Introductory.

Gentlemen: The physician who does not wish to treat his patients according to old-established routine practice, and who does not feel satisfied with prescribing in a purely superficial manner (so-called ''expectant treatment") will consider it his duty and will make it a general guiding principle in the treatment of his cases never to advise therapeutic measures of any kind without having first decided to what extent they are justified and what results may be expected from them. Self evident as these postulates may appear they are nevertheless frequently violated, particularly in the treatment of chronic diseases; chronic disorders of metabolism and of nutrition, especially, are frequently treated in a very careless and superficial manner without any clear ideas apparently on the part of the physician in regard to the exact indications obtaining in each individual case. It seems almost incredible to contemplate how many physicians display a very shallow appreciation of the art of healing when they send diabetics and patients suffering from gall-stones to Carlsbad or Neuenahr, rheumatic cases to Wiesbaden, sufferers from heart disease to Nauheim, purely as a routine practice; when others habitually prescribe milk for cases of nephritis and interdict the use of meat to sufferers from renal disease, or attempt to make the lean fat and the fat lean, etc., always without any clear conception of what they are doing. This schematic method of treating certain chronic forms of disease is encouraged by the elaboration into the smallest detail of many so-called "methods of cure"; this whole system of therapy would actually appear ridiculous if unfortunately harm were not done in so many cases ; when a medical history of our times comes to be written in the future we will certainly be accused of having endorsed almost any method of treatment that seemed to contain something new or seemed to present certain special features; many physicians and many so-called "enlightened" laymen unquestionably merit this reproof for they seem to adopt any such method of treatment without first attempting to render critical judgment on its merits and demerits. As a matter of fact, however, it would be wrong to identify this unfortunate tendency with the trend of modern scientific medicine. On the contrary we are fully justified in saying that the principle to avoid all dogmatism and all schematic methods is apparent to-day in matters therapeutic and that the tendency is apparent to strictly individualize, as far as that is possible, in the treatment of the class of disorders we are discussing.

There is always danger in "individualizing" for we may lose sight of the broad guiding principles that should govern all therapy, and become swamped in a mass of detail; in order to avoid this, certain broad points of view should be adopted. It is necessary to learn to distinguish the essential from the non-essential. It is important above all to know what we are trying to combat, why we are combating it and what we expect to accomplish by the method of procedure that we adopt. The determination of all these factors coincides with the "indications" for certain therapeutic measures.

In preparing the part on "Obesity" for Nothnagel's Handbook of Special Pathology and Therapy, I was struck by the fact that none of the many writings on Obesity that have appeared in the course of the last decades contain a comprehensive elaboration of the indications for reduction cures in this disease. I consider it a grateful task, therefore, to discuss the most important principles that should guide us in instituting such reduction cures from a uniform point of view. In order to render correct judgment in regard to the advisibility of instituting reduction treatment in any given case it is essential to understand these determining principles and to interpret them correctly.

Before beginning treatment of any kind in an obese subject it is always necessary in the first place to decide the question whether or not to institute a so-called reduction cure or whether to content oneself with preventing the further deposit of fat and with preventing or removing disturbing and dangerous complications. It will frequently be found that the physician and the patient entertain different views on this subject. Reduction cures have become so popular that many patients undergo a course of treatment of this kind on their own accord and without consulting a physician; others merely consult a physician in order to learn the correct measures to be adopted for the purpose they have in view but not in order to find out whether a reduction cure is necessary or indicated; still others do not consult a physician at all but simply begin a reduction cure on their own responsibility and according to their own method. Frequently prescriptions are followed that are obtained from some acquaintance who may claim to have derived benefit from them, or certain popular writings are consulted that give the desired information and, finally, certain watering places are visited that enjoy the reputation in the reduction of obesity. This independence of action in regard to the treatment of obesity we naturally encounter more frequently in women than in men and more commonly in young girls and in middle-aged women than in older women. It is often a very difficult task for the physician to persuade his client of either sex that a reduction cure may be unnecessary or even dangerous. Even if we succeed in convincing our patient for the time being, the fight is by no means definitely won, for such patients only too often discover more accommodating advisors either among physicians or in the ranks of pseudo-physicians.

We also frequently witness the reverse. A person who is too obese may consult a physician for this or that trouble and the physician may discover that the symptoms of the patient are due to excessive fat and may advise a reduction cure on these grounds; the patients on the other hand merely recognize that they are suffering from some organic disorder and expect local treatment for the relief of organic symptoms; they do not understand how a reduction cure can be of any benefit nor how their trouble can be relieved by causing a loss of fat; in fact they may refuse to undergo a reduction cure because they fear the weakening effect of this procedure. In many of these cases we are dealing with sufferers from so-called "relative" obesity, in other words, excess of fat according to current ideas is not great and the patients themselves do not regard themselves as "obese"; the physician on the other hand who studies all the factors that are operative in cases of this character realizes how much he can benefit his patient by getting rid of the excess of fat and appreciates how much he can improve the functional powers of certain organs (for instance, the heart, the lungs, the liver, the muscles and joints) by reducing the fat content of the body.

What principles should guide the physician in deciding for or against a reduction cure? In the first place I wish to place myself on record as opposing the view, that we hear so frequently expressed, that reduction cures are a weakening procedure and constitute, in other words, a so-called "weakening cure." The ideas prevalent in the minds of the laity in regard to this matter are altogether exaggerated; a perusal of the literature shows that for many years an earnest, but by no means pleasing, refreshing debate has been waged on this subject; one author will ad vise this system of dieting another that one. I feel justified in stating positively that a reduction cure, provided it is really indicated and provided the proper method is adopted and carried out expeditiously, is by no means a weakening procedure, particularly if the peculiarities of each individual case are carefully considered in administering such a cure. Under the conditions outlined a reduction cure can always be tolerated without detriment to the patient and as a rule improves the general functional powers of the organism. It will be seen, however, that such a favorable judgment can only be rendered if a series of conditions are fulfilled that sound simple enough but that nevertheless call for careful consideration and presuppose much practical experience on the part of the physician who supervises the reduction cure. Errors are committed in many of the points that I have mentioned; the most frequent errors being those that lead to the adoption of a reduction cure when such a method of procedure is not indicated, and errors in the method itself.

I have already called attention to the fact that many patients consider themselves altogether competent to decide the important question whether or not a reduction cure should be instituted; this is largely due to the fact that on superficial investigation this decision seems very simple indeed. In regard to the method I am forced to confess that unfortunately many physicians treat cases of this kind according to some prearranged scheme and not according to the require ments of each individual case of obesity. Here in Germany - and I suppose the same obtains in other countries - we have a number of sanatoria and many physicians who are committed to certain definite methods of dietetic treatment, methods that are usually known by some well-known name; in all such institutions the particular method that is in favor is adopted for each patient who goes there for treatment, and all the physicians who swear by any one particular method of treatment apply it in each case that comes under their care. The method is their idol and the patient and his disease are merely the object on which to try the method. In the whole field of dietetic therapy this one-sidedness and narrowness is nowhere more pronounced than in reduction cures; this unfortunate condition of affairs is the direct result either of stupidity or of cheap and venial advertising that misleads those who are not competent to render judgment on their own accord. Reduction cures are therefore a happy hunting ground for the charlatan and the fakir and for all the exploiters of the "method swindle." How often do we hear physicians say: In ordering reduction cures I prescribe the diet given by Dr. X., or I treat my cases according to Dr. Y.'s method and obtain the most gratifying results. This is a very one-sided and narrow standpoint to occupy and it is merely a matter of luck if this one-sidedness does not lead to the committing of serious error. We possess so many physical means of treatment and such a large variety of dietetic schemes that in deciding on a method of reducing fat the peculiarities of each individual patient can without difficulty be considered and included in the calculation. In numerous cases, it is true, the choice of the method is more or less indifferent and we may be permitted to exercise considerable latitude, may in fact allow the patient to determine the method he wishes to adopt according to the requirements of the external circumstances obtaining in each case; in others again the success of the treatment and the feasibility of instituting a reduction cure at all, not to speak of the well-being and the very life of the patient, may depend on our choice of method.