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 passing along the alimentary canal.
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 rectum,
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.
There is no occasion to describe minutely the symptoms of so familiar a
disease as lead-colic, or as colic from irritation by indigestible food,
when they occur in their typical forms. In the former case the marked
constipation which ushers in the attack of pain, and the peculiar
greenish-yellow sallowness nearly always seen in the countenance, ought
to be sufficient to direct examination to the gums (for the blue line)
and inquiry as to any possible impregnation of the system with lead,
owing either to the nature of the patient's occupation, or to some
accidental entry of the poison into the drinking-water, or its
inhalation from the walls of newly-painted rooms, etc. In the latter
case, the fact that the attack of colic was shortly preceded by a meal,
either of obviously indigestible food, or too copious in quantity and
heterogeneous in kind, or too hastily eaten without sufficient
mastication, supplies a clew.
But there are a few cases representing minor degrees of either of these
kinds of colic, that are much less easy to diagnose distinctly.
Lead-poison sometimes enters the system continuously, for a long period,
but in proportions too minute to produce the effects which we identify
as an attack of lead-colic. I believe that for the production of the
latter complaint it is necessary that the poisoning shall be
sufficiently intense completely to paralyze a considerable piece of
bowel, thus altogether hindering peristalsis, or, rather, making the
peristaltic acts of the non-paralyzed portions above worse than
fruitless. But there is a minor degree in which it may happen that the
local affection (owing, I believe, to a less extensive deposit of lead
in the bowel) does not reach the decidedly paralytic stage; the state
then is one of irregular and painful spasm of individual fibres (quite
possibly intermingled with paralysis of a few others), and the practical
result is irregularity of evacuation--now diarrhoea, and again
constipation--and the frequent recurrence of twinges of pain that are
easily mistaken for abdominal neuralgia. Such symptoms as these are
nearly always found to have occurred, if proper inquiry be made, in
those examples of chronic lead-poisoning in which the toxic process goes
on to the development of epilepsy, or marked symmetrical paralysis of
the wrist-extensors, without the patient having ever suffered an attack
of ordinary colic. In these slow and insidious cases the constitutional
affection may not have reached the height at which the complexion and
general aspect of the patient suggests metallic poisoning: and the case
may present very neuralgia-like features. The absence of the _points
douloureux_ is not, as we have seen, conclusive against neuralgia in its
early stages. It is therefore an excellent rule, in all cases of chronic
recurrent spasmodic pain in the abdomen, especially in men, to
investigate the possibilities of lead-poisoning; and, if the slightest
suspicious appearance of the gums be found, this track of inquiry must
be followed up exhaustively before we abandon the idea. The absence of
all special neurotic history in a patient's family should increase our
suspicions respecting pains of this character that continue with an
obstinacy which makes it unlikely they are due to improper food.
Pains of abdominal irritation are, however, without doubt produced in
some cases by unsuspected faults of diet, and may even recur in such a
quasi-periodic manner as to strongly suggest the idea of neuralgia in
the lumbo-abdominal nerve. One special variety of this happens, I
believe, much more often than is thought. A patient will habitually take
considerable quantities of some article of food which he does not
readily digest, but which is not at all acutely irritant: under these
circumstances a simple accumulation is apt to take place in the colon,
especially at the top of the ascending colon, the top of the descending
colon, or just above the sigmoid flexure, or else in the caecum. The
result of accumulation in the last of these places is not unfrequently
typhlitis and perityphlitis, this part of the bowel having (for some
reason) a special tendency to inflammation. Deposits in the other
localities named are rarely the cause of inflammation, but they very
frequently give rise to violent pain, which is exceedingly apt to be
taken for the pain either of gall-stone, of renal calculus, or else of
some abdominal neuralgia. In cases, therefore, where there is any
possibility that accumulation is the cause of pain, it is highly
desirable to commence with a dose of castor-oil and laudanum, followed
up, if needful, by the administration of a large warm-water enema, given
through an O'Beirne's tube. The most violent and recurrent attacks of
pain in the renal region, the flank, the abdomen, or the groin, will
sometimes be instantly cured by such means, sufficiently proving the
non-neuralgic character of the complaint.
I have elsewhere explained that the impaction of a renal or an hepatic
calculus, in the ureter or the ductus choledochus, may set up a true
neuralgia in persons with the requisite congenital predisposition. The
passage of renal or hepatic calculi may give rise to symptoms falsely
suggesting neuralgia, which require just to be mentioned here. But there
is no need to dwell much upon the diagnosis, for the passage of renal or
hepatic calculi has always attendant symptoms and features of
constitutional history, which ought to preserve the physician from
mistake. The sensation of constriction, of nausea and vomiting, the
faintness approaching to collapse, the persistent and constantly
increasing severity of the pain up to the moment at which mechanical
relief occurs, to say nothing of other phenomena, are distinctive to the
skilled observer, and, when taken in conjunction with the history of
past attacks, if any, will always prevent mistakes. In the few cases
which might still be doubtful it will be well to try the effect of a
relaxing dose of chloroform, which, in the case of calculus, will often
put an end to the paroxysm at once and finally.