This class of disorders is the most important. Among them I may mention valvular lesions, myocarditis, myodegeneration of the heart, fatty heart or rather heart weakness complicated with obesity, arteriosclerosis, aneurysm of the aorta, etc.

When Oertel treated of the therapy of diseases of the circulatory apparatus together with obesity in the Handbook of General Therapy, this was in reality a very one sided standpoint to occupy; at the same time this classification of the subject has since been shown to be of the greatest practical importance and at the same time of considerable historical interest and significance. Oertel argued that the treatment of these two classes of disorders was inseparably connected.

Even before Oertel's day the dangers of obesity in heart disorders were clearly recognized (for instance in the prognosis of acute infectious diseases, pneumonia, typhoid fever, etc.), but no one stated the dangers arising for heart cases when they were complicated by obesity so emphatically as did Oertel, and no other writer so forcibly described the great advantages accruing to heart cases thus complicated, from therapeutic measures directed towards a reduction of excessive fat. We may even say that on the contrary many clinicians before Oertel considered reduction cures harmful in heart disease because they believed that such treatment had a weakening effect on the organism, and should not be instituted in heart cases. If I speak of heart cases in this place I do not refer merely to sufferers from heart lesions proper, from valvular disorders, and from diseases of the heart muscle, but to all patients who are afflicted with diseases that impose increased work on the heart as, for instance, patients with arteriosclerosis, kyphoscoliosis, advanced degrees of emphesematous destruction of pul monary capillaries, extended adhesive pleuritis, etc. All these cases have this in common that the heart is forced to perform increased and excessive work and is soon brought into a condition of hypertrophy with danger of dilatation and insufficiency of the heart muscle, etc. The deleterious effects on the heart are increased whenever the body carries an excessive ballast of fat. The greater this ballast the greater the demands on the heart and the smaller the surplus of energy at the disposal of the heart musculature for overcoming the pathologic obstacles to the circulation of the blood.

As a rule it is altogether impossible to exercise any direct effect on the lesions of the circulatory apparatus itself; how should it be possible, for instance, to dilate a stenosis of the cardiac orifices or to re-establish the permeability of obliterated pulmonary capillaries? In cases, however, that are complicated with obesity we can successfully combat the latter condition and by relieving it save the heart a great deal of excessive work, and in this way enable the impaired organ to devote all its surplus energy to combating the irremediable effects of the pathologic-anatomic disturbance with the circulation of the blood-stream. These theoretic considerations have been brilliantly corroborated by practical experience. To judge from all the reports of numerous writers, and I may include a large clinical experience of my own, reduction cures instituted in a correct manner constitute one of the most valuable adjuvants to the treatment of circulatory diseases that we possess.

There are, of course, numerous cases in which the degree of obesity is so great or in which the lesions of the circulatory apparatus are so far advanced that it is altogether impossible to restore the heart to its normal functional activity.

The most satisfactory and the most suitable cases for reduction treatment are those in which slight disorders of the circulatory apparatus are present, that are very well compatible with life, and at the same time moderate degrees of obesity, cases in which the first signs of failing compensation are just beginning to appear; these constitute the majority of cases of heart disease that present themselves for treatment. If in patients of this character the one damaging factor, viz., obesity, is excluded, and if in addition other measures are instituted that strengthen the heart, many years of life, even many decades of comparative wellbeing, may be granted these sufferers.

The results of this plan of treatment are, of course, still more positive if the first signs of failing compensation are not even allowed to appear, and if in all cases that are afflicted even with slight disorders of the circulatory apparatus all excessive fat is gradually removed, or if not removed at least prevented from increasing so as to lead to more advanced degrees of obesity. This is a particularly good field for prophylaxis and it must be considered one of the most important duties of the family physician to carefully prevent the incidence of obesity in all cases that come under his care in which he recognizes some weakness of the cir culatory apparatus, as, for instance, some valvular lesion developing in early years; in all cases of this kind he must know and understand that obesity is a most undesirable and a dangerous complication.

The peculiarities of each individual case must, of course, determine the exact modus operandi to be pursued in combating the tendency to obesity. A few general points of view can nevertheless be established.

In hopeless cases that offer no chance of recovery it is, of course, useless to institute a reduction cure. It is well, however, not to draw the line too closely in this respect, and not to declare too many cases as beyond repair. It will be found that in the different forms of impairment of the heart, of heart weakness, that we encounter in obese subjects, better results are as a rule obtained than in simple cases of heart lesions; effects are sometimes produced that could hardly be foreseen. I consider those cases grave in which edema is present and in which attempts to treat the case energetically with digitalis and similar remedies have been abortive. In all such cases danger is threatening. Although naturally no one will for one instant consider the advisability of instituting a regular dietetic reduction cure in cases of this character, we must never forget that in all such patients the diet is reduced anyhow even without our suggestions to reduce the amount of food; in fact, we will rarely succeed in inducing patients of this kind to eat much; these cases always develop thirst but at the same time have a considerable aversion for solid food. The only measure that promises some success in these desperate cases is a limitation of the amount of liquid nourishment combined with the administration of strong heart stimulants like camphor, ether, strong spirituous liquors, etc. It is frequently a difficult matter to carry out this limitation of liquid pabulum but it is worth while to make the attempt; for in all cases that can be helped at all we will witness distinct signs of improvement within a week or two. As soon as all immediate danger is passed we should begin to strengthen the heart with careful gymnastic exercises and hydrotherapeutic measures. I think that Schott was right when he called attention to the fact some years ago that many obese subjects derive marked benefits from this method of treatment even in apparently desperate cases. As soon as the first favorable results are obtained we should always follow the treatment up with a second course of digitalis and we will as a rule find that now the results of this therapy are much more favorable than they were before. As soon as the powers of the heart are improved the appetite too as a rule increases. It would be altogether wrong to limit the amount of food at this period for fear of increasing the fat deposit; the appetite of the patient should therefore not be reduced but should be welcomed as a sign of improvement. As a matter of fact, patients who have just recovered from a severe heart attack should be allowed a liberal diet which, of course, must be carefully administered and arranged in such a manner, as regards quality and quantity, as not to overload the digestive organs. Not until all im mediate danger of renewed heart weakness is eliminated should we begin to impose restrictions in regard to the diet, and not until then should we think of advising a reduction cure proper; at the same time we should not allow the most favorable period for this treatment to elapse, and should certainly not omit this method of therapy altogether, for otherwise we may expect to witness the development of renewed attacks of cardiac insufficiency. If it can be done at all, patients of this kind should be treated clinically as long as there is any danger from this source.