the metabolic variety, it principally gathers in and upon the abdomen, in the region of the hips, and on the buttocks. Another observation I have made in a number of obese girls is that in the specific form of the affection the hair of the head is full and attains great length, while it is much less abundant and comparatively short in metabolic obesity. Both forms of juvenile obesity only demand treatment either when the overweight is so excessive as to interfere with the function of certain organs, or in the presence of grave concomitant disorders. Uncomplicated cases of less than 30 per cent. overweight are better not subjected to any continuous treatment, as this will always produce more or less pronounced disturbances in the developing organism. Treatment, if instituted at all in such cases, should be directed toward maintenance of the individual's present body-weight. It should be of such a nature as to prevent protoplasm decline on the one side, and further accumulation of fat on the other side. If, in other members of the family, metabolic obesity has already appeared at an early age, or if it is soon recognized after its onset, a proper preventive treatment conscientiously executed will avert its formation altogether or materially influence its progress. The preventive treatment of the metabolic form, which must be preeminently a dietetic one, will be of no avail in checking the course of transitory obesity, and as this is the result of certain detrimental anomalies, I do not see by what means we may in the early stages intercept its progressive tendency. Juvenile metabolic obesity in which treatment is indicated should be subjected to about the same dietetic regulations as if it were metabolic obesity in the adult. Successfully to combat metabolic obesity in the adolescent and yet to prevent the consumption of body-albumin, the caloric value of the nutriment should amount to 30 to the day and kilogramme of bodyweight. This is a somewhat higher amount than that needed in the treatment of such cases occurring in the adult; it is necessary because, first, a marked reduction in nourishment is usually not well borne by the growing individual for any length of time; secondly, the youthful obese, as a general rule, is more actively engaged in physical exercise, and, thirdly, the percentage of over-weight in most cases is less than in cases occurring in the adult. To determine the necessary amount of calories, the height of the patient, and with the assistance of the appended table the corresponding weight in kilogrammes, should be ascertained. Ignoring the absolute weight of the patient, the number of kilogrammes thus obtained should be multiplied by 30, for instance: Boy, aged sixteen, absolute weight, 72 kilogrammes, height AUTHOR'S TABLE DENOTING MEAN HEIGHT AND WEIGHT OF BOTH SEXES IN THE DIFFERENT AGES OF LIFE IN THE UNITED STATES 35... 68.90 175 40. 45. 50. 55. 67.32 171 60. 70. 157.30 71.5 68.90 175 166.60 73. 63.39 68.11 173 161.70 73.5 62.99 160. 67.72 172 156.20 71. 61.81 157. 151.80 69. 61.42 156. 66.93 170 149.60 68. 61.02 155. 126.50 57.5 66.14 168 145.20 66. 60.23 153. 117.70 53.5 63.54 161.4 127.60 58. 161. 133.10 60.5 132. 128.70 60. 58.5 126.50 57.5 = = 165 centimetres. Normal weight corresponding to 165 centimetres 60 kilogrammes, therefore 60 x 30 1,800 calories, which should be daily yielded by the prescribed nourishment. The amount of liquids to be taken should be the same as I have calculated for the adult in this condition, that is 45 cubic centimetres to the day and kilogramme of normal weight. The dietetic treatment alone will suffice in most instances. In other cases an increased amount of exercise, gymnastics of the lungs, massage, hydrotherapeutic and other measures, must be resorted to in addition to the former. Medicine should be administered, if at all, only for the accompanying disorders, and never for the reduction of metabolic obesity during adolescence. In cases of transitory obesity demanding treatment, dietetic restrictions are not only superfluous in the vast majority of cases, but often effect lasting injury to the youthful organism. Our therapeutic efforts in such instances should be directed rather to that of the complications and concomitant disturbances than to the obese condition itself. The latter, if extreme and giving cause for alarm, may be treated by preparations of thyreoid. A safe form of administering thyreoid substance, a tablet which I have made use of for a number of years, is this: Physical treatment, in any of its branches, may be of benefit in individual cases of transitory obesity. 1. Metabolic obesity of early infancy, due to over-feeding, artificial foods rich in carbohydrates, and the long periods of sleep, disappears as a general rule when the infant is put on a different diet and when it starts to walk. 2. The methods which I employ in determining the volume-weight of the living organism were published in my articles on Investigations upon Corporeal Specific Gravity, and upon the Value of this Factor in Physical Diagnosis (Medical Record, February 9, 1901), and On the Treatment of Obesity (Journal of American Medical Association, February 15, 1902,) to both of which I refer the reader. 3. Loc. cit. (On the Treatment of Obesity.) 4. Specific obesity of adolescence ceases with the close of that period, but, as a matter of fact, in most instances it has already disappeared before that time. One could surmise that the continued existence of its underlying causes would also favor its continuation beyond that period, This seems true, but if the underlying anomalies are of a severe and lasting nature, the adolescent individual will succumb to them long before the attainment of maturity. LXI. A SMALLPOX EPIDEMIC IN AN ORPHANAGE BY F. C. CURTIS, M. D. AND HENRY L. K. SHAW, M. D. ALBANY A TYPE of smallpox of almost universal prevalence commenced in 1898 and being generally abnormal by reason of its mildness brought forth many expressions of doubt as to its true variola character. Clinical observations of this anomalous type of the disease are therefore eminently desirable. The epidemic we have to report illustrates so very well the most extreme possible variations from the normal, together with undoubted proof of its |