The bodily signs may be divided into such as have developed before puberty, indicating a strong inherited factor, and those which develop at the onset of manifest disorder. Early signs are a disproportionately large size of the two upper front teeth, the first incisor, or a dimple on both sides of the sacral bone just above the buttocks. When the arms are outstretched with the palms upward, the forearms appear sharply angled outward from the upper arms. The same applies to the lower extremities. The patient cannot bring his feet together without the knees overlapping; he is, in fact, knock-kneed.
The beginning accumulation of abnormal fat shows as a little pad just below the nape of the neck, colloquially known as the Duchess' Hump. There is a triangular fatty bulge in front of the armpit when the arm is held against the body. When the skin is stretched by fat rapidly accumulating under it, it may split in the lower layers. When large and fresh, such tears are purple, but later they are transformed into white scar-tissue. Such striation, as it is called, commonly occurs on the abdomen of women during pregnancy, but in obesity it is frequently found on the breasts, the hips and occasionally on the shoulders. In many cases striation is so fine that the small white lines are only just visible. They are always a sure sign of obesity, and though this may be slight at the time of examination such patients can usually remember a period in their childhood when they were excessively chubby.
Another typical sign is a pad of fat on the insides of the knees, a spot where normal fat reserves are never stored. There may be a fold of skin over the pubic area and another fold may stretch round both sides of the chest, where a loose roll of fat can be picked up between two fingers. In the male an excessive accumulation of fat in the breasts is always indicative, while in the female the breast is usually, but not necessarily, large. Obviously excessive fat on the abdomen, the hips, thighs, upper arms, chin and shoulders are characteristic, and it is important to remember that any number of these signs may be present in persons whose weight is statistically normal; particularly if they are dieting on their own with iron determination.
Common clinical symptoms which are indicative only in their association and in the frame of the whole clinical picture are: frequent headaches, rheumatic pains without detectable bony abnormality; a feeling of laziness and lethargy, often both physical and mental and frequently associated with insomnia, the patients saying that all they want is to rest; the frightening feeling of being famished and sometimes weak with hunger two to three hours after a hearty meal and an irresistible yearning for sweets and starchy food which often overcomes the patient quite suddenly and is sometimes substituted by a desire for alcohol; constipation and a spastic or irritable colon are unusually common among the obese, and so are menstrual disorders.
Returning once more to our sylphlike lady, we can say that a combination of some of these symptoms with a few of the typical bodily signs is sufficient evidence to take her case seriously. A human figure, male or female, can only be judged in the nude; any opinion based on the dressed appearance can be quite fantastically wide off the mark, and I feel myself driven to the conclusion that apart from frankly psychotic patients such as cases of anorexia nervosa; a morbid weight fixation does not exist. I have yet to see a patient who continues to complain after the figure has been rendered normal by adequate treatment.