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1847]

Beau on Intercostal Neuritis and Neuralgia.

259

[*Other cases are adduced, but these are the principal ones, and considering that whenever Dr. Rinino specifies the amount of blood taken, he states this to have been a pound, and that his bleedings were sometimes repeated five, ten, or even thirteen times, and that for not very well characterized chronic inflammation, he proves himself to be a worthier follower in the footsteps of Guy Patin than is often met with in these degenerate times. The lavish use of the lancet in fact prevails, as we have observed in our notice upon Tommasini (p. 271), to a greater extent in Italy than in any other European country; but we imagine that, even there, Dr. R. will make few proselytes. That cases may every now and then be met with which may be benefited by such treatment we do not doubt, and the placing them on record has its utility by exciting attention to the important fact indicated by the author, and certainly too frequently overlooked, that the essential inflammatory character of a disease may be masked or concealed by a train of pseudo-asthenic and nervous symptoms, which have supervened. Infinite mischief would however result, if this exceptional case were generalized into a principle. ]-Rev.

ON INTERCOSTAL NEURITIS AND NEURALGIA. By Dr. Beau. Since the researches of MM. Bassereau and Valleix intercostal neuralgia has taken its place among the acknowledged affections of the economy; but with it other cases, for which the term neuritis would be more applicable, have been confounded. Dr. Beau's attention was first directed to the subject while contemplating the nature of the painful sensations in injuries of the ribs. Of two such cases, in the one case a severe contusion of the thorax, and in the other actual fracture, took place at the junction of the posterior and middle thirds of the ribs ; and in both cases, while some degree of pain existed at the precise seat of injury, that of an intense character was located anteriorly rear the sternum. It was the latter that became intolerably increased by coughing, sneezing, or other respiratory efforts. In these cases the pain was explicable only on the supposition of an inflamed state of the intercostal nerve consequent upon the injuries, the severest suffering being referred to the periphery in consonance with a well-known law.

Neither of these patients dying the positive proof of the existence of such neuritis was wanting; but these cases led to the consideration of others of much more common occurrence, in which the existence of the peripheric pain and the means of proving its dependence upon an inflamed state of the nerve alike exist. Such are cases of inflammation of the pleura, whether simple or complicated with pneumonia. It is familiarly known that the “pain in the side," so constantly present in these, is seated in the great majority of cases near the breast. It is, in fact, but the expression of pain at the peripheric extremity of the intercostal nerve, induced by inflammation of the portion of this nerve which is in contact with the inflamed pleura. The posterior portion of the nerve alone is inflamed, and yet the severe pain is excited at its periphery.

The intercostal nerves during the posterior portion of their course, that is from the articulation of the ribs to their angle, are in immediate contact, on the external side, with the external intercostal muscle, and, on the internal side, with the parietal layer of the pleura. From the angle of the ribs to their termination, the nerves cease to be in immediate relation with the pleura, being separated from it in all the rest of their course by the internal intercostal muscle. It seems scarcely possible for the nerve to be so closely in relation to the inflamed pleura

* For an account of similar cases by Tommasini see Med.-Chir. Rev. N. S., I., 300,

without its participating in the diseased action ; and, in point of fact, at postmortem examinations we always find this portion of the nerve more or less in. flamed during the whole portion of its course that is in contact with the inflamed pleura, such inflammation not extending beyond the angle of the ribs, where the nerve becomes separated by the muscle from the pleura. There is frequently a somewhat intense injection, not only of the neurilema but of the nerve itself

, with enlargement of its substance, as may be seen by comparing it with the uninflamed nerves in contact with uninflamed portions of pleura. The inflamed nerve has not seemed more friable than the others, but is sometimes slightly adherent to the contiguous pleura. It is to be remembered that pleurisies, and pleuro-pneumonias, are situated in the great majority of instances at the posterior portion of the chest, and yet the pain is felt at its anterior portion, as already observed. If this statement be correct, the pain induced at the anterior extremities of the intercostal nerves should vary in its longitudinal direction according to the height in the thorax at which the pleuritic inflammation is seated, and this is precisely what takes place ; for, accordingly as the pleurisy affects the four or five first, or the four or five lower intercostal nerves, so is the pain felt at the anterior portion of the corresponding intercostal spaces. And, as the anterior extremities of the five last nerves, instead of turning up with the cartilages, proceed downwards and forwards, between the muscles of the abdominal parietes, towards the median line, the pain proceeding from the inflamed pleura is then manifested in the abdomen. It results from these details, that the seat of the peripheric pain of the inflamed nerve may serve as an excellent guide to the exact seat of the pleurisy, as all we have to do is to trace directly backwards along the course of the affected nerve. If local bleeding applied to the seat of pain instead of the seat of the neuritis, readily dissipates the pains, it does so because it operates a derivation at a certain distance from the inflamed part upon the intercostal vessels feeding the inflammation—just as, in orchitis, we place leeches over the cord, and not upon the scrotum.

Ordinarily all the nerves in contact with the inflamed pleura are equally inflamed, but all are not equally painful at their extremity." It will be found in general, that that nerve is most affected which corresponds to the rib possessed of most extensive movements. This is why, in most cases, the patients refer the most vivid pain to the anterior portion of the sixth or seventh intercostal space, because in most patients, and especially in men, the seventh rib is that which executes the greatest amount of movement. The patients will generally complain of pain at one of the intercostal spaces, but it is rare for only one nerve to be thus affected; and, if we compress the spaces adjoining that at which the sensations of the patient seem to be centered, we find that others are similarly affected, though in different degrees. The difference in the intensity of suffering is very great; for, while some nerves are excessively painful, others, equally inflamed, give signs of scarcely any pain. Differences in pathological susceptibility analogous to this are however familiar to attentive observers; and it is the entire absence of such susceptibility in certain individuals that permits latent pleurisy and pleuro-pneumonia to become developed without the manifestation of pain in the side, or any other symptom of the disease.

We have hitherto laid it down as a law, that the posterior inflamed portion of the nerve only manifests pain at its anterior extremity ; but there are some exceptions to this. We have observed, in the most careful manner, cases of pleurisy, in which pain existed simultaneously at the extremities of the intercostal nerves, and at the portion of the spinal column corresponding to the affected

The latter pain is not however spontaneous like the former, but for its induction requires slight pressure to be made on the side of the spinous processes corresponding to the inflamed nerves, and then as many painful points will be recognized posteriorly as anteriorly. Every one is aware that, during percussion of the posterior portion of the thorax in pleurisy, pain is produced.

nerves.

1847]

Beau on Intercostal Neuritis and Neuralgia.

261

This is always referred to the inflamed pleura, but in fact is a posterior radiation of the inflamed intercostals. This pain at the posterior portion of the thorax is not fixed, as the anterior pain in the intercostal branch properly so called, but in the branch which terminates in the muscles and skin of the back; and yet in necroscopies we are enabled to show that this dorsal branch is no more inflamed than is the anterior extremity of the intercostal nerve, the pain being, in the one case as in the other, a distant result of inflammation affecting the portion of nerve in contact with the inflamed pleura.

These pains of the side, then, commonly termed pleuritic, are justly so called, on account of their relation to pleurisy: But pleurisy does not produce them directly, inasmuch as they result from the inflamed state of the proximal extremity of the nerve. The pains which continue to be felt after the cessation of a pleurisy, and which are usually referred to adhesions, are, in point of fact, produced by the neuritis become chronic. When there is inflammation of the lung without inflamed pleura, we have then no pains in the side, no neuritis capable of producing them having been generated. There is another form of pleurisy, in which the intercostal nerves are liable to become inflamed—that which is consecutive to pulmonary tubercle, and which is then seated at the upper part of the chest. The pain resulting from this is felt at the anterior part of the first intercostal

spaces, but is much less severe than that of acute pleurisy. Those dull pains existing just under the clavicles, and which, according to pathologists, are a frequent symptom, and an immediate result of the presence of tubercle, are, in fact, produced by the development of pleuritis consecutively to the tubercle. Besides these pains, phthisical patients occasionally suffer from others in the supra-clavicular region of a far more intense character, forcing cries from the patient, and requiring the endermic use of morphia for their relief. These, in all probability, depend upon a neuritis of the first intercostal nerve, which sends one of its branches to anastomose with the brachial plexus. This last is in communication with the cervical plexus, and we can understand how the neuritis of the first intercostal may in this way induce pain in the region of the neck; and even down the arm.

In comparing intercostal neuritis with intercostal neuralgia, we should first distinguish the varieties of this last. The most important of these is that described by M. Bassereau as “commonly sympathetic of an affection of some viscus, whose suffering is transmitted to the intercostal nerves by means of the anastomoses of the great splanchnic.” M. Bassereau believes the uterus and its appendages to be the seat of the irritation thus propagated, inasmuch as women are much oftener the subjects of intercostal neuralgia than men, and that the women so affected, in the majority of cases, are suffering from some disturbance in the uterine functions. M. Beau demurs to this latter conclusion, believing that disorder of the digestive organs is the point of departure of the neuralgia ; for-1, the great splanchnic is in communication with the semilunar ganglions and lunar plexus ; 2, although these females are suffering from derangement of the uterine functions, they are so in a much more marked degree from that of the digestive organs; and, 3, that in all the male patients liable to this neuralgia, the number of whom is greater than M. Bassereau believes, there is a marked disorder of these. Dyspeptic symptoms need not be excessive, and yet the disorder they indicate may have a pathogenic influence upon various organs. So connected with dyspepsia has M. Beau long considered this neuralgia, that he always terms it in his clinical lectures the dyspeptic neuralgia. Wherever such neuralgia disappears completely, the digestive functions have recovered their normal integrity; and to combat the neuralgia effectually we must attack the dyspepsia-all means directed to the relief of the former, without attention to the latter, being merely temporary and palliative in their operation. This dyspeptic neuralgia affects principally the nerves corresponding to the ganglions, which furnish the constituent branches of the trisplanchnic nerve, that is to say,

the intercostal nerves comprised between the 5th, 6th, and 7th intercostal spaces. As in neuritis, there is always one nerve more affected than the neighbouring ones, and that corresponding to the rib possessed of the most extensive movements. Generally five or six intercostal spaces are simultaneously attacked, although in different degrees. This neuralgia, as shown by M. Valleix, also frequently presents three painful points: one at the termination of the intercostal branch, another where the middle perforating branch is given off, and the third over the dorsal branch, near the spinous processes. Its duration is generally chronic, like that of the dyspepsia upon which it depends, and during its progress it exhibits sometimes regular, but generally irregular intermissions.

The second variety of intercostal neuralgia is that dependent upon rheumatism, rheumatic neuralgia, commonly termed pleurodynia. 'Very frequently only one of the intercostal nerves is affected, but the pain is very intense, especially if excited by pressure. It sometimes reaches the extent of preventing the patient laying down, and impeding the respiratory movements, which become short, irregular, jerking, and accompanied by interrupted exclamations. It is worse at night than by day, the maximum of its intensity being seated at the anterior portion of the intercostal nerve. It may be sometimes excited posteriorly by pressure over the dorsal branch of the nerve, but it never spontaneously arises there, as it so frequently does in neuralgia of a dyspeptic origin. This acute form only continues for some days, and may be accompanied by fever, when it puts on the greatest resemblance to neuritis. It affects men as frequently as women, while dyspeptic neuralgia, just as dyspepsia itself, most frequently affects

In comparing neuritis with these neuralgias, we observe that their symptoms have much resemblance, especially as regards rheumatic neuralgia. The pain of this, as of neuritis felt towards the anterior portion of the intercostal space, is very intense. It is less so in the dyspeptic variety, and the patient in the latter frequently complains of pain over the dorsal branch of the nerve, which in neuritis or rheumatic neuralgia is generally only produced upon pressure. The dyspeptic form especially affects the nerves between the 5th and 7th rib, while the seat of pain varies in the others according to that of the pleurisy, or the part affected by the cold, which has induced the rheumatism. Dyspeptic neuralgia is liable to frequent intermissions and exacerbations, which neuritis and rheumatic neurosis rarely are.

“ The ideas, so long since considered as classical, respecting the vivid sensibility of the pleura and the pungent kind of pain resulting from its inflammation, ought, I believe, to be discarded, seeing that the acute and pungent pains of pleurisy do not proceed immediately from the infiamed pleura, but from the intercostal nerves, which the inflammation of the pleura has invaded.”--Archives Generales, T. 13, pp. 161-181.

[This paper must be regarded as containing an interesting and ingenious suggestion on the part of Dr. Beau rather than a demonstration ; for he particularizes no anatomical inspections that he has made in corroboration of his views. The accuracy of the conclusions it contains will however doubtless be soon sufficiently tested.--Rev.]

women.

On ExostosES AND THE OPERATIONS THEY REQUIRE. By M. Roux. Pathologists have comprehended under the general term Exostosis affections of an entirely different nature. In this way have been confounded together-1, Simple, chronic, partial or general hypertrophy of a bone : 2, Osteosis with circumscribed swelling of the affected bone, só often observed as a symptom of constitutional syphilis : 3, Aneurismal tumours of bone : 4, Sarcomatous swelling ; 1847]

Roux on Exostosis.

263

5, The degeneration termed by A. Cooper fungus or medullary exostosis : and 6, those tumours, organized like the bony tissue itself, which spring from the bone like natural apophyses, or exhibit themselves as great tubercles or excrescences within the external layers of the bone, upon which they seem as if implanted. These last are, properly speaking, exostoses, and it is to these alone attention is directed in this paper. I distinguish them carefully from those supernumerary apophyses which the bones of some subjects present, and which are almost always multiple and often very numerous in the same individual, and are more or less similar in form to the natural apophyses. The exostosis, properly so called, is, on the contrary, almost constantly solitary; an anormal condition confined to one point of the osseous system. Once, however, I saw two very compact exostoses situated on the maxillary bones, one on each side the nose; and quite recently I have seen a young man, having an exostosis on the thumb of the right hand, and another on the index finger of the right. This was the first time I had seen true exostoses, and those voluminous ones, on the phalanges.

I was sometime since about to collect my various observations upon this affection together, when the following case presented itself to my notice. A man, æt. 28, consulted me for a hard nipple-shaped tumour, firmly attached, like an appendix or apophysis, to the lower part of the femur, at the uppermost border of the ham. Although seemingly the size of a child's fist, it barely raised the skin beneath which it was placed. By careful examination, and separation of the muscles among which it was placed, a narrower base or kind of thick pedicle attaching it to the femur could be distinguished. The growth had commenced some years before, and after continuing somewhat rapidly it remained stationary for about eighteen months or two years. Quite recently, a collection of fluid had formed between the culminant portion of the tumour and the external soft parts, and this latterly has given the tumour the appearance of increasing. I did Dot hesitate to regard this Auid as a little synovial sac, a sort of hygroma, just like that which so frequently forms in the bursæ of the patella, olecranon, &c. under the influence of contusions or continued pressure ; and my opinion was strengthened by the prompt disappearance of the Auid upon the application of a strong solution of muriate of ammonia. As the exostosis itself had been for some time stationary, caused no deformity and little inconvenience, notwithstanding that the vessels and nerve must have undergone some change of position, any operation for its removal was out of the question.

This made the seventh time that I had observed a pediculated exostosis of this kind, seated at the lower third of the femur, and constituting an isolated affection. In most of the cases the tumour was seated anteriorly, in the immediate vicinity of the capsule. Whence comes this disposition of the lower part of the femur to be especially affected? I know not: but if I may judge from three or four cases I have met with in the humerus it is the upper part that is most constantly affected. According to my experience, too, the different parts of the skeleton vary much as to their degree of liability to exostosis. The femur seems so far beyond any other bone: then comes the humerus, the maxillæ, and then the phalanges, especially the last phalanx of the great toe, raising the nail, distending its matrix, and inducing a more or less acute pain. Dupuytren met with these cases of exostosis of the toe several times, and his directions for their removal are excellent. The nail is to be removed after longitudinally dividing it, and the tumour, which is rarely larger than a large pea or the point of the little finger, cut away with a saw, or better still, on account of its spongy texture, with a pair of cutting forceps.

Whatever place they occupy, or upon whatever bone they become developed, these tumours have certain general characteristics which it is useful to be aware of. 1. A very remarkable one is that, although they may be found in adults, these persons were first affected by them at an earlier period of life. It is for the

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