So far as I have seen, the subjects of this affection are by far the most frequently women; and I am inclined to attribute this predisposition of the sex not to inherent peculiarities of female organization, but to the fact that a much larger proportion of intemperate women than of intemperate men indulge in secret excess. They never get drunk, probably, but they fly to the relief of alcohol upon every trivial occasion of bodily or mental distress; and this habit may have been going on for years before it comes to be suspected by their friends or their medical attendant. Meantime, they have been more or less looked upon, and have looked upon themselves as, "debilitated" and "neuralgic" subjects, and have come, either with or without mistaken medical advice, to consider free stimulation as the proper treatment for the very ailments which have been produced by their own unfortunate habits. I cannot avoid the expression of the misgiving, that imperfect diagnosis, and consequent erroneous prescription, have done great harm in many such cases. It has happened to me no less than three times within the last six months to be called to lady patients, all suffering from alcoholism induced by a habit of taking stimulants for the relief of so-called neuralgic pain; and in the most distressing of these the mischief had been greatly aggravated by a prescription of brandy, based on the erroneous idea that the pains were truly neuralgic. I have already protested against this kind of medication, even in cases that are truly neuralgic in character; but it is doubly mischievous where given for a state of things which actually depends on alcoholic excess.
It is undoubtedly very difficult, sometimes, to elicit the truth, even in cases where we may entertain considerable suspicion that alcoholic excesses are the real cause of the pains which the patient calls neuralgic; more especially where the patient is aware that he or she is taking an amount of alcohol which is seriously damaging to health. And it is therefore necessary to look out for every possible additional help to our diagnosis. Besides the cardinal features of the disease—the insomnia, loss of appetite, foul breath, haggard countenance, and pains encircling the limbs near the joints rather than running longitudinally down the extremities there are certain moral characteristics of the patient that often tells a significant tale. The drinker, especially if a woman, is shifty, voluble, and full of plausible theories to account for this and the other phenomenon. It will be well to try the effects of a somewhat sudden though not uncourteous remark, to the effect that the diet should be strictly unstimulating. If this be introduced with some abruptness, in the course of a conversation not apparently leading to it, the patient's manner will not unfrequently betray the truth; while, if our suspicions are groundless, we shall also probably perceive that, in the unconscious, or frankly surprised, expression of the countenance. We may sometimes derive crowning proof of the existence of alcoholic excess by cautious questions which at least reveal the fact that the patient suffers from spectral hallucinations; this is a far commoner occurrence in chronic alcoholism than is generally supposed; it needs to be inquired for with great tact, but, when established beyond doubt, and joined to insomnia and the peculiar foul breath, is of itself sufficient to establish a positive diagnosis of alcoholic poisoning.
The results of treatment, in true neuralgia and in alcoholic pains, respectively, establish an important difference between these affections. In the former malady, for instance, the hypodermic injection of morphia always produces striking palliative, and very often curative effects. In alcoholic pains this remedy either affords only trifling relief, or more commonly aggravates the malady by increasing the general nervous excitement; and the only true treatment is at once to suspend all use of stimulants, to administer quinine, and to insist upon a copious nutrition. If any hypnotic must be employed, let it be chloral, or bromide of potassium with cannabis Indica. It will be well also to put the patient upon a somewhat lengthened course of cod-liver oil. There is one special symptom from which the chronic alcoholist often suffers acutely, namely a hypersensitiveness to cold; for this I found the use of Turkish bath two or three times a week, for three or four weeks, very useful in one case that was under my care. It will be important to insist that the patient shall take the bath only after that shorter method which I have described in speaking of the prophylaxis of true neuralgia.
CHAPTER VII.
THE PAINS OF SYPHILIS.
Syphilis, as has already been shown in Part I. of this work, may excite true neuralgia in subjects already predisposed to the latter. The case of Matilda W., previously given, is an example. The pains, however, which are now to be described, are those which occur in the ordinary course of a constitutional syphilitic infection, and have nothing to do with neuralgia proper, from which they should be carefully distinguished.
There are two varieties of syphilitic pains proper, which are quite distinct. The first kind is represented by the so-called dolores osteocopi, which occur in the early stages of the constitutional affection, coincidently with, or just before, the secondary skin-eruptions. The second kind are those which occur in the tertiary stage, and are the immediate precursors of the formation of periosteal nodes.
It is the first of these varieties of syphilitic pains which is least commonly confounded with neuralgia. The pain is referred to the superficial bones, of which those most frequently attacked are the forehead, sternum, clavicle, ulna, and tibia, pretty much those selected for the growth of nodes at a later stage of the disease. Besides the bones, the shoulders, elbows, and nape of the neck are attacked sometimes simultaneously, sometimes successively. The pains are readily controlled by proper treatment; if untreated, their course is very uncertain. When they manifest themselves at the outset of the disease, they usually cease when the cutaneous eruption is fairly out. Commonly, there is no swelling or heat at the painful places; but, when the pains are very severe, nodes now and then form at this early period.[52]
These early syphilitic pains, in their violent aching character, and their intermittence, occasionally resemble true neuralgia very closely; but they are usually distinguished from it by their symmetrical disposition and by their attacking several bones at once. Moreover, they nearly always show the peculiarity of being distinctly aggravated by the warmth and repose of bed even if they be not altogether absent (as is not unfrequently the case) when the patient is up and moving about. A typical case of this kind is not so likely to be confounded with neuralgia as with rheumatism; but we occasionally meet with cases in which the pains are localized in a manner much more resembling the former. Thus I have met with several instances in which a patient, entirely unconscious (or professing to be unconscious) of having been syphilized, complained of violent pain in one tibia, recurring every night at a certain hour, and at first undistinguishable from that variety of sciatica in which the pain is principally felt in this situation, especially as it was relieved by firm pressure, just as neuralgia is in the early stages. And in one remarkable case, which came under my care at Westminster Hospital, the resemblance to clavus was most misleading: