SYMPTOMATOLOGY 141 



the chain connecting these pathologic processes. It may be here mentioned 

 that in the etiology of the so-called hypertrophic hepatic cirrhosis gout appar- 

 ently plays a part; indeed the liver appears to be implicated in primary 

 arthritic gout, and even more frequently than is usually assumed. 



However, the heart and the vascular system play a far more important role 

 in gout than the liver, at least from the standpoint of the practitioner. 



In regard to the heart, it may be remarked that in primary arthritic gout 

 functional disturbances occur frequently; such are palpitation, intermittent 

 beats, arrhythmia, and other irregularities of the heart's action, decided pain in 

 the precordia, etc. These occur mostly as prodromal or intermediate symp- 

 toms, and as a rule diminish with the development of the gouty paroxysm. 

 In general, they are not of serious import, and are often mild and transitory ; 

 nevertheless, they are frequently distressing to the patient. , I have often 

 observed such prodromal symptoms in gouty patients combined with stubborn 

 intestinal disturbances, principally obstinate constipation, and have seen the 

 cardiac symptoms disappear with a proper evacuation of the bowels after large 

 enemata of oil. These functional cardiac disturbances which develop in pri- 

 mary arthritic gout are usually observed in persons under fifty years of age. 

 In older persons, especially in such as have had a number of severe attacks of 

 gout, we should bear in mind that these symptoms are caused by organic 

 changes in the circulatory apparatus, even though by physical examination 

 no gross disturbance can be determined. I am very careful not to say in such 

 cases " The heart is normal," but content myself with the expression : " I can 

 find nothing abnormal in the heart." Particularly serious in such cases are 

 attacks of angina pectoris, although I know quite a number of gouty patients 

 who, in spite of this, have lived for a long time. In the case of older gouty 

 patients, especially those who suffer from attacks of angina pectoris, there is 

 often disease of the coronary arteries. In fact we see, as the result of gout, 

 all the different parts of the heart (myocardium, endocardium, valves, peri- 

 cardium?) attacked, sometimes singly, sometimes in combination. Occasion- 

 ally, deposits of urates have been found in the excrescences of the cardiac valves 

 and in so-called ossification of the aorta. Apart from these cardiac disturb- 

 ances, there is also gouty renal inflammation which occurs in primary arthritic 

 gout after a longer or shorter time, and I shall revert to this later. There 

 are no specific cardiac symptoms of gout ; nevertheless, when investigating the 

 etiology of attacks of angina pectoris, we should in the first place think of 

 gout. How a cardiac affection can arise upon a gouty basis may perhaps be 

 understood from the etiology. We can readily understand that, in the course 

 of primary arthritic gout, the heart as well as the vascular system must become 

 damaged because the organs of circulation are overwhelmed with blood laden 

 with urates which do them injury. In the arteries, under these circumstances, 

 there is developed a chronic inflammatory process, atheroma or an endarteritis ; 

 and phlebectases must also be explained in the same manner, at least in part. 



Frequently disease of the urinary organs develops in the course of primary 

 arthritic gout. I refer in the flrst place to the complication of gout with 

 nephrolithiasis. This latter association has been denied by some, but incor- 

 rectly; by others it is declared to be a mere coincidence. But here, in my 



