144 GOUT 



fact must be expressly pointed out that gout, obesity and diabetes mellitus 

 are intimately related, which is evident from the circumstance that two of 

 these diseases, or not infrequently all three, simultaneously occur in the same 

 person. There is an extensive literature regarding the connection between 

 obesity and gout. Some look upon obesity and gout as inseparable accom- 

 paniments of one another. Still I must emphatically state here that gouty 

 patients are by no means all fat. Many are so, but even these may emaciate 

 after they have become cachectic as the result of gout. Certainly there are, 

 as has been stated, many fat gouty patients, and I may here refer to ray arti- 

 cle upon obesity, in which I mentioned such a case occurring in my practice, 

 and took occasion to discuss the relation between gout and obesity somewhat 

 more in detail. This observation is specially interesting because it concerns a 

 lady who had well developed typical attacks of gout, which are by no means so 

 rare as is usually supposed, but, on the contrary, in my experience, are fre- 

 quent enough in women suffering from obesity. In discussing obesity, I re- 

 ferred to the developm.ent of fiat-foot which we occasionally observe with in- 

 creasing corpulence, particularly in persons with a hereditary predisposition to 

 obesity and gout ; these are mostly young individuals of either sex. The rela- 

 tions between gout and diabetes mellitus need not be here considered. But it 

 may be noted that gouty and diabetic symptoms not infrequently alternate with 

 one another, a fact which causes the diabetes to assume a somewhat intermittent 

 character. The excretion of sugar is then slight, as a rule, and the so-called 

 diabetes arthriticus frequently shows a course similar to that described by 

 Johann Peter Frank as diabetes decipiens. A. Gilbert and Emil "Weil attrib- 

 ute this form of diabetes mellitus to an insufficient or entirely absent function 

 of the liver. Alimentary and rapidly disappearing, so-called simple, glyco- 

 surias, which I always look upon with suspicion, are not so rare in gout. 



We must now consider the relation between gout and rheumatism. What 

 is to be understood by this? First, there are a number of so-called cases of 

 chronic arthritic rheumatism which should be considered as gout. When per- 

 sons about fifty years of age, who have previously never suffered from any 

 disease resembling acute articular rheumatism, are attacked by an afebrile 

 disease which particularly implicates or almost exclusively affects the small 

 Joints, which is accompanied by inflammatory symptoms, and which runs its 

 course with acute exacerbations, gout should first be thought of. This is also 

 true of the cases in which the joints show a certain deformity, and in which 

 we usually recognize the presence of so-called deforming articular rheumatism, 

 a disease which probably has no uniform etiology. An investigation of the 

 family history certainly plays an important role in the diagnosis of such cases. 

 Further, in considering the relation of rheumatism to gout it must be remem- 

 bered that rheumatism, like all morbid processes that damage the joints, when 

 combined with the gouty predisposition, furthers the development of gout, 

 for anything that limits the free circulation of the fluids in the extremities 

 favors the development of gout in persons who are predisposed. 



Kheumatism not only attacks the joints but all their component parts, i. e., 

 the muscles as well, and must be looked upon as a more or less active occa- 

 sional cause of gout. In a similar manner connecting links of relationship may 



