[9] Mott, 'The Croonian Lectures on the Degeneration of the Neurone,' p. 110, 1900. GOUT. Of the many instances of disorder and disease of the heart and arteries that I have met with in gouty subjects at or over 40 years of age, I have made a careful study of 29 taken from my private case-books. Twelve of these (10 M. + 2 F.) had suffered from ordinary articular gout, the other 17 (6 M. + 11 F.) had irregular gout, as defined in my first lecture. The average age was 62. In no instance was there albuminuria. The physical condition of the heart and arteries and the patient's complaints were remarkably alike in the two groups. In 23 of the 29 the heart proved to be enlarged, either on one or both sides. In less than half the number the cardiac action was feeble; in a small number the impulse was entirely imperceptible; the heart- and pulse- rate was ordinary; the rhythm was but seldom irregular. It is a very remarkable fact that in no fewer than 12 out of the 29 cases of gouty heart a systolic murmur was to be heard over the aortic area, the manubrium and the right carotid, significant of disease either of the aortic arch or of the aortic valves--in every instance independently of rheumatism or other obvious cause than gout. This result is an interesting confirmation of the pathological observations of Dr. Norman Moore and Sir Dyce Duckworth given by the latter,[10] and of the statement of Murchison[11] of his experience "that atheroma of the arteries at an unusually early period of life, and diseases of the aortic valves which are not congenital, and are independent of injury or rheumatism, are met with far oftener in persons who are the subjects of the lithic acid dyscrasia, or who have had gout, than in those who have had no such tendencies." In seven (25 per cent.) of my cases a more or less developed systolic murmur was found in the mitral area, significant either of valvular atheroma and sclerosis or of leakage from ventricular dilatation. Very curiously I have never met with aortic incompetence of gouty origin. When no murmur exists the cardiac sounds are commonly somewhat feeble, and the second sound may be of ringing quality--this more commonly in goutiness than in developed gout. In agreement with this connection, the radial pulse is more often tense in the subjects of irregular than of regular gout[12]; altogether, high tension is found in more than one-half of the cases. The great majority presented distinct thickening of the arterial walls. As I suggested in our study of the etiology, these pathological changes appear to be the result of malnutrition of structures (the myocardium, valves and arteries) worked at high pressure; and in addition to the local disturbance of metabolism in the cardiac and arterial walls, which are fed with gouty blood, there is the damaging effect on them of similar disease of the _vasa vasorum_ and _vasa cordis_ or coronaries.[13] Besides