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Gouty Affections of the Circulatory Apparatus

heart, cardiac, gout, liver, accompanied, chronic and arthritic

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Cardiac diseases are very frequent among arthritic subjects, but it is often difficult to decide between gout, rheumatism, and other dis eases as to the part they respectively play in the causation of the particular cardiac disorder that may be in question. In the majority of cases the disturbance is of a functional character; but there is, besides, a considerable number of examples of genuine organic dis ease of the heart.

Cardiac palpitation, without permanent lesion of the organ, is sometimes noted at the outset of an acute attack of gout. This usually occurs among the earlier manifestations in youthful subjects whose viscera have not yet been damaged by chronic disease. The paroxysm of palpitation usually occurs, without considerable pain or alarming conditions, during the night; and on rising in the morning the great toe is seen to be swollen, and the heart is relieved. True cardiac inflammation never supervenes upon such an attack.

Somewhat similar irregularity of the action of the heart is fre quently experienced during the intervals between the attacks of gout. The patient is often oppressed by a feeling of precordial distress, ac companied by violent beating of the heart. As a matter of fact, such symptoms are seldom encountered among vigorous young men who are neither anmnic nor given to excessive use of tobacco, unless they are predisposed to rheumatism or gout. It must be remembered that one of the characteristics of the arthritic diathesis is a predisposition to disorders of the digestive apparatus. Now the nervous connections between the stomach and liver and the heart are so intimate that in digestion cannot fail to disturb the cardiac functions. Consequently, the commotions to which the heart is liable under such conditions may be considered primarily as the result of dyspepsia, and second arily as the outcome of the gouty dyscrasia. In severe cases the act of gastric digestion is accompanied by flushing of the face, tumul tuous irregular intermittent pulsation of the heart, with precordial op pression, and sometimes a degree of pain that is suggestive of angina pectoris. But with the completion of digestion agitation subsides, and the heart beats normally until the next meal.

Such being the violence of the disturbance that is excited among youthful and comparatively healthy subjects, it is easy to comprehend the gravity of the disorders that exist when the worn-out heart of an aged, obese, and atheromatous arthritic is in question. In such

cases there is almost constant irregularity and frequent intermission of the movements of the heart, as the result of irritation propagated from the stomach and the liver through the medium of the nervous system, and especially as a consequence of intoxication with the products of gastro-intestinal fermentation, and with nitrogenous ref use (urates, etc.) that has been retained in the circulating fluids of the body. Under the influences of these hindrances to healthy nutri tion the muscular substance of the heart falls into a condition of pro gressive degeneration; the ventricular cavities become dilated; with every fresh attack of gout the organ grows weaker, until at last all healthy function is rendered impossible. Cardiac asthma, stagnation of the blood, passive engorgement of the liver, oedema, general dropsy, universal embarrassment of function, collapse, and death, follow each other in inevitable succession.

The paroxysmal recurrence of cardiac asthma constitutes one of the most frequent and formidable evidences of masked gout. Some times accompanied by a copious bronchial flux, there may suddenly arise great danger of immediate suffocation. In other cases, the col lapse of the cardiac musculature itself induces fatal syncope, or at least an alarming prostration accompanied by an almost complete arrest of the circulation.

Besides the morbid changes thus indicated, the ventricular walls are liable to hypertrophy in cases of gout that are characterized by a very trifling deposit of urates about the joints. In such cases the disease appears to expend itself chiefly upon the internal viscera, producing chronic interstitial inflammation of the kidneys, liver, and heart. During the later stages of chronic gout, especially after the nutrition of the heart has been checked by atheroma of the coronary arteries, the muscular substance of the organ undergoes fatty degen eration, and this may lead to rupture of the ventricular wall, or to fatal syncope through the utter failure of the contractility of the car diac tissues.

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