Gout occurs both in individuals with abundant and with scanty adipose tissue. In the latter group gout is decidedly less frequent; it is particularly that form of gout which is produced by chronic lead intoxication that is encountered in thin people. Here the form in which gout appears is usually very severe and involvement of the kidneys as a rule occurs very early. In lead workers, afflicted with gout, whose general nutrition is greatly reduced, I frequently try to improve their general strength by a fattening diet. I have never, however, been satisfied with the results obtained. It is not a difficult matter to increase their weight, but as soon as this is accomplished a disproportion very readily develops between the powers of the heart and the mass of the body, so that cardiac difficulties make their appearance and the danger of cardiac insufficiency must always be feared. I, therefore, advise against any attempt to fatten subjects afflicted with gout, especially with lead gout.

Arthritis urica much more commonly accompanies an obese constitution, hence the venerable but by no means correct idea that gout is a specific sequel of high living. A certain connection no doubt exists between gout and obesity. So far, however, we are not able to analyze this relation scientifically and are limited to the teachings of experience. Just as emphatically as I advised against any attempt to fatten a lean sufferer from gout, so emphatically do I recommend attempting to reduce the fat as early as possible in any obese sufferer from gout. If this is not done the heart becomes injured. I need hardly call attention to the fact that even in simple obesity insufficiency of the heart muscle is an extraordinarily common phenomenon. In gout certain additional noxious factors affect the heart ; for we must assume that in this disease certain toxic substances (endogenous intoxication, autointoxication), not necessarily, however, uric acid, exercise this poisonous effect. It is very doubtful whether the most careful diet can prevent the peculiar self-intoxication that occurs in a gouty organism. The one thing we can do is to keep the production of uric acid at the lowest possible level and in this way suppress the severe exacerbations of the gouty process. A gouty individual, however, remains gouty even though no more attacks occur and no more uric acid tophi are deposited. Even after typical manifestations of gout (attacks, tophi) have been suppressed, disagreeable and even dangerous sequelae very frequently develop, consisting in cloudiness of the lense, iritis, sciatica, neuritis, also dangerous neuritis of the vagus nerve, nephritis. The nature of these disturbances seems to indicate that certain toxic factors are operative in producing them. Among the organs that are most frequently affected by these unknown, but in my opinion decidedly real, toxic factors, is the heart muscle itself. In a case, therefore, in which gout and obesity are combined, the heart is threatened from two directions (toxic injury from gout, mechanical injury from obesity). One of these dangers we can remove by early interference, that is, by producing a gradual loss of weight by means of careful restriction of the diet. No doubt many of the most brilliant results obtained in regard to the general well-being and the general strength of gouty subjects in Carlsbad, Homburg, Kissingen, Marienbad, are attributable primarily to the loss of weight that is accomplished. On the other hand, numerous failures, in particular injury to the heart muscle, are chronicled in watering places, particularly in Carlsbad and Marienbad. The latter occur at once, or more frequently some time after, a reduction cure has been undertaken. Physicians in general, therefore, have become strongly prejudiced within recent years against reduction cures in gout and thoroughly condemn them. I am not altogether in accord with this prejudice, for the dangers of a reduction cure can certainly be obviated if active steps are taken in early stages, that is, in medium degrees of obesity, or if, at least, every effort is put forward to prevent any further increase in weight. In more advanced degrees of obesity and even in cases in which the combination of gout and obesity has already produced the first signs of cardiac insufficiency the urgent indication to reduce flesh can also be met, provided only that one proceeds with sufficient care. I have carried out many such reduction cures in obese individuals with a weak heart, but only under the most careful control in a hospital or a sanatorium, and I have never witnessed any unfavorable effects upon the heart. On the contrary, a great improve ment and a permanent one about the heart is obtained from this treatment in all such patients.

In this place I must insert a very important observation. In the preceding paragraphs I took the stand that sufferers from gout should be permanently placed upon a diet poor in purins, and I gave instructions how this is best done. If it is desired, however, to institute an energetic reduction cure in a sufferer from gout one should deviate from this plan. When I first began to occupy myself with studies relating to the pathology and the treatment of metabolic diseases, I occupied another standpoint and attempted to combine a reduction cure with the administration of a purin-free diet. Thus, for instance, a diet incorporating about 1500 to 1700 calories was arranged, consisting largely of vegetables with the addition of a little egg and milk. Later, however, I abandoned this diet altogether because I saw cardiac complications develop in several instances, and I then decided to adopt a diet incorporating abundant albumen and one especially rich in meat; and it is only since that time that I have secured permanent and favorable results from reduction cures instituted in gouty subjects. In arranging such a reduction cure, therefore, the perversion of the uric acid metabolism should temporarily be relegated to the background to be reconsidered later when the loss of weight has been accomplished. True, I occasionally had the misfortune of seeing a typical attack of gout develop during the reduction cure. These attacks, however, were of short duration; and the ultimate effects, as far as the general health and strength of the patients, and in particular the condition of the heart were concerned, were excellent.

I place particular emphasis upon these studies and experiences because there is in modern therapeutics a tendency toward the same errors that I committed formerly and that I have since recognized and learned to overcome. In many watering places where obese sufferers from gout congregate, a vegetable régime is instituted. Whatever one's views may be in regard to the justification of a vegetarian mode of life, one cannot conceal the fact that the combination of such a régime with a weakening drinking cure, with undernutrition and a great amount of muscular exercise, combined with exhausting hydrotherapeutic means, etc., as instituted in Carlsbad, includes certain elements of danger for any individual, but particularly for a person not used to a vegetarian diet. I can formulate the same criticism against milk cures and vegetarian reduction cures, that have recently become so popular and that are given in many sanatoria, for instance, in Lahmann's institute for the treatment of gouty sufferers from obesity. During the cure proper everything proceeds splendidly, and for a short time afterwards the patients feel very well. Instances are, however, accumulating in alarming number of patients who within one to two months after the reduction cure suffer a complete collapse and develop serious degrees of cardiac insufficiency. The cause for this is, then, usually sought in certain external factors; but in my personal experience the cardiac insufficiency so frequently follows one or another exhausting reduction cure, with the many deprivations that it entails, that an etiologic connection between the two must be assumed. I express the hope that this warning will suffice to prevent obese patients with gout from undertaking exhausting reduction cures in the future.