This case presents several interesting features, similar instances of which have not as yet been reported.
Patient.
—A blacksmith was admitted to the wards of the fourth medical division of Bellevue Hospital, suffering from acute gout, involving the knee and large toe joints. He had had several previous attacks of gout and twenty years earlier a chancre with well-marked secondary symptoms. He had used alcohol to excess for years. He also complained of attacks of vertigo and syncope.
Physical Examination.
—An obese man, five feet seven inches tall, somewhat dyspneic. The apex beat is in the fifth left interspace, four and one-half inches from the median line, and distinctly heaving. The outlines of the heart are difficult to determine on account of the thick chest wall. The heart action is slow and regular, 44 to the minute, and the sounds are normal except for an accentuated aortic second. At the