Besides the sensory disorders above indicated, the peripheral nerves are also subject to motor disturbances that take the form of muscular spasm, involving sometimes an individual muscle, and sometimes arousing a whole group of muscles. The spasms are of very frequent occurrence among the introductory symptoms of a gouty attack; they are often experienced during the intervals between the paroxysms of the disease, and with advancing years they become one of the most tormenting incidents in connection with chronic gout. In certain cases, they are-so often repeated and are attended with such a degree of exalted reflex excitability, that they seem to be de pendent upon morbid changes in the spinal cord. Probably, however, they simply express the general condition of irritable weakness into which the entire organism has fallen. Even among arthritically pre disposed individuals who have never suffered with articular inflamma tion or uratic deposits, it is a common event to witness transient spasms of the fibres of the orbicular muscles of the eyes and mouth, or of the facial muscles and muscles of the extremities. Some observers are of the opinion that epileptiform convulsions may be occasionally excited by similar irritation of the brain and nervo-muscular appara tus with gouty blood. A further analogy with epilepsy is suggested by the fact that these spasmodic affections are occasionally followed, as sometimes happens after an epileptic seizure, by temporary pare sis of the over-excited muscles.
Angio-neurotic wdema is not infrequent among the gouty, espe cially among females and neurotic patients. It often appears about the joints, and in the loose areolar tissue of the eyelids, lips, breasts, prepuce, and labia. The phenomena of swelling and pain are rapidly developed, and often subside or are transferred elsewhere as rapidly as they appeared. Sometimes the hands or the neck are visibly en larged for hours at a time, without considerable pain other than a sensation of stiffness and clumsiness in the affected parts. The oc currence of these phenomena among the members of a gouty family, together with their frequent association with other arthritic manifes tations of a decided character, and their relief by colchicum and alka lies, all combine to show their dependence upon the specific diathesis.
The connection between the above-indicated symptoms and morbid excitations of the sympathetic nervous system is so clearly apparent that it is evident that gouty phenomena are not limited to the cere brospinal nervous apparatus. The visceral plexuses and nerves are frequently the seat of painful disturbances that affect the functions of secretion and nutrition. It is in the abdominal and pelvic organs that some of the most distressing manifestations of ganglionic ner vous disorder occur. Painful menstruation and ovarian tenderness are common experiences, even before the access of articular gout, or even in cases that never advance beyond prodromal stages of the diathetic disease. The walls of the stomach, intestines, bladder, and urethra are not infrequently the seat of obstinate suffering that is re lieved only by anti-arthritic measures. In many instances these pains are migratory and transient, skipping rapidly from one part of the body to another; but they often remain fixed for considerable periods of time. A distinctly paroxysmal character can be, however, usually observed, and nocturnal exacerbations are of frequent occur rence. Sometimes the coincidence of these paroxysms with the vary ing alkalinity of the blood can be clearly determined. Fatigue of every kind, moral, intellectual, and physical, operates powerfully to aggravate the painful attacks, and they are greatly ameliorated by rest and proper food. Among neurotic dyspeptics who have in herited the arthritic diathesis this form of neuralgia is not uncom mon, even though pronounced symptoms of gout have never been ex perienced. Eichhorst mentions it as a gastrointestinal neuro,is
which he enumerates among the phenomena of diabetes. Other writers have vaguely noted it as a symptom of " lithfemia," but its connection with the sympathetic nervous system, and its dependence upon arthritism, have not been defined with sufficient clearness by the majority of writers. These visceral neuralgias are most fre quently experienced during the changeable weather of the spring and autumn months, and during the early heats of summer, in this re spect conforming to the course of gout. They usually occur among constipated individuals who have reached middle or advanced life; but they sometimes are felt by the youthful members of gouty fami lies. When the stomach is chiefly involved, the painful paroxysms commence when the organ is empty—toward noon, or in the latter portion of the afternoon, or during the night, generally after mid night—and they persist for one or two hours or until relieved by food or medication. The favorite seat of the pain when the stomach is principally affected is in the epigastrium or in the left hypoclion drium. It is not limited to a single focus, but is vaguely diffused through the upper portion of the abdomen. Sometimes it extends into the cardiac area, or even as far as the arms. The character of the pain is of a nature that distinguishes it from other abdominal pains. It may be accompanied by tenderness of the epigastric region, particularly in the sternal third of the right rectos muscle, but such tenderness is distinct from gastralgia. It is not increased by pressure or by movement. The patient may cough, sneeze, laugh, walk, or run without influence upon the location, character, or inten sity of the suffering. Ordinarily the paroxysm is not intolerable, but sometimes it is horribly severe, and is attended by a feeling of fearful exhaustion. It is a dull, deep-seated, widely diffused and persistent distress, quite different from ordinary gastralgia, colic, or peritonitis. It cannot be mistaken for the pain that exists in the gastric crisis of tabes dorsalis, or in chronic alcoholism, or in periph eral neuritis. By the sufferer it is readily distinguished from the more tolerable pains that occasionally have their seat in the abdominal wall, sometimes alternating with the gastro-enteralgic paroxysms. In short, it possesses all the characteristics of neuralgia affecting the sympathetic nerves. Such pain, when severe, is more intolerable than ordinary peripheral neuralgia. When the enteric plexuses are involved, the distress is usually less severe, but not less annoying than when the stomach alone is affected. Sometimes the pelvic nerves are the seat of irritation, and the patient may suffer intensely with rectal or vesical agony, especially after sexual intercourse. Pro longed and painful erections sometimes prevent sleep during the later hours of the night. During the intervals between the paroxysms, especially if food and sleep have been procured, bodily comfort may be complete. But the termination of gastric digestion, or the oc currence of bodily fatigue, or an exposure to cold damp air may be immediately followed by a return of pain. Gradually the becomes exhausted from suffering and loss of sleep he is morbidly sensitive to cold, becomes neurasthenic, and is incapable of physical or mental activity. Yet some of these sufferers present a florid ap paaram!e, and retain their usual weight. Many of them are hypo chondriacal; and some of the more intelligent class can scarcely be persuaded that they are not victims of malignant disease of the stom ach or other abdominal organs.