Mental disorders are sometimes witnessed in gouty subjects. These disturbances are usually modified in accordance with the tem perament of the individual, so that the sufferer sometimes exhibits only the most wonderful patience and amiability throughout a life time of disease. But in the majority of cases the irascibility of the patient is something phenomenal. Depression of spirits, hypochon dria, and excessive irritability are generally experienced. In this respect the state of the brain conforms to the general condition of morbid excitability and debility into which the entire organism has fallen. Gouty insanity has been described by many authors ; but such an event is of rare occurrence, so far as alternation with gout or substitution for gout is concerned. Doubtless, many insane people are gouty, and the depth of despair into which many gouty patients are plunged may lead to some confusion in the analysis of symptoms. It is often difficult in these cases to draw the line be tween actual insanity and the various forms of nervous perversion that may arise during the course of articular disease. Still it is unnecessary to ascribe to gout the different neuroses, such as chorea and hysteria, that may be associated with it. This should be done only when the facts of alternation and of substitution of one for the other are beyond question, and when independent morbid condi tions and lesions of the nervous structures cannot be discovered. An exception should be made, however, in favor of hemicrania. This singular neurosis so constantly occurs in gouty families, is SO fre quently experienced among the precursory phenomena of the arthritic diathesis, and is so clearly connected with the articular crisis that its relationship does not admit of question.
From this brief view of the cerebral accidents of gout, it is evident that there are ninny points of resemblance between it and cerebral rheumatism. There is the same retrocession of articular manifesta tions, the same violent onset of cerebral disturbance, the same ten dency to delirium, coma, and death. On the reverse of the picture, however, aphasia, which is so common in cerebral gout, is an excep tional event in cerebral rheumatism. Vertigo belongs to gout, while delirium, convulsions, and excessive elevation of temperature are more frequently witnessed in rheumatism. In both diseaees the post-mortem appearances are insignificant and out of proportion to the gravity of the symptoms by which they are accompanied.
It is very doubtful whether the spinal cord is ever the seat of genuine gouty inflammation. Gouty subjects have suffered and died with myelitis, but there is no satisfactory evidence that this differed iu any particular from ordinary inflammation of the spinal cord. The unique case, recorded by 011ivier, in which- there was a general deposit of orates upon the external surface of the dura mater and the sheaths of the spinal nerves, shows that the fibrous tissues within the spinal canal can be damaged by infiltration. But in this case the cord and its inner envelopes remained healthy. If the spinal cord ever becomes diseased through gout, it must be the result of indirect influences like those that excite sclerosis in the kidney, heart, blood vessels, liver, and spleen. It is also probable that the transient feel
ing of weakness iu the lower limbs that is sometimes experienced by gouty patients has its origin in fugitive disturbances of nutrition that are really dependent upon gout. There is no reason why the poison of gout, like that of syphilis, should not create a predisposition to chronic myelitis ; and when no other cause of inflammation can be discovered, the affirmative inference becomes unavoidable.
With similar reservations the influence of gout upon the periph eral nerves is incontestable. Neuralgias of the greatest severity and obstinacy are among the most frequent consequences of gout. By their recurrent and paroxysmal manifestations they often resemble the evolution of articular gout. No part of the body appears to es cape their incidence, and their duration varies from that of the most transient fulgurant pain to the uniutermitting and persistent agony of chronic inflammation. Chief among the disorders is sciatica, which may occur either as a simple neuralgia or as an uncompromising neuritis. It is occasionally accompanied by anesthesia and muscu lar atrophy, but usually the principal symptom is pain along the course of the sciatic nerve and its branches. It is extremely liable to recurrence and to frequent exacerbations without apparent cause. Sometimes it alternates distinctly with articular manifestations; but more frequently it seems to be excited by accidental exposure to cold or injury.
Neuralgias of the trifacial and intercostal nerves follow sciatica in the order of frequency. The writings of the English are rich in de tails regarding these peripheral pains, which are usually worse at night, and are clearly connected with the prodromes of articular gout. Sometimes they cannot be clinically distinguished from the pains of muscular rheumatism, and they may assume the forms of lumbago, or of deltoid or crural pain. The recti abdominis muscles are frequently thus affected. Occasionally, pain is experienced in the tongue or about the teeth, usually fugitive in character, but sometimes yielding only after weeks of suffering. Sometimes it is in the deep muscles of the spinal column that pain is felt, or it may occupy the track of any deep nerve, especially at night, causing unusual sensa tions, as if an almost intolerable cutaneous itching bad been trans ferred from the surface to the central tissues of the part. In many instances, fortunately, these torments are very fugacious, but some times they manifest a degree of prominence that is suggestive of sub acute peripheral neuritis. When they are encountered in robust and vigorous subjects, they usually yield to vegetable diet and purgatives, followed by colchicum and sodium salicylate; but among aged and broken-down subjects they are the result of permanent degeneration of tissue, and are seldom relieved by medical treatment without re course to surgery.