39 See J. J. Putnam, “A Form of Painful Periarthritis of the Shoulder,” Boston Med. and Surg. Journ., 1882.
INTERCOSTAL NEURALGIA is a very important form, both on account of its frequency and obstinacy, and because it is often associated both with anæmia and chlorosis and with affections of the visceral organs, especially the uterus. The distressing cardiac palpitation of neurasthenic patients often associates itself with pain in the left side, and there is an intimate connection between neuralgia of the cardiac plexus (angina pectoris; see below) and neuralgia of the intercostal and brachial nerves.
Pain in this region, often due to neuritis, may accompany acute and chronic thoracic disorders, and may be the precursor of herpes zoster. Caries of the vertebræ and meningitis should be thought of, and cancer if the neuralgia is very persistent, even if it is paroxysmal in character.
TREATMENT.—Besides the general indications for treatment referred to above, it is worthy of special note that nerve-stretching has been successfully tried for intercostal neuralgia. In one interesting case seven nerves were stretched at one operation.40 The reporter discusses the surgical aspects of the operation, and points out that the nerves should be sought for, not directly beneath the rib, but behind and beneath it, and thinks that the failure to bear this fact in mind might lead to puncturing the pleura.
40 Lesser, Deutsch. Med. Wochenschr., Sto. 20, 1884.
MAMMILLARY NEURALGIA (irritable breast of Astley Cooper), though often met with in company with intercostal neuralgia, may occur entirely independently. It is sometimes bilateral, and is apt to be associated with irregularity of the uterine functions. Cutaneous hyperæsthesia is often present to a distressing degree, and small tumors of either temporary or permanent duration may make their appearance (A. Cooper), which, however, do not affect the prognosis.
There is no especially effective TREATMENT beyond what has been spoken of. Surgical interference is not especially to be recommended, though it has occasionally been useful.
LUMBO-ABDOMINAL NEURALGIA, or neuralgia of that part of the lumbar plexus which supplies the flank and abdomen and the external genital region. These neuralgias are apt to accompany those of the intercostal nerves and share in their significance.
The most important facts with regard to them are that they are intimately associated, in relation both of cause and of effect, with affections of the abdominal and the pelvic organs and of the testis. Neuralgias of the terminal branches of the lumbar plexus, the obturator and anterior crural nerves, though well recognized, are comparatively rare.
One of the chief respects in which they are important is in calling attention to the possible presence of disease of the hip-joint or of periarthritis of the hip, as well as of tumors or inflammation within the pelvis.