In two other cases of lumbo-abdominal neuralgia which were under my care, there were also very painful points in the spermatic cord and in the testicle. One of these cases will be referred to under the head of Visceral Neuralgia. Another case, in which severe quasi-neuralgic pain was referred to the groin, will be described in the chapter on the Pains of Hypochondriasis.
(_f_) _Crural Neuralgia._--This appears to be rare as an independent affection occurring primarily in the crural nerve. Valleix had only seen it twice in all his large experience, and I have never seen it myself. Neuralgic pain of the crural nerve is almost always a secondary affection arising in the course of a neuralgia, which first shows itself in the external pudic branch of the sacral plexus; or else occurring as a complication of sciatica. A remarkably severe example of the latter occurrence was observed in an old man who still occasionally attends the Westminster Hospital. He has been a martyr to the most inveterate bilateral sciatica for between two and three years; and, within the last three months, it has extended itself into the cutaneous branches of the curval nerves of both thighs. So great an aggravation of the pain is produced by any muscular movement, that the patient can only walk at the slowest possible pace, moving each foot forward only a few inches at a time. The bilateral distribution of the pain is remarkable in this case; but there can be no doubt of its really neuralgic character, from the truly intermittent way in which it recurs, and the absence of any history whatever to point in the direction of rheumatism, gout, or syphilis.
The nervous supply to the skin of the anterior and external portion of the thigh includes: (1) The middle cutaneous, (2) the internal cutaneous, and (3) the long saphenous branch of the anterior crural nerve; (4) the cutaneous branch of the obturator; and (5) the external cutaneous nerve, derived from the loop formed between the second and third lumbar nerve. The sensitive twigs derived from the two latter sources, equally with the branches of the anterior crural, are liable to be secondarily affected by neuralgia, which commences in the lumbo-abdominal nerves; but it must be a rare event for them to be the seat of a primary neuralgia. The only occasion on which I have seen anything which looked like the latter was in the case of a porter, who, in straining to lift a very heavy load, ruptured some part of the attachment of the tensor vaginæ femoris. But the susceptibility of all the nerves of the front of the thigh to secondary or reflex neuralgia receives numerous illustrations. The extremely severe pain at the internal aspect of the knee-joint, which is such a common symptom in morbus coxæ, is evidently a reflex neuralgia of the long saphenous nerve, the ultimate irritation being situated in the branches of the obturator nerve which supply the hip-joints. For some reason unexplained, it happens that this saphenous nerve is specially liable to be affected in a reflex manner: for instance, this happens in a considerable number of cases of sciatica. I have a lady now under my observation, in whom the secondary neuralgia of the saphenous nerve has become even more intolerable than the pain in the sciatic, which was the nerve primarily affected. The pain in these cases very frequently runs down the inner and anterior surface of the leg to the internal ankle. Sometimes the branches of the anterior crural become the seat of intensely painful points in the course of a long-persisting sciatica. A patient at present under my care has a spot, about the size of a shilling, just at the emergence of the middle cutaneous branch from the fascia lata, which is intensely and persistently tender to the touch, and the skin here is so exquisitely sensitive to the continuous galvanic current that the application of moistened sponge-conductors, with a current of only fifteen Daniell's cells, causes intolerable burning pain; whereas at every other part of the limb the current from twenty-five cells can be borne without much inconvenience.