Monday, May 12, 2008

Fat and Blood, Chapter II: Gain or Loss of Weight Clinically Considered (S. Weir Mitchell)

S. Weir Mitchell

Webmaster's Notes:

Fat and Blood: An Essay on the Treatment of Certain Forms of Neurasthenia and Hysteria
, by S. Weir Mitchell, has been included on this site because Dr. Mitchell's famous "Rest Cure" was instrumental in changing the course of Charlotte Perkins Gilman's life, and, indeed, the infamous cure was cited several times by Gilman.



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
areolæ 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 anæmia, 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.

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.

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

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

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.

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.

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]

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 anæmic 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 anæmia 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 anæmic. Meanwhile, the group of fat anæmics is of the utmost
clinical interest, as I shall by and by point out more distinctly.

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 anæmia, vary in their
constituents. It is not at all unlikely that such is the case, and that,
for example, the fat of an obese anæmic 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

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.

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

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

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.

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 æsthetic 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.



[Footnote 2: The Pennsylvania Orthopædic Hospital and Infirmary for
Diseases of the Nervous System

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

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

[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).]

[Footnote 6: Statistics (Anthropological) Surgeon-General's

[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.]

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

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

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

Original publication information:







Copyright, 1877, by J.B. LIPPINCOTT & CO.

Copyright, 1883, by J.B. LIPPINCOTT & CO.

Copyright, 1891, by J.B. LIPPINCOTT COMPANY.

Copyright, 1897, by J.B. LIPPINCOTT COMPANY.

Copyright, 1900, by J.B. LIPPINCOTT COMPANY.

Copyright, 1905, by S. WEIR MITCHELL.


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