Modern phthisiotherapy, according to Brehmer and Dettweiler, calls for abundant nutrition in phthisis. The results of this treatment are so extraordinary and so satisfactory that we need not be surprised to find many cases of tuberculosis who become quite obese. As a rule patients are between twenty and thirty-five. The majority of them were so fortunate as to discover the disease at an early stage, and, following modern methods of treatment, underwent prolonged rest and fattening cures. While I recognize that a systematic fattening treatment is most beneficial in tuberculosis and exercises a most favorable influence on the course of the disease, and while I am inclined to encourage such treatment in suitable cases, I must nevertheless raise my voice in warning against any exaggeration of this mode of treatment. Unfortunately we find such exaggerations are frequent now-a-days. The natural result is that many cases of tuberculosis are converted into obese individuals whose functional powers are much reduced. I have followed a number of such cases and I am not of the opinion that the condition of obesity renders these people more fit to struggle against the tubercular invasion and the inroads of the disease that has affected their lungs. As long as they can lead the lazy life that is imposed on them in the different institutions where this treatment is given, everything goes well and they are exhibited as shining examples and the pride of the institution. As soon, however, as they return to the routine of everyday life outside of the institution, the course of the disease usually takes a rapid turn for the worse, and a second course of fattening treatment is rarely capable of saving them. In other cases the patients retain their good health even after they leave the sanitarium, but these subjects have gained some 40 or 50 pounds and are consequently decidedly obese; they suffer from this condition and are for all future time exposed to the dangers that this state engenders.

I should like to insert in this place the history of a case of this character. The patient was a woman of 22 years, moderately well nourished (weight, 58.8 kilos). After her first puerperium she went through a mild attack of pleuritis; when this was over a few suspicious fine râles were heard at the right apex, and after prolonged search a few tubercle bacilli were discovered in the sputum. Domestic circumstances made it desirable to remove this patient from home. At this time I suggested that the woman, who was a spoiled and pampered individual, should spend the winter in the mountains, especially as she was a very vigorous person otherwise. It was decided, however, to send her to a sanitarium that was situated in the vicinity. The reports received from this institution were very favorable; the general health was good, there was never any fever, and the weight increased. The râles at the apex disappeared within a few months and were never heard again although the lungs were examined twice a week. She remained in this institution all winter long and returned home at the expiration of seven months apparently perfectly well and having gained 19 kilos. At home she voluntarily continued to live on an abundant fattening diet and gained 10 kilos more during the summer months. In August of the same year I was consulted a second time as the patient had in the meantime developed difficulty in breathing and had suffered several fainting attacks. Nothing abnormal was discovered in the lungs. The patient, however, presented all the features of advanced obesity of the anemic type, with alarming weakness of the heart and the muscles. Several months of careful treatment were required to reduce the weight somewhat and to increase the functional powers of the heart and of the muscles. This patient has never again - two years and a half have elapsed since that time - regained the same degree of freshness and vigor that she enjoyed before she began the sanitarium treatment.

It might be argued that the dangers of obesity as compared to the dangers of tuberculosis are very insignificant. This is undoubtedly true, but might we not ask whether it is necessary to drive off one foe by opening the gates to another one? It is unnecessary to attain more than a certain optimum of nutrition even in the treatment of tuberculosis; in fact, it is bad practice to force feeding beyond this point. I am glad to find that Blumenfeld occupies the same stand in a dissertation that this author has recently taken. I would certainly hesitate to institute a reduction cure in any sub ject who has lately passed through some tubercular affection of the lungs or who is actually afflicted in this way; I would only advise this in case the condition of obesity itself threatened imminent danger. At the same time I feel called upon to warn against too forced feeding in the treatment of pulmonary disease; in other words, I advise raising nutrition to a point that may be considered good and satisfactory but not to carry feeding so far that the patient becomes actually obese; for wherever the fat deposit becomes excessive there is little room for the healthy development of the muscles. This applies still more to sick persons than to well subjects. And as the strengthening of muscle tissue guarantees a far better outlook for the future than the accumulation of fat I can only warn against the artificial induction of obesity in these cases.

I herewith conclude this review of the indications for reduction cures. I am fully aware of the fact that I have been unable to give more than a general sketch. While I have, I believe, done full justice to the more important points that must be considered, I realize, at the same time, that in practice many cases will be encountered in which a decision in regard to the advisability of a reduction cure will have to be arrived at from other points of view than those enunciated in this treatise; the principles that will have to govern this decision in each individual case are such that they cannot be discussed from a general therapeutic standpoint.