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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