I intend to discuss the indications for an obesity cure very briefly, because this subject has been thoroughly discussed in another monograph of this collection (Vol. 1, 1900).

Must a reduction cure be regarded as "weakening"? This question can be definitely answered in the negative, provided an important preliminary inquiry has been properly solved; namely, whether or not there is any indication at all for instituting a reduction cure; and provided one proceeds in the proper manner. The last postulate is of the greatest importance, and I will have occasion to refer to it later in detail. If the indications are properly formulated, and if the proper path is followed, the patient will not become weaker, but on the contrary stronger from the treatment. A reduction cure itself cannot weaken the patients, but mistakes that may be made in instituting a reduction cure can produce this effect.

High degrees of obesity

That is, a body weight exceeding by 25 kg. or more the weight that corresponds to the height of the patient, must almost always be considered an indication for a reduction cure. In children one is accustomed to speak of a high degree of obesity, if the body weight exceeds the average by about 10 kg. If all the organs are healthy, there are no objections to undertaking a reduction cure in such cases. In children, however, and in very old people, even if the organs are sound, a certain amount of care must be exercised. The higher the degree of obesity the slower should one proceed in the latter class of cases.

Medium degrees of obesity

That is, (15 to 25 kg. of overweight), occurring in young people and in subjects up to the 6th decade of life and between, may also be considered fit for a reduction cure, provided the individuals are otherwise healthy. Especially in subjects who have to perform a great deal of physical labor, reduction of the fat is exceedingly desirable, because the heart and arteries become overstrained and wear out more rapidly if they have to supply this unnecessary ballast. In old people, however, one should always approach a reduction cure with a great deal of hesitancy, even though one undertakes to reduce their flesh very slowly and under the most careful control of the whole organism, especially of the heart.

Slight degrees of obesity

That is, (an overweight of from about 5 to 15 kg.) do not constitute, from the medical standpoint, a cogent reason for undertaking a reduction cure in healthy people, especially if their weight has been constant for a long period of time. In case, however, a tendency to increased weight has become manifest, then one is justified in taking steps to reduce flesh, especially as at this period a loss of weight may be produced by very slight restrictions that can hardly be dignified with the name of a reduction cure. As far as the patients themselves are concerned, the motive that determines them to consult a physician when they are afflicted with mild degrees of obesity is rather vanity than discomfort, and this applies to women, of course, much more commonly than to men. The physician, provided he possesses not only a knowledge of medical practice, but also has an insight into human nature, will hardly underestimate the importance of this factor. If from a false sense of professional dignity he refuses to place his medical knowledge at the disposal of the patient for this purpose, then she will either prescribe a reduction cure for herself or else will entrust the treatment to some quack; in either case, her health is apt to be endangered.

Particular circumstances may render it desirable, even in milder degrees of obesity, that per se do not seem to urgently call for a reduction cure, to proceed actively; for instance, in diseases of the circulatory organs, in chronic bronchitis, pulmonary emphysema, narrowing of the thorax or kyphoskoliosis, chronic diseases of the organs of locomotion, etc. In all these cases it is of value to remove surplus ballast in order to prevent premature wear and tear.

On the other hand, there are a number of conditions that constitute a warning against instituting a reduction cure. Advanced age has already been mentioned. Diabetic subjects as a rule fare better if the adipose tissue remains somewhat above the normal average.

The same applies to cases of genuine arthritis urica. I have frequently seen cases of gout that were essentially harmless and that developed only rare and mild attacks assume a more serious form as soon as an energetic reduction cure was undertaken. It is true that in sufferers from gout the condition of the heart and arteries must be considered, and derangements about these organs may force one to undertake a reduction cure. In all such cases, however, one should proceed with the greatest care and very slowly. And finally, pulmonary tuberculosis must be mentioned. Here, too, a degree of adiposity slightly exceeding the normal is rather beneficial than otherwise, provided the degree of obesity is not too great and does not actually constitute an advanced form. These two groups of cases must be distinguished. In the first group the obesity of tuberculous individuals must be considered as an artificial product of excessive dieting. This should be prevented as indicated in previous paragraphs (see Vol. VIII). Provided, however, this error has once been committed and the patients have become too fat, then the greatest care must be exercised in again reducing the body weight. Such patients tolerate very poorly a reduction in the food intake, and there is always danger of rekindling a latent tuberculous process in the lungs. In the second and smaller group of cases, the patients approximately maintain the same weight that they possessed before the infection occurred, even though they are suffering from fever and are ingesting relatively small quantities of food. I believe that all these latter cases, that so far have only been regarded as medical curiosities, are really afflicted with a perverted thyroid function; and I urgently recommend a careful study of the thyroid in such subjects, both intra vitam and at autopsy.

There is still another disease the progress of which is unfavorably influenced by obesity, namely, contracted kidney; here, therefore, there is a strong indication for instituting a reduction cure, especially in all those patients who are afflicted with an advanced degree of cardiac hypertrophy and who have a tendency to dilatation of the left ventricle. Here again I must advise to proceed with the greatest care and very slowly. There is hardly any other disease in which a rapid reduction cure is more poorly borne than in contracted kidney. The result of a reduction cure in these cases is almost invariably weakness of the whole musculature, including the heart muscle. I am of the opinion that any attempt to institute a reduction cure in contracted kidney should be made in a sanatorium. Incidentally one might mention in this place that occasionally too rapid a reduction cure or a reduction cure that is carried out for too long a time, may initiate chronic renal disease. As a rule, one is here dealing with contracted kidney. My deceased clinical teacher, C. Gerhardt, used to call attention to this point in his clinic in every case of contracted kidney that he demonstrated. Later I have seen many cases that corroborated his view.