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Louis J. Aronne · Rekha B. Kumar
Editors

Obesity Management
A Clinical Casebook

123
Obesity Management
Louis J. Aronne • Rekha B. Kumar
Editors

Obesity Management
A Clinical Casebook
Editors
Louis J. Aronne Rekha B. Kumar
NewYork–Presbyterian NewYork–Presbyterian
Hospital Hospital
Weill Cornell Medical College Weill Cornell Medical College
New York, NY New York, NY
USA USA

ISBN 978-3-030-01038-6    ISBN 978-3-030-01039-3 (eBook)

https://doi.org/10.1007/978-3-030-01039-3

Library of Congress Control Number: 2018965172

© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether
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The use of general descriptive names, registered names, trademarks, service
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Preface

As the prevalence of global obesity reaches pandemic pro-

portions, it is our responsibility as physicians to learn current
and effective interventions, give patients treatment options,
and interact with patients with obesity in a compassionate
manner. Despite our awareness of the increase in obesity
prevalence and the known costs incurred due to complica-
tions of this disease, most physicians do not feel well-trained
in treating patients with obesity or giving nutritional advice.
A great advance in this area has been the creation of the
American Board of Obesity Medicine (ABOM), which has
now credentialed more than 2000 physicians in obesity medi-
cine through a certification exam. This has led to a critical
mass of physicians who have knowledge of the disease state
and have shown competence in their understanding through
passing the exam. Despite that, we are lacking in clinical
training programs and practical educational tools on specific
clinical scenarios that the obesity medicine physician may
encounter.
In this clinical casebook, we asked obesity medicine pro-
viders at the Comprehensive Weight Control Center at Weill
Cornell Medical College to help compile prototypical cases
we see in our practice, which is dedicated to the state-of-the-­
art obesity treatment. Each chapter begins with a clinical
scenario that depicts a patient with medically complicated
obesity and then proceeds through assessment and diagnosis
as well as options for a treatment plan. The cases culminate
with a patient outcome and a summary of clinical pearls and

v
vi Preface

pitfalls relevant to each patient scenario. We hope this clinical

casebook can be a practical tool for educating physicians in
the clinical care of patients with obesity.

New York, NY, USA Rekha B. Kumar, MD, DABOM

New York, NY, USA Louis J. Aronne, MD, DABOM
Conflict of Interest

Dr. Aronne reports receiving consulting fees from and/serv-

ing on advisory boards for Jamieson Laboratories, Pfizer,
Novo Nordisk, Eisai, GI Dynamics, Real Appeal, Janssen,
UnitedHealth Group Ventures, and Gelesis, receiving
research funding from Aspire Bariatrics, Eisai, and
AstraZeneca, having an equity interest in BMIQ, Zafgen,
Gelesis, MYOS, and Jamieson Laboratories, and serving on a
board of directors for MYOS, BMIQ, and Jamieson
Laboratories. He is a consultant to Janssen Pharmaceuticals
and Sanofi.
Dr. Rekha Kumar serves as the Medical Director of the
American Board of Obesity Medicine. She reports serving as
a speaker for Novo Nordisk and Janssen Pharmaceuticals,
having equity interests in Vivus, Zafgen, and Myos
Corporation.

New York, NY, USA Rekha B. Kumar

New York, NY, USA Louis J. Aronne

vii
Contents

Part I Metabolic Syndrome

1 Identifying and Treating the Metabolic Syndrome�������   3

Caroline A. Andrew

2 Identifying Comorbidities of Obesity ��������������������������� 11

Caroline A. Andrew

Part II Insulin Resistance Syndromes

3 A Patient with High Cardiometabolic Risk ����������������� 21

Alpana Shukla and Lindsay Mandel

4 Polycystic Ovarian Syndrome����������������������������������������� 31

Alpana Shukla and Lindsay Mandel

Part III Type II Diabetes and Obesity

5 Diagnosing Type II Diabetes and Choosing

Medications in Patients with Obesity����������������������������� 43
Rekha B. Kumar

6 Cardiovascular Outcome Profiles

of Anti-­Diabetes Medications����������������������������������������� 49
Rekha B. Kumar

ix
x Contents

Part IV Psychiatric Medication-Induced Weight Gain

7 Selective Serotonin Reuptake Inhibitors

(SSRIs) and Weight Gain ����������������������������������������������� 55
Leon I. Igel

8 Antipsychotic Medication-Induced Weight Gain��������� 61

Leon I. Igel

Part V Behavioral Interventions

9 Nutritional Approaches and Self-Monitoring��������������� 71

Janet Feinstein

10 Motivational Interviewing and Assessing

Readiness to Change������������������������������������������������������� 79
Rachel Lustgarten

Part VI Bariatric Surgery

11 Surgical Options and Criteria for Bariatric

Surgery������������������������������������������������������������������������������� 87
Beverly G. Tchang and Devika Umashanker

12 Postoperative Management and Nutritional

Deficiencies����������������������������������������������������������������������� 95
Beverly G. Tchang

Part VII Pharmacotherapy for Obesity

13 Choosing a Medication ��������������������������������������������������� 105

Katherine H. Saunders

14 Anti-Obesity Pharmacotherapy After

Bariatric Surgery��������������������������������������������������������������� 121
Katherine H. Saunders
 Contents xi

Part VIII Genetic Syndromes with Obesity

15 Melanocortin 4 Receptor (MC4R) Deficiency������������� 129

Ana B. Emiliano

16 Prader-Willi Syndrome (PWS)��������������������������������������� 139

Ana B. Emiliano

Index����������������������������������������������������������������������������������������� 147
Contributors

Caroline A. Andrew, MD Hospital for Special Surgery,

New York, NY, USA

Ana B. Emiliano, MD, DABOM The Rockefeller University,

Clinician at the Comprehensive Weight Control Center, Weill
Cornell Medical Center, New York, NY, USA

Janet Feinstein, MSRD Comprehensive Weight Control

Center, Division of Endocrinology, Diabetes and Metabolism,
Weill Cornell Medical College, New York, NY, USA

Leon I. Igel, MD, DABOM Comprehensive Weight Control

Center, Division of Endocrinology, Diabetes and Metabolism,
Weill Cornell Medical College, New York, NY, USA

Rekha B. Kumar, MD, DABOM Comprehensive Weight

Control Center, Division of Endocrinology, Diabetes and
Metabolism, Weill Cornell Medical College, New York, NY, USA

Rachel Lustgarten, RDN Comprehensive Weight Control

Center, Division of Endocrinology, Diabetes and Metabolism,
Weill Cornell Medical College, New York, NY, USA

Lindsay Mandel, BA Weill Cornell Medical College,

New York, NY, USA

xiii
xiv Contributors

Katherine H. Saunders, MD, DABOM Comprehensive

Weight Control Center, Division of Endocrinology, Diabetes
and Metabolism, Weill Cornell Medical College, New York,
NY, USA

Alpana Shukla, MD Comprehensive Weight Control Center,

Division of Endocrinology, Diabetes and Metabolism, Weill
Cornell Medical College, New York, NY, USA

Beverly G. Tchang, MD Comprehensive Weight Control

Center, Division of Endocrinology, Diabetes and Metabolism,
Weill Cornell Medical College, New York, NY, USA

Devika Umashanker, MD, DABOM Department of Bariatric

Surgery, Hartford Hospital, Hartford, CT, USA
 Part I
Metabolic Syndrome
Chapter 1
Identifying and Treating
the Metabolic Syndrome
Caroline A. Andrew

Case Presentation
A 45-year-old male presents to an obesity medicine specialist
for evaluation. His body mass index (BMI) is 40 kg/m2. His
past medical history is significant for hypertension (HTN)
and dyslipidemia. Medications include hydrochlorothiazide,
losartan, rosuvastatin, and a daily aspirin. Blood pressure has
been difficult to control despite his medications, and his car-
diologist is considering adding a third agent. Family history is
notable for both parents with obesity and HTN; his father
had bariatric surgery. One of his sisters is overweight and has
type 2 diabetes. He works as the manager of a construction
company and is on his feet most of the day. He denies any use
of tobacco and drinks one to two beers every night. His typi-
cal diet consists of a breakfast of eggs and toast, and then he
will typically eat out for lunch and dinner, often stopping for
dinner at fast-food restaurants on his way home.
On review of systems, he denies having any chest pain,
shortness of breath, palpitations, or lower extremity edema.

C. A. Andrew (*)
Hospital for Special Surgery, New York, NY, USA
e-mail: andrewca@hss.edu

© Springer Nature Switzerland AG 2019 3

L. J. Aronne, R. B. Kumar (eds.), Obesity Management,
https://doi.org/10.1007/978-3-030-01039-3_1
4 C. A. Andrew

His exam is notable for a blood pressure of 140/90 mmHg

and heart rate of 78 bpm. His waist circumference is 43 in.
Recent fasting labs are remarkable for glucose 103 mg/dL,
low-density lipoprotein cholesterol (LDL-C) 112 mg/dL,
high-density lipoprotein cholesterol (HDL-C) 38 mg/dL, and
triglycerides 170 mg/dL.

Assessment and Diagnosis

This patient presents with class III obesity (BMI > 40 kg/m2)
and the metabolic syndrome. Body mass index (BMI) is used
as a screening tool for overweight and obesity, by assessing a
person’s weight in relation to height. A BMI of 18.5–24.9 is
considered normal. A BMI of 25.0–29.9 is overweight, and
class I obesity is defined by BMI 30–34.9, class II BMI
35–39.9, and class III BMI of 40 or higher [1]. The 2013
American Heart Association/American College of
Cardiology/The Obesity Society (AHA/ACC/TOS) guideline
for the management of overweight and obesity in adults rec-
ommends that patients be screened at least annually by mea-
suring height and weight and calculating BMI. Patients who
fall in the overweight or obese range are at risk for cardiovas-
cular disease (CVD), and those who have BMI >30 are at
elevated mortality risk from all causes [2]. BMI is an excellent
screening tool, but it is also important to identify patients
who have a BMI within the normal range, but who present
with comorbidities commonly associated with obesity, such as
type 2 diabetes or the metabolic syndrome. The National
Institute for Health and Clinical Excellence (NICE) guide-
lines support the use of lower BMI thresholds in the Asian
populations (23 kg/m2 for increased risk and 27.5 kg/m2 for
high risk) for further evaluation and treatment [3]. The ­AHA/
ACC/TOS guideline also recommends the inclusion of waist
circumference measurement in the evaluation of a patient [2].
Evidence demonstrates that cardiovascular risk increases
with increased waist circumference, although there is a lack of
strong evidence supporting the use of specific waist circum-
ference cutoff points as markers for increased risk. Until
 Chapter 1. Identifying and Treating the Metabolic... 5

further evidence is available, the guidelines recommend the

continuing use of the cutoff points included in the National
Institutes of Health/National Heart, Lung, and Blood Institute
(NIH/NHLBI) or World Health Organization/International
Diabetes Foundation (WHO/IDF) guidelines, >40 in. in men
and >35 in. in women, to identify patients at increased risk for
CVD [4]. The IDF provides different cutoffs of waist circum-
ference based on ethnicity [5].
BMI and measurement of waist circumference provide
easy and accessible methods of measuring and screening;
however, the medical assessment of a patient with obesity
requires a comprehensive history and physical examination in
order to fully assess for disease risk factors. With a history of
HTN and dyslipidemia, as well as an elevated waist circumfer-
ence, this patient shows a high likelihood of having the meta-
bolic syndrome. The metabolic syndrome is a condition
defined by a constellation of risk factors for cardiovascular
disease and/or type 2 diabetes.The American Heart Association
(AHA) and NHLBI define the metabolic syndrome as having
any three of the following criteria: elevated waist circumfer-
ence (>40 in. in men, >35 in. in women), elevated triglycerides
(>150 mg/dL or on treatment), reduced HDL-C (<40 mg/dL
in men <50 mg/dL in women or on treatment), elevated blood
pressure (>130 mm Hg systolic blood pressure or >85 mm Hg
diastolic blood pressure or on treatment), and elevated fasting
glucose (>100 mg/dL or on treatment). This patient meets all
of the criteria for the metabolic syndrome [1].
Risk factors for the metabolic syndrome include obesity,
specifically abdominal obesity, and insulin resistance [6, 7]. In
the National Health and Nutrition Examination Survey III
(NHANES III), the metabolic syndrome was present in 5% of
those subjects with normal weight, 22% of those who were
overweight, and 60% of subjects with obesity [8]. In the
Framingham Heart Study, an increase in weight of 2.25 kg or
more over 16 years was associated with a 21–45% increase in
the risk of developing the metabolic syndrome [9]. In addition
to obesity, other factors associated with increased risk of devel-
oping the metabolic syndrome include postmenopausal status,
smoking, high carbohydrate diet, and limited physical activity.
6 C. A. Andrew

Soft drink and sugar-sweetened beverage intake has also been

associated with increased risk [9–11]. Medications, including
antipsychotics, have been shown to increase risk. Finally, indi-
viduals with a family history of metabolic syndrome are at
increased risk; genetic factors are thought to have a strong role
in the development of the condition [12–14]. This patient’s
strong family history of obesity, HTN, and diabetes explains
some of his own risk for developing the condition.

Management
Treatment of the metabolic syndrome focuses on modifiable
risk reduction, including counseling regarding lifestyle
changes to address obesity, physical inactivity, and diet. Drug
therapy can also be considered to manage elevated LDL-C,
blood pressure, and glucose [1].
First, this patient can be counseled about the importance
of weight loss. Even modest weight loss of 3–5% is likely to
be clinically significant and can reduce his level of triglycer-
ides and fasting blood glucose and decrease his risk of devel-
oping type 2 diabetes [2]. If he can lose weight, he may see an
improvement in his HTN, a decrease in LDL-C, and an
increase in HDL-C and may be able to discontinue some of
the medications he is currently taking to control his blood
pressure and high cholesterol levels [2].
There are a variety of diets that can be offered to this
patient. The AHA/ACC/TOS guideline for weight loss rec-
ommends either 1200–1500 kcal/day for women and 1500–
1800 kcal/day for men (although these values should be
adjusted for patient’s body weight) or a 500 kcal/day–
750 kcal/day energy-deficit or an evidence-based diet that
restricts certain food types, thereby providing an energy-­
deficit [2].
The AHA/NHLBI have specific guidelines for the treat-
ment of the metabolic syndrome. A goal weight reduction of
7–10% during the first year of treatment is recommended.
For physical activity, individuals should aim for at least
30 min of continuous or intermittent moderate-intensity
 Chapter 1. Identifying and Treating the Metabolic... 7

physical activity, at least 5 days per week. Resistance training

should also be incorporated into the schedule at least 2 days
per week. An anti-atherogenic diet should be followed, by
reducing intake of saturated fats, trans fats, and cholesterol.
Official recommendations are for saturated fat to comprise
<7% of total calories and total fat 25–35% of total calories.
Dietary fat should be mostly unsaturated and intake of sim-
ple sugar should be limited [1]. Medications may be initiated
as adjunctive therapy to lifestyle changes in order to lower
LDL-C levels and decrease blood pressure. Aspirin might be
added prophylactically for patients at high risk for athero-
sclerotic cardiovascular disease (ASCVD) [1].

Outcome
This patient sees a dietician who starts him on a plan that is
in accordance with AHA/NHBLI guidelines, trying to mini-
mize saturated fats and cholesterol in his diet. He starts to
cook at home instead of visiting fast-food restaurants. He
starts to take short walks on his lunch break in order to incor-
porate some exercise into his day. After he starts to lose
weight, his blood pressure is better controlled, and although
he remains on medications, he avoids adding a third agent.
On repeat labs, there is an improvement in HDL-C and
LDL-C levels. He follows up with his primary care physician,
cardiologist, and obesity medicine specialist every
6–12 months in order to have his waist circumference mea-
sured and BMI calculated, in addition to other aspects of the
routine history and physical examination.

Clinical Pearls and Pitfalls

• An initial assessment of a patient with obesity or

components of the metabolic syndrome must include
the calculation of BMI and measurement of waist
circumference.
8 C. A. Andrew

• Initial assessment of obesity and metabolic syn-

drome must also include a complete medical history,
family history, diet and lifestyle history, and a com-
prehensive set of blood tests including (but not lim-
ited to) a fasting lipid panel, glucose, and basic
metabolic panel.
• Patients who fall in the overweight or obese range
are at risk for cardiovascular disease (CVD), and
those who have BMI >30 are at elevated mortality
risk from all causes.
• Modest weight loss of 3–5% can be clinically signifi-
cant and decrease a patient’s risk of developing type
2 diabetes.
• Treatment of the metabolic syndrome includes
addressing lifestyle, such as diet and exercise, and
considering lipid-­lowering therapy or antihyperten-
sive therapy when indicated.

References
1. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel
RH, Franklin BA, et al. Diagnosis and management of the
metabolic syndrome: an American Heart Association/National
Heart, Lung, and Blood Institute Scientific Statement.
Circulation. 2005;112(17):2735–52. https://doi.org/10.1161/
circulationaha.105.169404.
2. Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG,
Donato KA, et al. 2013 AHA/ACC/TOS guideline for the man-
agement of overweight and obesity in adults. J Am Coll Cardiol.
2014;63:2985–3023. https://doi.org/10.1016/j.jacc.2013.11.004.
3. National Institute for Health and Clinical Excellence (NICE)
guidelines. BMI: preventing ill health and premature death in
black, Asian and other minority ethnic groups. July 2013. https://
www.nice.org.uk/advice/lgb13.
4. National Institutes of Health/National Heart, Lung,
and Blood Institute. Managing overweight and obesity in
adults: systematic evidence review from the obesity expert
 Chapter 1. Identifying and Treating the Metabolic... 9

panel. Nov 2013. https://www.nhlbi.nih.gov/health-topics/

managing-overweight-obesity-in-adults.
5. International Diabetes Foundation. The IDF consensus world-
wide definition of the metabolic syndrome. 2016.
6. Lemieux I, Pascot A, Couillard C, Lamarche B, Tchernof A,
Almeras N, Bergeron J, Gaudet D, Tremblay G, Prud’homme
D, Nadeau A, Despres JP. Hypertriglyceridemic waist: a marker
of the atherogenic metabolic triad (hyperinsulinemia; hyper-
apolipoprotein B; small, dense LDL) in men? Circulation.
2000;102:179.
7. Carr DB, Utzschneider KM, Hull RL, Kodama K, Retzlaff BM,
Brunzell JD, Shofer JB, Fish BE, Knopp RH, Kahn SE. Intra-­
abdominal fat is a major determinant of the National Cholesterol
Education Program Adult Treatment Panel III criteria for the
metabolic syndrome. Diabetes. 2004;53:2087–94.
8. Park Y, Zhu S, Palaniappan L, et al. The metabolic syndrome:
prevalence and associated risk factor findings in the US popula-
tion from the Third National Health and Nutrition Examination
Survey, 1988–1994. Arch Intern Med. 2003;163(4):427–36.
9. Palaniappan L, Carnethon M, Wang Y, et al. Predictors of the
incident metabolic syndrome in adults: the insulin resistance
atherosclerosis study. Diabetes Care. 2004;27(3):788–93.
10. Gennuso K, Gangnon R, Thraen-Borowski K, et al. Dose-­
response relationships between sedentary behaviour and
the metabolic syndrome and its components. Diabetologia.
2015;58(3):485–92.
11. Green A, Jacques P, Rogers G, et al. Sugar-sweetened bever-
ages and prevalence of the metabolically abnormal pheno-
type in the Framingham heart study. Obesity (Silver Spring).
2014;22(5):E157–63. https://doi.org/10.1002/oby.20724.
12. Pankow J, Jacobs D, Steinberger J, et al. Insulin resistance and
cardiovascular disease risk factors in children of parents with
the insulin resistance (metabolic) syndrome. Diabetes Care.
2004;27(3):775–80.
13. Mills G, Avery P, McCarthy M, et al. Heritability estimates for
beta cell function and features of the insulin resistance syndrome
in UK families with an increased susceptibility to type 2 diabetes.
Diabetologia. 2004;47(4):732–8.
14. Van Tilburg J, Wijmenga C, van Haeften T, et al. A genome scan
for loci linked to quantitative insulin traits in persons with-
out diabetes: the Framingham offspring study. Diabetologia.
2003;46(11):1588.
Chapter 2
Identifying Comorbidities
of Obesity
Caroline A. Andrew

Case Presentation
A 55-year-old woman presents to an obesity medicine specialist
for evaluation. Her BMI is 37 kg/m2. She has tried multiple diets
in the past, with some success, but finds that she always regains
the weight she loses. Her past medical history is significant for
hypertension, for which she takes metoprolol and hydrochloro-
thiazide. She has osteoarthritis in her knees and is planning to
have knee replacement surgery in a few months. For knee pain
she takes ibuprofen daily. On further questioning, she reveals
that she has not been sleeping well. Her husband complains
that she snores. She wakes up multiple times throughout the
night, does not feel well rested in the morning, and falls asleep
at her desk occasionally in the afternoon. She has been taking
diphenhydramine occasionally to help her fall asleep at night.
Review of symptoms is negative for chest pain, palpitations,
shortness of breath, and lower extremity edema. Vitals: T 37.6,
BP 140/80, HR 68, RR 12, and O2 98%. Exam is notable for
crepitus in both knees, no evidence of effusions. Routine labs,
including CMP, CBC, and HbA1c, are within normal limits.

C. A. Andrew (*)
Hospital for Special Surgery, New York, NY, USA
e-mail: andrewca@hss.edu

© Springer Nature Switzerland AG 2019 11

L. J. Aronne, R. B. Kumar (eds.), Obesity Management,
https://doi.org/10.1007/978-3-030-01039-3_2
12 C. A. Andrew

Assessment and Diagnosis

This patient has class 2 obesity (BMI 35–39.9 kg/m2). She also
suffers from HTN and osteoarthritis and, based on her history,
may carry a diagnosis of obstructive sleep apnea (OSA), a
common comorbidity of obesity. The prevalence of comorbidi-
ties in people with obesity has been found to be correlated
with the degree of obesity. The odds of having multiple comor-
bidities increases significantly with each class of obesity [1].
OSA is a disorder defined by episodes of airway obstruction
that affect ventilation during sleep [2]. Features of the condi-
tion include intermittent hypoxia and hypercapnia, interrupted
sleep, daytime sleepiness, loud snoring, changes in intrathoracic
pressure, and increased sympathetic nervous system activity
[3]. Obesity is a risk factor for OSA. The adipose tissue creates
a mechanical effect and pressure on the upper airway, causing
pharyngeal narrowing and reducing lung volumes. Obesity can
also affect the central nervous system (CNS) through adipo-
kines and adipocyte-binding proteins that affect respiratory
neuromuscular control [4]. The prevalence of OSA has been
estimated to be 14% of men and 5% of women [5]. The preva-
lence is much higher among the population with overweight
and obesity; it is estimated to be 70–80% among patients being
evaluated for bariatric surgery [6].
The American Academy of Sleep Medicine recommends
obtaining a detailed sleep history from any patient in whom
obstructive sleep apnea is suspected. The physician should ask
about snoring, witnessed apneic events, choking or gasping
behavior at night, restlessness, and daytime sleepiness. There are
several screening questionnaires that can also help a provider
identify who might be at risk. The Epworth sleepiness scale is
one that is commonly used, although there is a lack of evidence
supporting its sensitivity and specificity [2]. Polysomnography is
the gold standard diagnostic test for OSA and should be ordered
for any patient in whom OSA is suspected. OSA is diagnosed
with an obstructive respiratory disturbance index (RDI) >15
events per hour with or without symptoms or an obstructive
RDI between 5 and 14 events per hour with symptoms [3, 7].
The treatment of OSA involves positive airway pressure
therapy, most commonly provided by continuous positive
 Chapter 2. Identifying Comorbidities of Obesity 13

airway pressure (CPAP). The CPAP maintains a positive pha-

ryngeal transmural pressure, greater than the surrounding
pressure, to preserve the airway space and prevent upper
airway collapse. The use of positive airway pressure therapy
has been shown to reduce the number of nocturnal respira-
tory events, decrease daytime sleepiness, improve blood pres-
sure, and improve quality of life [8, 9].
Osteoarthritis is another common comorbidity associated
with obesity. Although OA has a multifactorial etiology, it is
well known that increased weight creates a mechanical stress
on the joints, causing breakdown of cartilage, in particular in
the knees and hips [10]. However, there has been found to be
obesity-related arthritis in non-weight bearing joints, such as
the hands, implying the involvement of systemic inflamma-
tion and circulating cytokines associated with adipose tissue
affecting the joints [10, 11]. The American College of
Rheumatology recommends weight loss for people who are
overweight or obese in the treatment of knee and hip osteo-
arthritis [12].
Obesity also increases a patient’s risk of developing
HTN. The prevalence of HTN has been shown to increase
with each class of obesity [13, 14]. This patient is already tak-
ing two antihypertensives, and her blood pressure is above
the target range in the office.
This patient is also taking medications that may contribute
to weight gain. Multiple prescription and over-the-counter
medications have been associated with weight gain. For
example, the patient’s medication metoprolol, as a beta
adrenergic receptor blocker, decreases energy expenditure
and can be associated with weight gain [15]. Other medica-
tions may cause an increase in energy intake, such as antipsy-
chotics and steroid hormones, or a decrease in energy
expenditure, as can be seen in certain diabetes medications
[2, 16]. Diphenhydramine, a member of the antihistamine
class of medications, can also affect weight. Intravascular
administration of histamine reduced food intake in animal
studies, and histamine antagonism caused increased food
intake [17, 18]. If possible, this class of drugs should be
avoided in patients who have obesity and are trying to lose
weight Table 2.1.
Table 2.1 Drug-Induced weight gain
14

Therapeutic Alternatives that cause less weight gain,

category Drug class May cause weight gain weight loss, or are weight neutral
Psychiatry Antipsychotic Clozapine Ziprasidone
Risperidone Aripiprazole
Olanzapine
Quetiapine
C. A. Andrew

Other
Antidepressants Citalopram Bupropion
and Escitalopram Nefazodone
mood stabilizers Fluvoxamine Fluoxetine (short term: <1 year)
Lithium Sertraline (short term: <1 year)
MAOIs
Neurology Anticonvulsants Carbamazepine Lamotrigine
Gabapentin Topiramate
Valproate Zonisamide
Endocrinology Diabetes Insulin Metformin
treatments Sulfonylureas Acarbose
Thiazolidinedione Miglitol
Obstetrics and Oral Progestational steroids Barrier methods
gynecology contraceptives Hormonal contraceptives IUDs
containing progestational
steroids
Endometriosis Depot leuprolide acetate Surgical methods
treatment
Chapter 2.

Cardiology Antihypertensives α-blocker ACE inhibitors

β-blocker Calcium channel blockers
Infectious Antiretroviral Protease inhibitors None
disease therapy
General Steroid hormones Corticosteroids NSAIDs
Progestational steroids
Antihistamines/ Diphenhydramine Decongestants
anticholinergics Doxepin Steroid inhalers
Cyproheptadine
Other potent
antihistamines
Identifying Comorbidities of Obesity
15
16 C. A. Andrew

Management
First, this patient should be referred for polysomnography for
further workup of possible OSA. Treatment of OSA will not
only improve her symptoms of daytime sleepiness but could
potentially treat her blood pressure. Weight loss can help
address all of her comorbidities. Establishing a diet and exer-
cise plan for weight loss may help improve her knee pain
related to osteoarthritis. As metoprolol has been associated
with weight gain, she should be switched to a weight-neutral
medication for high blood pressure, such as an angiotensin-­
converting-­ enzyme (ACE) inhibitor, angiotensin receptor
blocker (ARB), or calcium channel blocker (CCB). She
should avoid taking diphenhydramine to help her fall asleep
in order to prevent any further drug-induced weight gain [19].

Outcome
The patient is diagnosed with OSA and begins to use a CPAP
nightly. She finds that she now feels much more rested when
she wakes up in the morning and is no longer falling asleep at
work. She stops using diphenhydramine and starts taking
lisinopril instead of metoprolol. As she begins to lose weight,
her knee pain improves and she is able to start walking for
exercise.

References
1. Booth HP, Prevost AT, Gulliford MC. Impact of body mass index
on prevalence of multimorbidity in primary care: cohort study.
Fam Pract. 2014;31(1):38–43.
2. Sharma AM, Pischon T, Hardt S, et al. Hypothesis: beta-­
adrenergic receptor blockers and weight gain: a systematic
analysis. Hypertension. 2001;37(2):250–4.
3. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice
guideline for diagnostic testing for adult obstructive sleep
 Chapter 2. Identifying Comorbidities of Obesity 17

Clinical Pearls and Pitfalls

• The odds of having multiple comorbidities increases

significantly with each class of obesity.
• OSA, a common comorbidity associated with obesity,
is a disorder defined by episodes of airway obstruc-
tion that affect ventilation during sleep.
• Polysomnography is the gold standard diagnostic test
for OSA and should be ordered for any patient in
whom OSA is suspected.
• It is important to take a thorough history when
assessing a patient with obesity, including a complete
and detailed medication history, as certain classes of
medications can be associated with weight gain.

apnea: an American academy of sleep medicine clinical practice

guideline. J Clin Sleep Med. 2017;13(3):479–504. https://doi.
org/10.5664/jcsm.6506.
4. Schwartz AR, Patil SP, Laffan AM, et al. Obesity and obstruc-
tive sleep apnea—pathogenic mechanisms and therapeutic
approaches. Proc Am Thorac Soc. 2008;5:185–92.
5. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla
KM. Increased prevalence of sleep-disordered breathing in
adults. Am J Epidemiol. 2013;177(9):1006–14.
6. Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld
BA, de Vries N. Obstructive sleep apnea is underrecognized and
underdiagnosed in patients undergoing bariatric surgery. Eur
Arch Otorhinolaryngol. 2012;269(7):1865–71.
7. Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring
respiratory events in sleep: update of the 2007 AASM manual
for the scoring of sleep and associated events. Deliberations of
the sleep apnea definitions task force of the American academy
of sleep medicine. J Clin Sleep Med. 2012;8(5):597–619. https://
doi.org/10.5664/jcsm.2172.
8. Jonas D, Amick H, Feltner C, et al. Screening for obstructive
sleep apnea in adults: evidence eeport and systematic review for
the US preventive services task force. AHRQ Publication No.
14-05216-EF-1 2017.
18 C. A. Andrew

9. Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive air-
ways pressure for obstructive sleep apnoea in adults. Cochrane
Database Syst Rev. 2006;1:CD001106.
10. Sellam J, Berenbaum F. Is osteoarthritis a metabolic disease?
Joint Bone Spine. 2013;80(6):568–73.
11. Sowers MR, Karvonen-Gutierrez CA. The evolving role of obe-
sity in knee osteoarthritis. Curr Opin Rheumatol. 2010;22:533–7.
12. Hochberg M, Altman R, April KT, et al. American College of
rheumatology 2012 recommendations for the use of nonphar-
macologic and pharmacologic therapies in osteoarthritis of the
hand, hip, and knee. Arthritis Care Res. 2012;64(4):465–74.
13. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and
stroke statistics-2017 update: a report from the American heart
association. Circulation. 2017;135(10):e146–603.
14. Nguyen NT, Magno CP, Lane KT, et al. Association of hyperten-
sion, diabetes, dyslipidemia, and metabolic syndrome with obesity:
findings from the National Health and Nutrition Examination
Survey, 1999 to 2004. J Am Coll Surg. 2008;207(6):928–34.
15. Leslie WS, Hankey CR, Lean ME. Weight gain as an adverse
effect of some commonly prescribed drugs: a systematic review.
QJM. 2007;100(7):395–404.
16. Pijl H, Meinders AE. Bodyweight changes as an adverse effect
of drug treatment. Drug Saf. 1996;14:329–42.
17. Kalucy RD. Drug-induced weight gain. Drugs. 1980;19(4):268–78.
18. Ratliff JC, Barber JA, Palmese LB, et al. Association of prescrip-
tion H1 antihistamine use with obesity: results from the National
Health and Nutrition Examination Survey. Obesity (Silver
Spring). 2010;18(12):2398–400.
19. Saunders KH, Igel LI, Shukla AP, Aronne LJ. Drug
induced weight gain: rethinking our choices. J Fam Pract.
2016;65(11):780–8.
 Part II
Insulin Resistance Syndromes
Another random document with
no related content on Scribd:
cunning to avoid being discovered and yet left the problem still
unsolved in his tortured brain.
Presently the little procession arrived at an open piece of ground in
the midst of the forest, like a fairy glade, surrounded as it was by the
stately trunks of the cocoa-palms standing majestically like the
columns of a Greek circular temple. In the centre of this open space
grew a gigantic tree, like a king circled by his courtiers.
Up to this monarch of the grove Tari led his captive, and halted.
Jim, as he slipped behind a clump of brushwood, recognised the
spot as one which he and Tari had stumbled upon during their
exploration of the afternoon, and he remembered that it was on the
opposite side of the island to the signal palm, the lagoon coming in
between.
The conspirators had chosen their spot well. It was far out of earshot
of the camp, and seemed as if designed purposely for the object
which they had in view.
Silently they went about their preparations, whilst the boy watched
them from his hiding-place with a horror in his eyes.
Making use of a grummet, Tari, with the coil of rope round his
shoulders, went up the tree like a cat. To any one who has never
seen a native go up a tree in this fashion it is a most astonishing
sight.
The rope circles the tree and the man's thighs, whilst he keeps his
balance with his feet pressed against the trunk, progressing upwards
by jerks. Each time, as he takes the pressure of his body off the
rope, he slips the grummet higher up the trunk, tautening it up with
his thighs before it can drop back again.
In this way Tari was soon at the top, and producing the boat's
halliard-block and a salvagee strop from inside his shirt, he fixed
them on the strongest branch he could find; then, reeving the rope,
lowered one end to the ground. This Bill Benson and Broncho took
hold of, and the Kanaka taking the other, they lowered him easily to
the ground, thus testing at the same time the efficiency of their
gibbet.
The doomed man was now led under the dangling loop, one of the
executioners still keeping a firm hold on the rope to his wrists, whilst
the others removed the gag.
Immediately the miserable wretch, dropping on his knees, burst into
a piteous appeal for mercy.
The bosun's mate turned away, unable to stand the dreadful sight,
but Broncho was made of sterner stuff, and listened to the raving,
distracted words with an unshaken sternness.
"Have mercy!" whimpered the terrified ruffian. "Have mercy! I'll be
your slave. Anything! I'll give you gold [eagerly], for I have it where I
can lay hands on it. I swear it. By God, I swear it; only let me go!"
Slowly Broncho shook his head.
"Christ! Have you no pity in your soul? Think what you are doing!
This is murder—cruel, bloody murder!"
"It's a shore-enuff proper-conducted lynchin'," growled the cowboy.
"What have I done to you? Lord God! What have I done? Free my
hands and I'll fight you square, anyhow you like! Anything but this,
this—this horrible death. I ain't fit to die. Lemme free an' have a
chance in a square fight."
"I don't fight wi' skunks o' your breed!" came the scornful answer.
At this the wretch broke down utterly and exhausted himself in wild
oaths of abuse; but after a string or two of these Broncho cut in
impatiently:
"I allow you'd better throw off any prayer-stock you-alls wishes to cut
loose. Your time's gettin' some scarce."
With a moan of terror the doomed ruffian threw himself down on his
face, howling like a cur, and casting to the winds all further efforts at
self-control.
Unmoved by this pitiful display of a cowardly soul, Broncho stepped
up to the writhing form and pulled him to his feet; then, with a slow,
deliberate care, adjusted the noose round the condemned man's
neck, and called to the others to haul in the slack of the rope.
All this time, Jim, crouching behind the brushwood and shaking all
over with fright, puzzled his poor head in a desperation as to how to
act.
At the last moment the thought came to him. Already the three men
were preparing to lay back on the rope, when right over their heads
came a weird, unearthly voice:
"Hangmen, beware! Do this deed and your time will shortly come!
Beware! beware!"
The effect was instantaneous. Tari and the bosun's mate dropped
the rope and sprang backwards in wild alarm; only the undaunted
cowboy stood firm.
Even the condemned man ceased his whimpering and looked up
fearfully.
"Blazes! What were that?" cried the scared bluejacket in a hoarse
whisper.
"Don' know," replied Broncho laconically. "A sperit mebbe, but no
sperit palaver is goin' to jolt up this lynchin'. Take a holt and h'ist
away."
"Take care! take care!" hissed the sepulchral tones again.
"My God!" groaned the prisoner, and would have collapsed, but a tug
at the rope about his neck by Broncho's steady hand caused him to
remain erect.
As for the superstitious bosun's mate, he crouched down as if
fearing a blow, whilst Tari, with a wild cry of "Spirit debble! spirit
debble!" fled madly from the spot.
Meanwhile, the small author of this terror-inspiring voice was tearing
back along the trail with all the speed he could muster.
Breathlessly he burst into the camp, and darting to Jack's side,
gasped incoherently,
"They're lynchin' him! They're lynchin' him!"
"Him? Whom? Why, it's Jim," exclaimed the rolling-stone, sitting up
and blinking his eyes, his example being followed by the surprised
Loyola.
"Come!" urged the panting boy. "Come quick! We may be in time. I
give 'em a good scare. Follow me!" and off he went.
Jack was up in an instant, rapidly putting two and two together from
the boy's wild words, and away he dashed in pursuit, with Loyola on
his heels.
As they ran Jim managed to gasp out between his sobbing breaths a
short account of Broncho's lynching, which drew an exclamation of
concerned astonishment from the rover.
All this time Broncho was using his best eloquence to get the
bluejacket to return to his grisly job.
"Brace up!" he urged, "brace up! You-alls ain't goin' to stampede the
trail at a bunch o' ghost talk."
"I can't, man! Blawst me, I can't do it," groaned the terrified Bill
Benson. "Gaud save us," he went on; "it were a warnin'!"
"Chucks!" growled the impatient and lion-hearted cowboy. "Rats to
'em, I say! Air you a quitter, Bill Benson? You, a British navy-man, a
quitter?" and there was scorn keen as a razor-edge in his drawling
voice.
"S'elp me Gaud, Broncho, I can't face it!"
"You heard 'em, Benson," put in Hawksley, seeing his chance; "you
heard 'em. Don't let that fiend hang me, or may my spirit haunt you!
May my blood be on your head and put a curse on all your days!"
"Silence, you gal-thief, silence!" hissed the angry cowpuncher, giving
a jerk to the rope which nearly dislocated the wretched man's neck;
then, addressing himself to the bluejacket, he went on:
"If you-alls baulk this ford, Benson, I'll put the coward's brand on you,
shore as I'm tabbed in the stud-book Buckin' Broncho."
"It's no use," returned the man-of-war's man sulkily. "I ain't out to
buck agin spirits—my courage don' run that swift. I ain't afraid as
long as it's men, but ghosts top the limit o' my gristle. They
overweights my firin'-battery absolute and entire."
For a second the cowpuncher glared in silence; then, slowly drawing
his revolver, cocked it and covered the bluejacket with its sinister
barrel.
"Mebbe this here argument'll revive you some," he drawled
contemptuously.
Broncho was bluffing, bluffing desperately, but he had not spent the
pay of so many seasons learning poker for nothing.
"Better catch a holt!" he went on significantly. "This here gun ain't out
for play. It's a business proposeetion which it ain't wise nor healthy to
monkey with."
After one wild, searching look into the stern eyes of the cowboy, Bill
Benson gave in and reluctantly resumed his hold on the rope; whilst
the unhappy Hawksley, seeing his last hope gone, burst afresh into a
flow of terror-inspired lamentations and prayers.
At last the moment had come!
"Lay back on it!" hissed the cowpuncher, as the two executioners
drew the rope taut.
In another second Hawksley would have been dangling in space.
Already he was on the tips of his toes, when "Crack!" and the rope
was cut through just above his head, and down he fell in a heap.
"Hold! What the devil are you doing?" cried a panting voice, and the
next moment Jack burst into the open, a smoking pistol in his hand,
followed by Jim and Loyola.
"You ain't wanted here, Jack Derringer," roared the baffled
cowpuncher. "He's my steer, an' rope him I will! I'll take it kind if you'll
quit blockin' up the scenery an' obstructin' this here execution."
"Why, Broncho, what's taken you? My old bunkie isn't going to turn
into a butchering desperado, is he? Come, old son, this little game of
yours has gone far enough."
"I stands a corralful from you, Jack, as you-alls knows; but you're
playin' mighty near the limit. I asks you again to vamoose," returned
the cowboy, sticking desperately to his guns; then he added more
softly, "It's for your own good, pard."
"No good's going to come to me by any man's murder in cold blood."
"It's a fair an' square lynchin', Jack, and a sight easier death than the
skunk desarves."
"Chuck it, Broncho, chuck it!" cried the rover. "It's no use. I can't
allow it. The thing's impossible."
"On'y a jerk er two an' the gal's yours, Jack. It ain't your shout. I
takes the responsibeelity. You-alls has no need to take a hand. He's
my beef. Lope up the trail a hoss-length or two, Jack, an' the gal's
free." Thus the cowboy tempted cunningly.
The blood rushed to the rover's face at the very thought. For a
second a mighty temptation to let events take their course assailed
him, and then, with a sinking misery in his heart, he regained his
manhood.
"No, Broncho, no!" he jerked hoarsely.
"Think o' the hell you-alls is condemnin' the poor gal to! Think of her
draggin' along her life-trail on the rope o' that hoss-thief," went on the
tempter. "I allows you ain't the right to sp'ile her life this way."
The others watched the pair, waiting on the result with beating
hearts. Would the cowboy's eloquence prevail? Would he after all be
allowed to carry out his dreadful project? A word from Jack and the
execution would continue. Every one realised the deadly temptation
the cunning Broncho was so insidiously putting before his friend.
Would the rover give in? Had he the right to spoil another life as well
as his own? No one dared to answer the question.
Suddenly Loyola threw her head back, and going to the hideously
tempted man, put her hand mutely into his, with a tender look of
perfect confidence.
Jack caught the look, and knew that she was telling him that she
would abide by his decision, whichever way it went. She trusted him,
trusted him absolutely—that was what her eyes said—to do that
which was right.
"What do you say?" asked Broncho, with an air of finality. "Shall I
turn him loose an' bog the gal's happiness in an everlastin'
quicksand, so as when the years o' hell an' misery pile up she comes
to hate you an' your high-falutin' moralities worse'n him?"
"My God, Lolie, you won't? Oh, say you won't!" groaned poor Jack.
"Never!" whispered the girl, a smile of the supremest courage upon
her face.
"Turn him loose," ordered the rover, in a voice which they could
hardly recognise as his; then, rounding on his heel, he walked slowly
out of the glade with bent head and miserable eyes.
A deep breath, almost a groan, burst from the lips of the onlookers.
Jim sobbed audibly. The strain had been too much for the poor boy,
now that he realised so fully all that his action had cost the man
whom he loved most in the world. Bitterly he cursed himself. He
would rather have seen Hawksley hanged a thousand times. Utterly
miserable and sick at heart, he flung himself upon his face on the
ground, his whole body shaking with the strength of his emotion.
And Loyola—what of Loyola? With a strange, glorious light shining in
her splendid eyes, she watched the receding figure of the rolling-
stone; there was no misery in her face, only a perfect sweetness of
content. Heedless of its consequences to herself, she only thought of
her lover's courage, and her spirit leaped within her in a great
exultation.
To her came the cowboy, asking sadly,
"I hope you ain't none raged with me, ma'am? I were playin' the hand
for you and Jack."
For answer she placed her hand in his and murmured softly:
"I understand, Broncho—and I shan't forget," with which the
cowboy's troubled face cleared wonderfully.
"An' my pard, Jack, ma'm'; I knowed all the time he were right. Any
other maverick would ha' weakened, but he didn't. He's all grit, is
Jack. I played up the hand for all it was worth, but I knew I was
beaten when he fust called me."
At this praise of the man she loved the woman fairly beamed upon
him; then her eyes turned slowly upon the unconscious form of her
husband.
Following her glance, Broncho growled gruffly:
"Luck's hopped your way to-night, mister. I allow a thunderbolt's bein'
constructed to put out your light, an' that's why Providence puts the
hobbles on us humans an' blocks our game. I surmise they ain't
none ready for you yet. Mebbe their heatin' plant ain't planned so as
it reaches high enuff figures for you-alls, an' them pitchfork gents is
busy fixin' it."
With which characteristic address he stepped to the side of its
unconscious object, followed by Loyola.
The all-but-hanged scoundrel lay there strangely white and still, his
legs crumpled up under him.
One glance of his experienced eyes, and the cowboy gave a queer
exclamation of surprise.
"What is it?" cried the woman anxiously.
But, instead of answering, Broncho hurriedly felt under the man's
shirt for the beat of his heart.
For nearly a minute he held his hand there, whilst Loyola and Bill
Benson watched him with a growing look of apprehension; then he
slowly drew back the eyelids and revealed a pair of glassy,
expressionless eyes.
With a recoil of horror Loyola staggered back and fainted, the
bluejacket catching her as she fell.
Hawksley was dead!
"Heart failure, I reckon!" muttered the cowpuncher grimly. "Seems
his tickets for the great unknown were taken after all!"
And he turned to the unconscious woman, whilst the bosun's mate
rushed to the lagoon for water.

FOOTNOTES:
[12] Tin hats = drunk.
[13] This is the name given by sailors to the small windmill
noticeable on all Norwegian wooden ships, which is used to pump
the water out of them.
 CHAPTER X
"THE BLACK ADDER"
Jack, sitting hunched up with his face between his hands in a
posture of utter despair, looked up dully as he heard the sound of
approaching feet; then, as the gloomy procession came out on to the
sands, he started to his feet with a cry.
First came Loyola, walking slowly with bent head and one hand on
Jim's shoulder; but it was the sight of what was behind her drew the
cry from his lips, for on the shoulders of Broncho and the man-of-
war's man lay the body of a man.
The rover rushed forward.
"Hawksley's cashed in!" came in a solemn voice from Broncho, as he
reached his side; but there was little need of the words. The fact was
evident enough.
"You hanged him after all?" burst out Jack, with a queer strangle of
reproach in his voice.
"No, pard; it ain't our funeral. The angels finished our job," explained
the cowboy quietly.
The body was covered with the boat-sail and laid under the big palm;
then the castaways flung themselves down to sleep, worn out by the
tragic events of the night.
Nobody awoke until long after sun-up, and as Broncho was serving
out their scanty rations, Tari appeared out of the scrub and slunk into
a corner with downcast eyes.
Jack awoke to find himself blind again, but as he felt the woman's
hand in his, he knew that she was at last free, and, notwithstanding
his blindness, a great comfort flooded his soul.
At breakfast Jim explained his share in the tragic lynching to the
astonished bosun's mate and Broncho, and the mystery of the
supernatural voice was cleared up.
At midday the body of Hawksley was buried at the foot of the big
palm in silence.
After the exciting events of the first twenty-four hours, life on the atoll
progressed smoothly enough.
At first the shock of the tragedy seemed to stun Loyola's
overstrained senses, but gradually, as the lazy, uneventful days
passed, the memory of all the late horrors wore off, and a great hope
of future happiness in Jack's arms filled her heart.
She began to pick up spirits and show more of that sunny
disposition, with its infectious gaiety, which had been such a feature
of her character before her unfortunate marriage.
At times a snatch of song would burst from her lips, which caused a
smile of satisfaction to flit over the faces of the castaways, and she
owned a devoted slave in each one of them.
"My, boys! but she's good gear!" commented Bill enthusiastically,
one lazy afternoon, indicating Loyola with his pipe as he reclined
under the cocoa-palms.
She and Jack, deep in talk, were pacing up and down the beach,
hand in hand, for such was their custom on account of the latter's
blindness.
She was telling him all the Island news, of new schooners, new
stations, and new captains: of how old So-and-so had taken a new
native wife, and Jack Bounce had been called down and thrashed by
a new chum; of the stranding of the Wee Willie whilst Cap'n Ben was
locked in his cabin killing imaginary snakes, and how the new trader
on Pleasant Island had got a forty-four Colt bullet through the back
from Nigger Bill, as a gentle hint to clear out; that Billy Cæsar, a
noted chief in the Hebrides, had been wearing out his teeth on tough
missionary again; how the blackbirder May Allen had lost a boat and
her new recruiter in the Louisiade Archipelago, and numerous other
small bits of South Sea gossip.
"She's shore a peach!" assented Broncho to the bluejacket's remark.
"Don't she smile be-e-autiful?" chimed in Jim, with an awestruck
voice of admiration. "Lor, but she's a fine lady!"
"You can see that stickin' out a foot," agreed Bill Benson. "She'll 'ave
a gunny-sack o' dibs too, bein' 'Awksley's widder. 'Eavens! but she is
'traps,'" and he turned up his eyes expressively.
"I don't surmise Jack'll let her handle any o' that Hawksley varmint's
crooked-gained wad," declared Broncho. "He's powerful proud, is
Jack."
"An' what about them maroonin' jokers on the Black Adder?" queried
the bosun's mate reflectively.
"Does you-alls allow they're liable to come heavin' up on the
scenery?" inquired the cowpuncher.
"Very pre-obbable," said the bluejacket. "They may 'ave the curiosity
to see 'ow we're makin' out. If that Dago Charlie—him that were
'Awksley's mate an' did the maroonin' act—if 'e, I sez, comes
protrudin' that snaky schooner our way, there'll be trouble, sure; but I
won't panic much if 'e do come mine-droppin' under our bows. I just
itches to draw a bead on 'im with one o' these Winchesters.
Howsomedever, I fancies he's too busy lootin' copra stations an'
fishin' other jossers' pearls."
"Let's bathe," proposed the boy suddenly; and rising languidly to
their feet, they strolled off to the lagoon.
Here they were wont to disport themselves in the water four or five
times a day, and to Jack especially this was a great pleasure, for he
found that his blindness was no great inconvenience in the water.
As the lagoon of this atoll was completely surrounded by the growth,
resulting from the toil of the coral insect, it was safe to bathe in it,
without fear of the dreaded sharks which swarmed round the outer
reef.
It made an ideal bathing-place. The white beach shelved gradually,
and such was the transparency of the water that the bottom, with its
clumps of coral, its glittering pearl-oyster beds, and its brilliantly hued
fish, could be seen with ease.
Jim, the first few days on the island, fished with his usual ardour, and
caught a number of queer-shaped marine monsters.
He was all keenness to cook and eat his catch, but Jack and Tari put
their veto upon it.
As the rolling-stone explained, only the inhabitants of an atoll can tell
what particular fish are poisonous and what are not, and on each
atoll they vary according to the phases of the coral.
Tari stated that this strange poisoning of the fish changed according
to the position of the planet Venus. This is the general belief among
all South Sea Islanders, but of the two theories Jack's was more
probably the correct one.
Jim, foiled in his fishing for fear of poisonous fish or fish with
poisonous spines, turned his attention to shell-collecting, and he
soon had quite a quantity heaped up, each one having the usual red
spots which cover both shells, coral, and shellfish on an atoll.
It was a very pleasurable experience for the adventurous boy, this
picnicing life on a coral island, and, though he said nothing, he felt
keenly disappointed when departure was decided upon.
He dreaded a renewal of the open-boat trials and sufferings, and if
the choice had rested with him there would have been no
relaunching of the whaleboat.
After nearly three weeks on the island, of rest and recovering from
the late trying times, they one day launched the boat out through the
surf, and, with a good load of cocoanuts, headed away before the
south-east trades for Papeete.
Hour after hour went by as the buoyant little craft ran gaily before the
steady trade wind, with a new pioneer at the steering-oar in the
shape of Mr. Bill Benson, late bosun's mate of Her Majesty's gunboat
Dido.
"She weren't a bad little bug-trap as things go, an' no Callao ship
neither," pronounced the navy-man, speaking of his late ship as they
took their midday tiffin. "She was too top-'eavy, though, to my likin'
for rough weather; the owner, too, was a bit wet on muslin. It was
enuff to give one fits to see the way 'e carried on in that little 'ooker.
Stunsails, mind you, on the fore, reg'lar old style. She could sail, too,
an' weren't such a bad model, on'y 'er bally old nose sp'iled the 'ole
effec'. I've passed many a Chinee junk in 'er under sail, an' some o'
them ain't no slouches neither with wind to suit them.
"Her engines, though—oh, Lord! just a lot o' scrap-iron. You'd 'ear
the tink-tink o' the bloomin' tiffy's 'ammerin' an' repairin' all day long.
And b'ilers—oh, my! them wretched artificers spent mos' of their time
crawlin' about on their bellies, tinkerin' of 'em.
"There weren't never no time wasted. D'rectly they wos cool enuff to
boil a lump er ice, in them pore sweat-rags 'ad to go, creepin' an'
crawlin' on dunnage wood so as their feet shouldn't catch fire; then
presently out they'd come, legs first, cooked to a turn an' 'most
senseless. An' the way she wasted steam through 'er numerous
cracks an' chinks would 'ave made the bloomin' Chancellor o' the
Excheq'r go muzzy.
"That were 'er on'y defec', though; otherwise she wos a' appy ship.
Full er talent, too. Gunnery very fair, footer team first chop, the
dramy a bloomin' constellation o' stars o' the first magnitude, finest
squee-jee band in the Pacific, whilst our Jimmy Bungs[14] was er
artist on the cinder-track. Wot more d'you want? But I guess my jaw-
tackle's workin' too free. Give that cocoa-juice a fair wind, will ye,
sonny," and he pointed to the pile of cocoanuts amidships.
"Do you-alls reckon that this war-canoe o' yours is browsin' around
anyways handy hereabouts?" inquired Broncho.
"She was diggin' out for a bit er cannibalisin' through the Line Islands
when I took my fancy dive."
"Then I surmise that we can diskyard the war-canoe from our hand
as bein' wo'thless."
"I don't think we are likely to get picked up," said Jack, from the
bottom of the boat. "The Paumotus are far from being popular with
Island traders, and we are much too far to the west for any of the
Cape Horners."
"That's so," admitted the bosun's mate. "We came through the
Paumotus in the old Dido, an' did some fancy navigatin' at that,
scrapin' our weeds off on coral reefs, an' jammin' through tide-rip
channels with the wind jumpin' all round the compass. I went all cold
up my back more'n once, muckin' through them bloomin' reefs."
"Ain't we goin' to stop at any of the islands on the way?" asked Jim
anxiously.
"Not if we can help it," replied the rover. "I had a bit of trouble in the
Low Archipelago once, and haven't forgotten it. You remember, Lolie,
in the old Moonbeam?"
"Yes," muttered the woman, and shivered.
"Cawpse an' cartridge occasion, Jack?" inquired the cowpuncher in
his off-hand way.
"Pretty near. Shooting in the South Seas is more noise than
business though, sometimes."
"Every tuppeny bust-up is a 'orrible war. One copper-coloured coon
with a slit skin will give t'other side a big vict'ry. Some er these Low
Islands, howsomedever, is 'most perishin' for long-pig stakes, an'
enjoys massacretin' whites now and agen if they gets the chaunce,"
said Bill Benson.
The afternoon passed in tobacco-smoke and siestas, and with the
stars came back Jack's eyesight, which event always seemed to
give him renewed life.
"Out of it, Bill," he cried, springing to his feet. "It's my wheel now, and
your watch below."
"Them sidelights o' yours is the most mysterious be'aved optics I's
ever shipmates with. I think you oughter adopt more drastic
measures than them blighted bandages. Them eyes o' yours have
run outer oil or somethin', or mebbe wants trimmin'," exclaimed the
bosun's mate as he shifted places.
"The nerve's gone wrong somehow."
"It's that 'ere luminary that puts the hobbles on 'em. It was him cold-
decked you, Jack," asserted Broncho.
"The moon's responsible for a lot of trouble in this world," said Jack.
"You never know the way it will strike you, either. Some people who
get moon-struck can only see in the daytime; others get their faces
screwed up, and some go half-witted; but I'm hoping that perhaps
when the moon changes my eyes will improve."
"Do you really think that, Jack? Oh, I do hope so, with all my heart,"
exclaimed Loyola earnestly.
"Wall, you've only three sun-ups to wait, Jack, if you allow that's your
high kyard," announced Broncho.
"Mebbe they've got eroded an' won't render, but if it's the blessed
moon you've manœuvred up against, I've heard tell that folks that is
hoodooed that way, such as lunattics an' paralytic jokers, gets worse
at the full moon. Don't you butter your dough too much on that idee,"
observed Bill wisely.
"The trades are going to leave us," put in the rover abruptly, after a
keen look at the sky.
"Goin' to have more calm?" asked Jim anxiously.
"Well, doldrum weather, I expect."
"Ca'm weather kinder palls on one," drawled Broncho disgustedly,
"'an it's shore onheathful, an' liable to make a gent feel moody an'
bad; but if it's a forced play, we makes it ontil somethin' goes pop."
"Don't you jokers go manufacturin' trouble. Your joints'll tingle just the
same when it does come alongside, an' if it do keep below the
horizon, you're frettin' your brain-cases 'bout nothin'," said Bill
reprovingly.
"'Last Post's' gone; it's about 'Lights Out,'" announced Jack. "Shy us
over that almanac before you bed down, Jim. I'll take a star
presently."
"I'm going to stand watch with you, Jack," declared Loyola decisively,
getting up and seating herself by his side in the sternsheets.
So it was decided that these two should take the first watch, Bill
Benson and Tari the middle, and Jack again the morning, as he
could not trust either Broncho or Jim sufficiently with the dead
reckoning.
The night passed quietly with but little wind. Loyola insisted on again
bearing Jack company in his lonely vigil from four to eight, and after
breakfast these two lay down in the bottom of the boat and slept
soundly till near midday, awaking to find a big change in the weather.
The whaleboat was going close-hauled into a dead head wind. She
was right off her course, heading a point to the east of north.
The Pacific sparkled under the strength of the tropical sun, and there
was a heavy swell running from the nor-west.
On different quarters of the horizon rain-squall clouds hovered black
and wind-torn.
The breeze blew fitfully, and occasionally came in stronger puffs,
which heeled the whaleboat over till her garboard streak showed to
windward.
It had evidently been blowing hard somewhere below the north-west
horizon, to account for the long hills of water rolling in from that
direction.
The atmosphere seemed very clear, and the surf, breaking on a line
of reef about a mile to the north, showed up plainly, as if it was only a
cable-length off.
In the west the rain was falling heavily and the sea was torn up by it,
a well-defined line of white water denoting the edge of the squall.
Loyola, with the first instinct of a sailor, took a keen look to windward
as she rose from her recumbent position.
"We're going to have a blow," she announced quietly, turning to the
rolling-stone, who was slowly filling his pipe with a clumsiness
caused by his blindness.
"Are we?" he muttered indifferently.
"You're right, ma'm," broke in Bill. "The wind broke off soon arter you
turned in, an' 'as been very unsteady ever since."
"Coming out of the nor-west," went on the woman calmly; "a nasty
quarter in these seas."
"Can you locate us at all, Jack?" inquired Broncho.
"What's your dead reckoning for the last four hours?" asked the
rover.
"We've been headin' a point off north most o' the time," returned Bill
Benson, "and ain't averaged more'n two knots an hour."
"St. Jean Baptiste can't be far below the horizon in the nor-west,"
said Jack, after making a rapid mental calculation.
"Pass me over the sextant and I'll get a noon sight," observed Loyola
quietly.
Bill stared in astonishment, and ejaculated half under his breath,
"Blawst me, but she's a sailor's daughter an' no mistake."
"She was four years old when Big Harry brought her out to the South
Seas in the old Moonbeam. When he lost his money he turned the
yacht into a trader, and kept his daughter with him, as she had no
mother, and she's been at sea most of the time ever since,"
explained Jack in a low voice, as this sea-maiden ogled the sun.
Silently they watched her. This taking of the sun to the uninitiated
always seems a most mysterious and wonderful operation, and
Broncho, Jim, and the bluejacket stared with eyes full of awe and
admiration.
The sun was now close to the meridian, and presently the woman
called out,
"Make eight bells!"
Jack laughingly beat the notes of the bell with a spoon on the barrel
of his six-shooter.
"Throw me over the almanac and tables, Jim," cried Loyola coolly,
and a minute later she announced their latitude.
"Think we're in for some dirt, Lolie?" inquired the rolling-stone
casually.
"Sure of it! What you say, Tari?"
"Missee qui' right, big blow by-an'-by."
"I hope not," said the boy anxiously. "In an open boat there ain't no
joke in it."
"I'm with you, Jim," declared the cowboy. "I'd rayther be lost in a
blizzard a whole lot with a good hoss under me, than be upheaved
an' junked about on this here onrestful sea."
Presently the wind died away completely, and the boat lay rolling
helplessly on the swell, her sails flapping.
The afternoon passed slowly. Bill, in the bottom of the boat, lay face
downwards, apparently dozing. Jim, next him, was listening with
open eyes to one of Broncho's cattle-yarns. Tari, in the bows, slept
placidly; and in the stern sat Jack and Loyola, conversing in low
tones.
None of the boat's crew noticed the rapidly approaching change of
weather. Loyola had her back turned to the heavy squall rising so
rapidly, and neither Broncho nor Jim perceived it until the blind man
cried suddenly,
"I smell wind!"
One glance was enough. Up sprang Loyola, and, seizing the
steering-oar, with one long stroke she swept the boat's head round.
Then with a screech the wind fell upon them. The boat gave a violent
lurch and lay down to it, the water pouring in over the gunwale.
Broncho and Jim, taken completely by surprise, were tumbled to
leeward on top of the bosun's mate, who was half drowned before
they could extricate themselves, whilst Jack was awkwardly groping
about in a vain effort to get in the awning.
The woman steered superbly, and her clear voice rang like a bell
above the squall as she called to Bill to get hold of the sheet before
the sail flogged itself to rags.
The rain fell in solid sheets, and the sea hissed as it beat upon it.
The boat, rushing madly before the wind, rocked wildly, and dipped
her rail under at each roll; whilst Jack, in a foot of water, baled
furiously to keep pace with the rain; the other four struggled
desperately with the maddened sail. Loyola, hanging on to the long
oar with her strong young arms, stood swaying gracefully to the
motion of the boat, as, calm and watchful, she held it steady.
The sunshine fled below the horizon to the south-east, chased by a
mass of heavy, threadbare clouds, which came pelting across the
sky.
The sail was quickly muzzled and close-reefed, and Loyola
cautiously brought the wind on to the quarter, feeling its strength with
practised hand.
But it was more than the brave boat could stand, and a sea washed
over the rail which nearly filled her.
"Down that sail!" yelled Jack, whilst he and Jim baled with furious
energy. "Down that sail!"
After the first tremendous downpour the rain fell steadily, but with
less weight. Meanwhile both wind and sea commenced to rise, and
though the whaleboat rode the big rollers splendidly, many of the
smaller waves slopped aboard and kept the balers hard at work.
With the sail off her, Loyola swung the boat's head up into the wind,
and held her with the steering-oar from falling off.
"Lemme relieve you, ma'm," called the man-of-war's man,
clambering aft.
"I'm all right," answered the plucky woman. "Give the balers a spell."
"What's the glass say?" jerked out the blind man, panting with his
exertions.