It must not be understood from what I have just said in my account of these cases that all disturbances of the heart in gouty subjects progress to valvular or vascular degeneration, with associated cardiac enlargement and degeneration. The friend whose case I have just described at some length had led an active life, as I said, for 40 years; and, as I hope to show in my next lecture, the condition is amenable to treatment if this is based on a correct appreciation of the cause that is at work. But it is equally true that if correct advice be not given, or if it be given but be neglected, as happens so frequently, the endocardium and the aorta and other arteries steadily degenerate, chronic interstitial nephritis makes its appearance, and the patient dies either slowly from cardiac failure or suddenly from cerebral hæmorrhage. CARDIAC STRAIN. I will now proceed to consider the clinical characters of a class of cases in which you, Sir, are particularly interested--strain of the heart in middle and advanced life. To make this part of my subject more plain, I will discuss in the first place acute strain of the heart as it occurs after the fortieth year; afterwards I will consider the condition of the heart and arteries at this age in persons who have strained them in youth or early manhood. A man of 65, who came to me complaining of his heart, gave the following account of the commencement of his trouble:--Four years previously, on making a very hard stroke at golf (the ball was bunkered), he was suddenly seized with a sensation of something having happened in his heart. He played up to the next hole, but now felt the chest oppressed; he sat down and got relief. This experience was repeated, and he gave up the round. Walking home two miles, he had to sit down occasionally with the same feeling. Ever since that occurrence exertion had produced the same effect. I found the ordinary physical signs of enlargement of both sides of the heart; a scarcely perceptible impulse; the cardiac sounds extremely feeble, the second being of a finely ringing quality; the pulse tense, quiet and regular, but the radial artery by no means sclerosed. The patient's principal complaints were of irregular action of the heart, which troubled him on lying down or when he was dyspeptic; and, as I have said, of post-sternal oppression on exertion. This man had neither albuminuria nor emphysema, but he had frequently suffered from ordinary articular gout. Belonging to this type of cardiac strain I have notes in all of 11 cases, which I will briefly summarise. Eight were men, three women; and their average age was 56. In all but one of them the heart was large, with feeble præcordial impulse; the sounds were small and feeble; the aortic diastolic sound was often ringing; in but one case was there a murmur--aortic systolic; with few exceptions the rhythm and the rate of the heart were ordinary. In half the cases