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CHAPTER X.

RHEUMATIC AND GOUTY DYSPEPSIA.

It is not our intention to enter into a description of the symptoms of rheumatism and gout; these diseases have some symptoms in common, but they are not identical in their character; and it is a subject of grave doubt amongst many physicians whether they are ever combined, that is to say, whether there be any such condition as rheumatic gout. Their origin has been referred to defective secondary assimilation, a term comprehensive in its character, but one that is often used to veil our ignorance of the phenomena of the healthy organism; after absorption has taken place into the blood, and the pabulum which is to supply the wants of the system has been brought into intimate relation with its several structures, growth is the result. This growth and manifestation of function involves chemical change and rearrangement of elementary composition; the glands grow, whilst they receive elements from the blood, and pour forth their normal excretions, whether it be the liver, the kidney, the pancreas, or the mammary gland. Similar changes ensue in relation to the muscular system,

and to the substance of the brain itself. During functional activity there is the entrance of fresh material, and the discharge of effete product; these changes constitute the life of the part, and in their aggregate they are the life of the whole. The phenomena themselves present new manifestations of force, whether in the development of heat, the production of motion, the putting forth of nervous energy. The result of these changes is variously shewn; the presence of urea and of uric acid prove a readjustment of nitrogenous compounds, and may to some extent be taken as an estimate of the amount of that internal change which is going on in the system. If the eliminative processes of these substances be checked, the products may be retained in the blood, and induce other changes in the system; and as the result of one form of defective secondary assimilation and of elimination, gout takes place. Dr. Garrod has demonstrated that there is excess of uric acid in the blood in gout; this excess, however, does not constitute gout; that is essentially caused by some antecedent defect of which this excess of uric acid in the blood is only a sign. The primary changes which induce gout affect the whole system, and hence the production of other symptoms beside the paroxysm of gout. So also with reference to rheumatism, it has been referred on insufficient data to an excess of lactic acid in the system; but this, if correct, is an insufficient explanation of the disease; we should next have to enquire why such

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acid is generated in the system, and again we are referred back to defective secondary assimilation, or to deranged chemical transformation in the nutritive changes of the tissues.

In both gout and rheumatism we frequently find peculiar functional disturbance of the stomach; and we may correctly speak of "gouty dyspepsia;" we do not mean that the disease of the stomach, is an essential part of gout, but that the state of the system, which issues in a paroxysm of gout, also induces characteristic dyspepsia. And, although the secondary changes which follow the absorption of food into the blood, have more especially to do with the proximate cause of gout, still the primary solution of food has also a causative relation.

In patients so affected the stomach is often taxed by overwork, and over stimulated at the same time; but frequently this is not the case, and the gouty patient may be abstemious in all his habits.

The symptoms of dyspepsia are sometimes well marked, and are in part referred to an abnormal state of the gastric juice; it is preternaturally acid, and is the cause of the heartburn so often complained of. Acid eructations are also present, "sourness at the stomach;" there is pain at the scrobiculus cordis, the tongue is often furred, and the pulse is irritable. The hepatic secretion is often disordered, and sallowness of the countenance, with irregular action of the bowels, and very dark or clay-coloured motions, are induced; the

urine also is high coloured, and there is abundant deposit of lithates. The urine, however, more fre

quently presents a large quantity of uric acid deposit, red dust, or gravel, as it is sometimes called, and under the microscope the crystalline character of the deposit is well shewn, rhomboidal crystals, or clusters of acicular

ones.

These gastric and other symptoms may be accompanied with some pain in the joints, as in the great toe; or with deposit of lithate of soda in the fibrous tissues about the joints, or in the ears; but the external signs be undeveloped, and the only indication of gout is an hereditary tendency in the parents or grandparents, the brother, or some other member of the family.

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In numerous instances the symptoms of indigestion are vague and ill-defined; there may be sense of oppression at the region of the stomach, with mental inertia, and incapacity for exertion, and sense of weakness. Sometimes severe pain in the head or neck is induced with disturbance of the sight and hearing, and even with vertigo and partial loss of consciousness; or, again, aching pain in the loins and in the limbs occurs, as neuralgia or sciatica; or, there is irritability of the bladder, and in persons advanced in life, the symptoms of stricture. We have witnessed the gastric affection so severe as to simulate the dyspepsia of organic disease, and these symptoms have entirely disappeared with the lessened tendency to gouty attack.

There are, however, two symptoms of gouty dyspepsia which deserve especial attention, namely, irregular action of the heart, and severe paroxysmal pain, known as "gout in the stomach," or if in the bowels, constituting a severe form of colic. The close sympathy of the cardiac plexus of nerves with the large nerve centres of the abdomen is frequently shewn in this dyspepsia; the pulse becomes small, irregular, and intermittent, and the patient is distressed by palpitation, and by breathlessness on exertion; he is disturbed at night by broken sleep, and may even be unable to lie down. The embarassment of the heart's action is sometimes less defined, and is manifested by dyspnoea on taking any exertion, even on stooping to the ground or kneeling. The sensation is one of distress rather than of pain, and sometimes it compels absolute rest, the patient, feeling as if the heart would cease to beat altogether unless quietness were maintained; the character of the symptom is that of "breast pang,"-angina pectoris. It may be that a cardiac bruit is produced from atheromatous thickening of the valves; but this abnormal sound is often entirely absent, and the heart disease is purely of a functional character. These and other symptoms often entirely disappear when the gouty dyspepsia is removed, and they sometimes cease after a paroxysm of gout itself.

Again, whilst these gastric and general symptoms

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