PAINS OF LATENT GOUT.
Pains which are connected with a chronic and more or less latent form of
gout not unfrequently receive the designation "neuralgic," and are
treated upon that erroneous theory of their pathology. I have already
endeavored to show that there is by no means that intimate causal
relation between gout and neuralgia which is very commonly assumed to
exist: true neuralgia is, I believe, only caused in an indirect and
secondary manner by the gouty condition setting up changes of the
blood-vessels, which precipitate the occurrence of the neuralgic malady,
to which the patient was otherwise predisposed from birth. But the
common idea, both without and within the profession, seems to be that
neuralgia is only one expression, and that a quite common one, of the
gouty habit. Nevertheless, with strange inconsistence, the kind of truly
gouty pains of which I am now speaking are constantly treated upon a
special plan, upon the supposition that they are neuralgic.
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
colchicum, 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
colchicum 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).