(Arthritis urica). It is a well-known fact that gout and obesity are frequently found together in the same individual. The prognosis of gout in obese subjects is comparatively favorable; the disease in such subjects rarely develops into that more serious form with deposit of numerous tophi and great destruction of articular structures, that is comparatively common in lean persons. It is also easier to attain good results from treatment in this class of gouty cases, for here moderation in living and extensive physical exercise are usually followed by favorable results. The treatment of gout and of obesity is therefore the same in many respects. Reduction cures in gout intended to influence both metabolic disorders at once have consequently been popular for a very long time, and form one of the most important and the most justifiable branches of the balneological treatment in Carlsbad, Homburg, Kissengen, Marienbad, Vichy and other places. In practice we usually limit ourselves to prescribing an annual course of such balneological treatment; in addition we, of course, give a few important regulations (interdiction of strong alcoholic drinks and of abundant quantities of liquid nourishment and of water), and a few unimportant ones (interdiction of dark meats). This method of treating our cases is without doubt correct and useful; at the same time we would benefit them a great deal more if we attempted to influence the general daily mode of life to a greater extent than we are in the habit of doing. We realize, however, that particularly in these cases it is a difficult matter to convince the patients that they are likely to sacrifice all the benefits derived from a course in Carlsbad, etc., if they immediately relapse into their ordinary mode of life. In many patients of this character who are pampered and who are used to an easy way of living and who do not care to make radical changes in their mode of life, a prolonged course of treatment in a sanitarium may be of great benefit, particularly in the sense of educating these people in the correct manner of living.

Great difficulties are offered in the selection of the correct diet for cases of gout complicated with obesity. If we follow Sydenham's old doctrine, we will have to limit the amount of meat to a great extent in the treatment of gout, whereas in the treatment of obesity it is not well to reduce the amount of meat for any length of time. Without indorsing the theoretic ideas advanced by Pfeiffer, I nevertheless agree with the practical advice he gives for the treatment of obese sufferers from gout, namely, not to fear the effects of abundant quantities of meat (lean meats of any kind or color); the only precaution to be observed in this practice is that the patients are also given a plentiful amount of green vegetables and of fruit at the same time.

In gouty subjects we frequently find a variety of disorders that call for a reduction cure with much greater urgency than the uric acid diathesis itself. I refer to genuine renal disease, arterioslerosis, attacks of cardiac weakness, etc. Some writers have attempted to classify the disturbances of the heart that are seen in cases of gout under the heading of an independent syndrome that they call gouty heart (Gichtherz, Th. Schott). Such a definition, it appears to me, is altogether without justification. If we study cases of this kind more thoroughly - and I have occasion to see many dozen such patients every year, in great part Englishmen who consult me when they come from Nauheim - we will find that almost without exception we are dealing with obese subjects who combine distinct arteriosclerosis and occasionally slight albuminuria with obesity. From the history of these cases we usually learn that the patient indulged in violent physical exercise in his youth and lived a luxurious life later on usually with excessive indulgence in alcoholic liquors. This mode of life we learn was carried on until the first symptoms of the disease appeared; here we certainly have ground enough for the simultaneous development of obesity and of serious injury to the circulatory apparatus. As soon as the slightest signs of gouty pain appear together with these symptoms, and in innumerable cases without any definite indication of gout, the average Englishman is inclined to attribute the whole symptom com plex to the gouty diathesis and to explain all his troubles on this basis. This view is certainly wrong. It would be of much greater benefit to every one concerned if we refrained from using the euphemistic expression gout and called things by their right name. If we did this we would not attribute the symptoms to any gouty disposition, but simply to chronic abuse of alcohol. From a therapeutic point of view the doctrine of gouty heart has been of great benefit. We have become accustomed in patients afflicted in this way to consider the condition of the heart more than the uratic diathesis and to arrange our treatment accordingly. As soon as the necessity of such a method of procedure is once recognized we will at once understand that it would be bad practice to refrain from devoting particular attention to the reduction of the obesity that so frequently complicates these lesions; in fact, when arranging a general plan of treatment we should always include obesity in our calculations. The change that has occurred in the views of many practitioners in regard to this matter is distinctly manifested in the tendency that is becoming more and more apparent not to send these patients, as heretofore, to some watering-place like Carlsbad, Neuenhar and Vichy, where the patient takes a course of alkaline waters, but to send them every year to some watering-place where corpulence is treated by a carefully selected dietary and where the heart is strengthened by such measures as baths, massage, gymnastic exercises, mountain-climbing, etc. (Carlsbad is to be recommended if the amount of water-drinking is to be limited, otherwise this place is not very suitable; Homburg, Kissingen, Marienbad, Nauheim, Tarasp have cold-water institutes, so-called "Terrapin" watering-places.)