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Chronic Gout with Visceral Complications

heart, sometimes, disease, symptoms, cardiac, renal, walls, patient and body

CHRONIC GOUT WITH VISCERAL COMPLICATIONS.

Every gouty person is an invalid. Even the robust and vigorous subjects of acute gout can never be ranked as perfectly healthy. And when the disease has assumed its chronic form the patient is a continual sufferer from the presence of urates in the joints and in the tissues elsewhere, as well as from an excess of uric acid in the blood. The vascular walls are the seat of chronic inflammation or of Mlle roma. The kidneys, the heart, the lungs, the brain—all the organs of the body suffer either directly from local disease, or indirectly from anemia, toxemia, and malnutrition. Slowly, but surely, the course of chronic gout tends toward the production of terminal ca chexia through the degeneration and utter failure of the vital organs.

The kidneys are usually the first of the internal viscera that ex hibit signs of distress. The clinical picture of renal disorder depends largely upon the nature of the concurrent affection of the heart. It is among the once robust and vigorous class of subjects that chronic interstitial nephritis is frequently accompanied by sclerosis of the myocardium and, sometimes, of the liver. These patients pass a considerable amount of urine, especially during the night, which may or may not contain albumin in moderate qnantity ; the pulse is tense and hard ; there are frequent attacks of cardiac palpitation, and some times a gallop rhythm is audible over the apex ; after a time the heart is evidently enlarged through hypertrophy of its muscular walls, without valvular lesions. During the later stages there is great dyspucea and precordial distress : the feet swell ; dropsy appears; the flow of urine diminishes, and the symptoms of uraemia usher in the fatal conclusion.

Among the enfeebled subjects of chronic gout renal disease is often accompanied by cardiac symptoms that differ entirely from those that have been just now described. Instead of muscular hy pertrophy the heart exhibits dilatation of its cavities, with flaccid walls, and fatty degeneration of the muscular tissue of the organ. Such patients are out of breath on the least exertion, and all their functions are feebly and imperfectly performed. They are pale, and often experience sensations of faintness, dizziness, numbness, and general prostration. In many cases these symptoms are aggravated by the diseased condition of the cerebral and cardiac vessels. The heart frequently beats irregularly and intermittently; its sounds are muffled and indistinct. The pulse, irregular, intermittent, rapid, and feeble, follows suit, and serves to indicate the extent of disorder into which the innervation of the heart has fallen. Death sometimes occurs suddenly, either from cardiac exhaustion or from actual rupture of its degenerated wall. If, however, life be not thus abruptly termi

nated, the retardation of circulation finally leads to the occurrence of dropsy that is dependent upon the combined effects of renal and cardiac disease. In many instances the phenomena of uremia are developed; death occurs as the result of this form of intoxication. The approach of uremia is usually very gradual, and it cannot be. mis taken by any one who is familiar with the symptoms of chronic renal disease and the manifold disturbances of the nervous system that follow in its track.

The pulmonary apparatus is sometimes the seat of disorders that characterize the onward progress of a certain number of cases of chronic gout. As age advances, these patients become the victims of dyspncea and emphysema. Asthmatic paroxysms frequently add to their ordinary and permanent distress. Bronchitis, of an obstinate and interminable character, becomes established. Finally, the walls of the heart give way and the ventricular cavities enlarge. Cyanosis, somnolence, and asphyxia terminate the scene.

Pleuritic effusions, occupying sometimes one side and sometimes both cavities of the chest, are occasionally noted. A passive conges tion invades the lungs, and their parenchyma may become oedematous, as a consequence of the general tendency to stagnation of the fluids of the body. Respiration becomes laborious, and the patient dies of slow asphyxia.

No more pitiable object can be imagined than the victim of chronic gout in the last stages of visceral disease. His hands deformed, and his fingers rendered useless through the accumulated tophi ; his feet, lower limbs, and body swelled with dropsy, he can neither stand erect, walk, nor help himself. An excellent appetite leads to overdisten tion of the stomach, followed by painful dyspepsia. The bowels are constipated; hemorrhoidal veins enlarge; the hips and thighs become brawny from excessive oedema, and the sexual organs are nearly lost from view through infiltration of the scrotum and sheath of the penis. Unable to exercise himself, the patient is confined to an armchair, and soon his whole time is passed in a sitting position, for he cannot lie down without danger of suffocation. Ulcerations form about the tophaceous masses and upon the dependent legs. Paroxysms of dyspncea, sometimes aggravated by an harassing cough, are accom panied by palpitation or intermission of the heart. Finally, the symptoms of uiTemia appear; diarrhcea sets in, sometimes vomiting; occasionally there are epileptiform or apoplectiform convulsions ; in vincible somnolence overwhelms the sufferer, yet he cannot sleep soundly or comfortably. Only when coma, long desired, arrives at last, is any real relief experienced after years of monotonous misery.