The attack of angina is occasionally closely simulated by what is called masked gout, especially when the disease is retrocedent. The fact of its existence in the joints, perhaps only the day before, and its sudden disappearance having been almost immediately followed by the spasmodic pain, is too marked a coincidence to be overlooked ; in other cases, the previous occurrence of extreme dyspeptic symptoms, and irregular pains, a gouty history and cliathesis, as well as the slower incursion and longer duration of the seizure, lead us to the conviction that it is not angina, and will probably serve to point out its true nature. It seems almost un necessary to add that, obscure as many of these cases of masked gout undoubtedly are, true diagnosis is most essential to correct treatment.
§ 5. Spinal Neuralgia.—Lumbago has been already mentioned as one of the most severe and common forms of muscular rheu matism ; pain in the back has been referred to as an indication of an attack of smallpox, and as not uncommon in fever generally ; it is also an accompaniment of irritation of the kidney, and is sympathetic of uterine disorder. But we still meet with pain in the ".ck which cannot be referred to any of those causes; in very many cases, it is merely one of the forms of hysteria, and as such, with its many anomalous characters, its irregular manifestations, and its power over the imagieation of its victims, has given rise • to many false theories, and to much pernicious practice; nothing can be more deplorable than the permanent mischief which has 'frequently ensued from confining such persons to a recumbent pmture, till the best advice and the most judicious treatment may fail for years to set them again on their legs. The views of those who ascribe this affection to irritation within the spinal canal, appear to me most unphilosophical and most unsatisfactory. We must, indeed, refer it to what has been distinguished as irritation— a condition of the sensitive extremities of the nerves, of which in reality we know nothing; but it is assuredly not an irritation of nerve centred or of nerve trunks.
This class of cases is deserving of careful study, in order that we may not be misled by them, as they form a large proportion of the nervous affections of the back ; their diagnosis is baied upon those general features which mark the hysteric tendency ; long ailment, without serious impairment of health ; inconsistency between subjective and objective phenomena ; excessive, but un real tenderness ; and pain, evidently not limited to one nerve or one set of nerves, unreasonably excited by trivial causes, and not increased by others, except the patient be led to expect that it ought to be. But it often requires great care to discriminate t,hese spurious affections from the pain caused by dise,ase of the vertebrve, before alteration in form and direction proves the pre sence of caries. If any one character more than another can serve to distinguish them, it is that a sudden jar or shock to the spine will necessarily increase the pain attendant on disease of bone.
One of the most common causes of backache among delicate persons is the exhaustion of muscle in maintaining the erect pos ture. The cause of irritation can be moat easily proved to be of this nature by its entire disappearance on the patient's assuming the recumbent posture : movement, by throwing the strain on other muscles, also affords temporary relief, and this serves to dis tinguish it from muscular rheumatism. The hysterical affection is very often engrafted upon this muscular pain.
When such cases are eliminated, only a very few remain to which the name of neuralgia, as already defined, can apply. They are very generally rheumatic in their origin, but do not exhibit in any great degree the character usually associated with rheumatism, of being aggravated by mption; we cannot get be yond the fact of local pain limited to parts supplied by a single set of nerves. It is important to observe whether there be any loss of ordinary sensibility or of muscular power, as such cir cumstances would indicate a more serious affection than simple neuralgia.