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Sciatica





Etiology.--What has been said of lumbago applies to a great extent
also to sciatica. There are a number of different affections which
have come to be grouped under the term sciatica. Here, much more
frequently than in the lumbar region, the cause of the pain is a true
neuritis. This may be of many forms. Occasionally it is syphilitic in
origin; whenever the sciatica is double it commonly develops on a
basis of diabetes, while in many cases it is of an infectious nature.
There is no special reason to think that there is a rheumatic
infection of the nerve, though inasmuch as rheumatic arthritis is
probably due to infections by many different kinds of microbes, it may
well be that some of these play a role in sciatica. There is no good
reason, however, why the word rheumatism or the term chronic
rheumatism should be applied either to lumbago or to sciatica.
Certainly there is no reason in any definitely known etiology of the
affections. Each individual case must be studied carefully. Always
these are local and not constitutional conditions, and usually
something in the patient's occupation, or in his habits of life, helps
us to understand the development of sciatica or lumbago and gives the
most valuable hints for treatment.

Men who shovel much and who bend one knee as they stoop in shoveling
will often suffer, though more frequently in the leg which they do not
bend than in the other. The same thing is true for men who use one
foot to run a lathe or a small printing press, or anything of that
kind. They must be taught to alternate in the use of their limbs.


Pressure.--Occasionally direct pressure upon the nerve is the cause
of the disturbance. I once was asked to see in consultation an elderly
lady who had complained very much, first of discomfort and then
numbness in her legs, until finally she lost all power in them below
the knees. The affection was considered to be some sort of creeping
paralysis. I found that her favorite chair, an old-fashioned cushioned
easy chair, allowed her to sink down so that the edge of the wood seat
frame pressed upon her just where the sciatic nerve comes closest to
the surface. As soon as the habit of sitting on this chair was changed
her numbness and inability to use her limbs began to disappear.


Alcoholic Neuritis.--In both lumbago and sciatica one underlying
factor is often present. This is the consumption of undiluted whiskey
in considerable quantities. Outdoor workers are prone to take an
occasional glass of whiskey, especially in the winter time, and a
copious quantity of malt liquors in the summer. Both of these
predispose to the development of a low-grade neuritis in
susceptible individuals. Alcohol is said to have an idiosyncrasy for
the anterior tibial nerves. That only means, as a rule, however, that
these nerves are more frequently affected by alcoholic neuritis than
others in the body. The reason for this special location of the
affection is that in people who stand and walk much, this constituting
their main form of exercise, these nerves are much used. They are
probably in such people (that is, if the intensity of impulses that
pass through them be taken into account) the most used nerves in the
body. It is this that makes them most susceptible to alcohol. In
people who stoop much or who have to work hard in stooping postures,
the nerves in the lumbar region and those that make up the sciatic
trunk are over-used. This makes them more susceptible to pathological
influences than others, hence the tendency for neuritis to develop in
them.


Intrapelvic Causes.--Sciatica may be due to various pathological
conditions within the pelvis. Women with fibroid tumors are
particularly likely to suffer from it. Their removal by operation does
not always assure against the occurrence of sciatic troubles. I once
saw an obstinate case of sciatica in which there was a story of a
fibroid having been removed years before and, though there were no
signs of any recurrence of the growth of another, there were some
adhesions in the region, and there was an obstinate constipation
particularly likely to have as one symptom an accumulation of fecal
material in the rectum until it was very hard. The keeping of the
bowels open meant more than anything else for the relief of the
sciatica. This patient subsequently died from what was diagnosed by a
well-known French surgeon as rupture of the bowels. This was probably
due to the adhesions that occurred after the old operation, done
without any regard to the possible development of such a sequela, some
twenty years ago. The sciatica was undoubtedly connected with the
group of disturbed conditions within the pelvis.


Position at Work.--In this case, as in others that I have seen, the
position assumed while at work seemed to have been an appreciable
factor in the production of the pain in the limb. The lady made her
living by writing and often wrote on a board resting on her knee--a
feminine, not a masculine habit. This brought pressure to bear upon
the right limb a little more than the other and then, when she crossed
her knees in order to put the writing board on top of the knee, this
side seemed to be used more than the other.

This question of the position in occupation, even though sedentary, is
very important. I have seen a strikingly typical case of the so-called
neuralgia paresthetica, the achy condition of the outside of the
thigh with some anesthesia and paresthesia, occur in an old lady who
still retained the girlish habit of sitting on her foot while she did
crocheting. I have often seen achiness of muscles of the trunk develop
in persons who read much in a cramped position because of the reading
light being too low or otherwise wrongly placed for group reading.
Whenever a patient has to stand much on one foot while doing
something, it is important to remember that there should be
alternation in the use of the limbs; otherwise sciatica and lumbar
pains will often develop, usually on the side corresponding to the
limb that is kept rigid.


Treatment.--Mental Persuasion.--The patient must be made to realize
that his affection is not rheumatism, but is due to local conditions.
Just as soon as a patient's mind is relieved by being made to
appreciate that certain habits in his occupation, or certain local
conditions that can be corrected, are responsible for much of
his discomfort, then that discomfort is much easier to bear. Even in
cases where actual neuritis has developed, or where there have been
changes in the intermuscular planes bringing considerable disability,
the aches caused by these will be much more bearable if the patient's
mind is set at rest as to the real significance of the condition. No
condition should be called rheumatic unless at some time in the
history of it there was an acute inflammatory condition with Galen's
classical symptoms--tumor, color, rubor and dolor. Pain alone is
never sufficient to justify the diagnosis. Painful disability is
usually due to local causes.


Treatment of Acute Symptoms.--For acute symptoms, the coal tar
products may be used and usually afford distinct relief. They include
all the old-fashioned salicylates as well as certain more recent
compounds, such as aspirin. Phenacetin, however, though usually not
thought of in this connection, is an excellent remedy for the
discomfort. These drugs should be used freely so as to give relief
from the painful condition. The fact that they afford relief, however,
should not be taken as an argument that the condition is rheumatic.
Rheumatism, as we know it, is an acute infectious disease and there is
no reason in the world for saying that the salicylates or cognate
drugs are specifics in this affection. They relieve the pain, but just
in the same way they would relieve the pain of toothache or of any
other painful condition. After the acute symptoms are removed, the
condition that remains may be treated in various ways, by massage, by
local applications, and by such manipulations as will restore the
normal circulation of the part. Care must be taken, however, to
distract the patient's mind from the local condition after a time, or
mental influence, by interfering with the capillary circulation, may
inveterate the symptoms. It is not good to keep patients at rest,
though rest, of course, is always indicated if there is much
discomfort. Sometimes, however, the discomfort is really due to the
fact that muscles have not been used for some time and so are easily
fatigued and may ache even under ordinary use. In this case, a gradual
restoration of the muscles to normal strength by progressively
increased exercise is important.


Counter-Irritation and Its Suggestive Value.--Personally, I have
found the use of turpentine particularly efficacious in connection
with suggestion. The old-fashioned system of ironing seems to do more
good than any ordinary application of turpentine. For this a piece of
flannel wrung out in warm water has some turpentine scattered over it
and then is placed on the affected loins or back of the thigh and
covered by another piece of flannel, and a hot flat-iron is rubbed
over it. The physical effect is a considerable hyperemia, but the
effect upon the patient's mind is especially interesting, the
unusualness of the mode of application adding decidedly to the effect.
It must not be forgotten, however, that there are some people who are
over-susceptible to the influence of turpentine, and its use is
followed by a rash.


Lumbar and Sciatic Psychoneuroses.--Many cases of lumbago and
sciatica are really psychoneuroses. They develop exactly as
psychoneurotic conditions do in the abdomen or in joints. Not
infrequently there is some accident or injury, some sprain or strain,
or exposure to dampness or draft, that serves as the occasion. The
Germans group all these occasions together under the word "insult."
The "insult" produces little physical effect but after some days or
sometimes weeks, the slight discomfort present secures the center of
attention and then the patient suffers from what seems to be
severe pain and often inability to move or use muscles. Even when
there is true sciatica or lumbago, that is, a genuine low-grade
neuritis of the lumbar or sciatic nerves, most of the symptoms may
come from the associated psychoneurosis. This is proved to be so by
the fact that such patients are often cured, for the time being at
least, by some shock or fright or sudden excitement, that makes them
move, forgetful of the pain and inability from which they suffered
just before. Besides, such cases are often cured by inert remedies of
many kinds, by local applications that have no specific effect, and by
various methods of treatment which cannot be responsible for the
recovery. The amelioration of the condition is due to the mental
influence accompanying the methods of treatment and the reassurance of
the patient's mind.


Diversion of Attention.--Almost anything that produces a continuous
succession of sensations on the surface of the affected area that
attract and hold the attention of the patient may prove a valuable
therapeutic suggestion and even eventual relief from symptoms that
have proved obstinate to more rational treatment. Liebault, the
well-known founder of the Nancy school of hypnotic therapeutics, tells
in his "Therapeutique Suggestive," that he has frequently cured
lumbago by the simple recommendation of a rather stiff piece of paper
to be applied over the patient's loins. The rationale of this
treatment seems to be that the patient's attention is attracted to the
skin surface by the sensations constantly produced by it and attention
is distracted from other feelings deeper in the muscles. It often
happens that after an acute lumbago has run its course, there is left
a chronic achiness only partly physical and largely psychoneurotic.
Some of it is undoubtedly due to the habit, formed during the acute
period, of keeping the muscles quiet, in order to avoid the spasmodic
pain that occurs on movement. Patients cannot, as it were, let go of
their muscles, and their discomfort is largely due to holding them in
a cramped position. The sensation produced by the paper on the
cutaneous nerves distracts the attention and brings about relaxation
of the muscles with decrease of discomfort and gradual relief of all
symptoms.

The paper acts as a constant source of suggestion for the cure of the
psychoneuroses when the affection is purely psychoneurotic. The mind
has become concentrated on the idea of pain and discomfort in this
region and needs another thought to occupy itself with so as to
neutralize this. Wearing the paper with the assurance, for instance,
that because of its impermeability to air it keeps the part more
thoroughly protected from variations of temperature and from such
possibilities of transudation as have before been possible, serves to
lift patients out of themselves and affords relief. Whenever the
sensation produced by the paper is noted, there is a renewal of the
suggestion and its curative effects. There are many plasters that have
obtained the reputation for curing lumbago. It is doubtful whether any
of these have sufficient medicaments on them to be of any serious
pharmaceutic significance. They are mostly rubber plaster. The
presence of this and the consciousness of the sensation produced by it
acts as favorably as does Liebault's sheet of paper.


Mechanical Agents.--It must not be forgotten, however, that a large
sheet of adhesive plaster firmly applied may act as a mechanical
therapeutic agent, somewhat in the same way that strips of adhesive
plaster relieve the pain of pleurisy, or are helpful in a sprained
ankle or a knee. The muscles may be held rather firmly together
and so there is no necessity for constant attention to prevent
spasmodic pain. Undoubtedly some of the newer large-sized adhesive
plasters produce an excellent effect in this way. If, besides, the
patient has the feeling that they must be doing him good because of
materials in their composition, the psychoneurotic elements are more
readily relieved. The old idea was that such plasters drew out the
pathological elements to the surface whence they were dissipated.
There is no truth underlying this thought.

In the old days blisters were applied rather freely to these regions
and the actual cautery was often employed. Both of these therapeutic
processes are likely to do good in chronic cases, but much more from
their psychic than their physical effects. The actual cautery is not
used nearly so much as it ought to be in chronic muscular and neurotic
conditions, for the mental effect of its application and the
distraction of attention to the skin surface while the cauterized
areas are healing are excellent remedies.

There are other counter-irritant procedures of the same kind that have
been used with reported successes in many cases. Hot needles, for
instance, if pushed deeply into the muscles, often have an excellent
effect. Some years ago a distinguished surgeon insisted that both
lumbago and sciatica might be cured in many cases by the insertion of
needles deeply into the muscles. He argued that what happened was that
these needles brought about an equilibrium of electricity in the
muscular structures which had somehow been disturbed. Deep injections
of water into the muscles also do good. Stretching of nerves has been
applied with reported success. After a time all of these measures
fail, however, because somehow after the novelty of the treatment
wears off for the physician, the patient's mind is not sufficiently
impressed and then the former results are not secured. Where there are
actual neuritic processes present they will almost surely fail. So
many of these cases are almost pure psychoneuroses, however, that it
is little wonder that anything which produces a strong impression on
the mind and leaves after it some condition that attracts attention
and so furnishes favorable suggestion will almost surely cure even
chronic conditions for which all sorts of physical remedies, employed
on rational grounds, have failed.

Anything that modifies the circulation, even to a slight degree, or by
causing a reaction in the local vaso-motor state, alters previous
conditions, tends to enable the patient to control the affected part.
These psychoneurotic conditions in large muscles help us to understand
what happens in organic diseases. There is a physical element that
must be modified, but unless a strong influence is brought to bear
upon the mind so as to arouse all its capacity for control, the cure
will not come. Anyone of a dozen things, however, may be used in this
way and often when one fails another will succeed. In obstinate cases
of lumbago and sciatica if necessary a number of these forms of
treatment should be used successively.


Hypnotism.--How much pure psychotherapy may mean for many of these
obstinate cases of lumbago and sciatica can be appreciated from the
many reports of cures by hypnotism or by suggestion in a light
hypnoidal state, or occasionally, under favorable circumstances, even
in the waking state. One of these cases, indeed, is responsible to
some extent for the French interest in hypnotism which attracted so
much attention in the last quarter of the nineteenth century.
Prof. Bernheim of the University of Nancy had seen a case of sciatica
in which every therapeutic means at his command had failed. As the
result of disuse the leg was emaciated and possessed little muscular
power. It looked as though the man would never be able to regain the
use of it properly. Dr. Liebault succeeded in curing the patient by
light hypnotic sleep, in which the suggestion that he would be better
was given while the physician stroked the limb. After the first seance
the patient was able to use the leg better and the discomfort was
greatly decreased. Further seances with Dr. Liebault brought further
improvement until finally the condition was cured. Prof. Bernheim, who
knew how intractable these cases are, had the case called particularly
to his attention and naturally wanted to learn more about the method
by which it had been brought about. Liebault's methods had been quite
contemned by the regular faculty before. After a series of experiences
under Dr. Liebault's direction Prof. Bernheim became enthusiastic over
the use of hypnotism as a curative agent and this led to the
publication of his well-known work "De la Suggestion et ses
Applications dans la Therapeutique." [Footnote 34] It was the
interest aroused at Nancy that led Charcot to take up hypnotism, and
while he came to very different conclusions, there is no doubt that
the work at Nancy meant much for our knowledge of suggestion in both
waking and hypnotic state in therapeutics.

[Footnote 34: On Suggestion and its Applications in Therapeutics.]





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