Part 17 (1/2)

There are six situations in which gouty pains are apt to be developed in a way to lead to the false diagnosis of neuralgia: (1) In the eye; (2) more indefinitely within the cranium; (3) in the stomach, simulating gastralgia; (4) in the chest, simulating angina pectoris; (5) in the dorsum of the foot, simulating neuralgia of the anterior tibial nerve; (6) in a somewhat diffuse manner about the hip and back of thigh, simulating sciatica.

It is not really a common thing to find such cases very difficult of diagnosis, provided that the possibility of their occurrence has been carefully noted; for the gouty habit has a number of slight manifestations which are usually enough to discover it even when its more decided symptoms are entirely wanting.

Thus, in the first place, it will be almost invariably found, on inquiry, that the patient has always been intolerant of beer and of sweet wines. Also, he has been liable (either after a single large excess in eating or a prolonged course of a diet too highly animalized in proportion to the amount of exercise taken) to attacks of general malaise, with or without uneasiness, just short of decided pain, about the metacarpo-phalangeal joint of the great-toe, and ending after a few hours or days with a free discharge of uric acid. Less frequently, but still very often, it will be found that he has some deposit of lithate of soda (chalk-stone) in some situation where its presence does not necessarily arrest attention; Dr. Garrod has shown how often these little tophi are found in the cartilage of the ear. Careful examination will sometimes detect their presence in the sclerotic of the eye. But in doubtful cases it would be always well to make a cautious trial of colchic.u.m, which, if the case be gouty, will nearly always produce an amount of relief sufficient to confirm the diagnosis of gout. At least, this rule holds goods for the external forms; but in the case of the supposed gouty pseudo-angina it is far best to trust to opium, as colchic.u.m may prove too depressing to a heart which may quite possibly be already the subject of organic disease. My own impression is, that it was these cases of gouty heart-pain, which are not true angina at all, that procured for opium its high reputation for relieving the latter disease, a reputation which is by no means confirmed by my own experience, since I have found that drug enormously inferior to stimulants like ether in its power to relieve genuine angina.

Lastly, if there be no other possibility of making ourselves certain whether there is or is not a gouty taint at the bottom of the quasi-neuralgic pains, we may adopt Dr. Garrod's test of subjecting the serum of the blood to a search for uric acid (thread-test).

CHAPTER X.

COLIC, AND OTHER PAINS OF PERIPHERAL IRRITATION.

Colic, or painful half spasm, half paralysis of the large intestines, is the best example of a kind of spasmodic pains to which some authors accord the name of neuralgia, as it seems to me without good reason.

They appear to be quite independent of the operation of the neurotic temperament, and to be caused entirely by the operation of some local irritant, or narcotic irritant, upon the muscular fibres of the viscus.

In the case of colic this influence is most frequently and most powerfully exerted by lead, which undoubtedly becomes locally deposited in chronic poisoning with that metal; at other times it is produced by the irritation of indigestible food pa.s.sing along the alimentary ca.n.a.l.

That there may be such a thing as enteralgia, of really neuralgic character, I do not deny; on the contrary, so far as regards the r.e.c.t.u.m, I have myself seen such a case. But true neuralgia of the large bowel is exceedingly uncommon; what goes by the name is usually either colic from local irritation of the viscus; or a mere hysterical hyperaesthesia of the lining membrane, which is one of the occasional phenomena of spinal irritation; or else it is a case of neuralgia of the abdominal wall, such as is included in the description of ”lumbo-abdominal neuralgia,”

in Part I. of this work.