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Medical Societies

ROYAL SOCIETY OF MEDICINEUN Jan. 17 there was a joint meeting of the sections of

Neurology and Orthopaedics which members of thesections of Medicine, Physical Medicine and Radiologywere invited to attend. Colonel GEORGE RIDDOCH tookthe chair and a discussion on

Sciatic Painwas opened by Dr. J. PURDON MARTIN. He said thatthe subject had become confused, partly owing to muchnew work in the last few years which had not beenproperly digested, and partly because of inexact termino-logy. By sciatic pain he meant pain referred to thecourse and distribution of the sciatic nerve. The cutane-ous distribution of the nerve was limited to areas belowthe knee, but it gave motor and deep sensory innervationto the muscles at the back of the thigh, and to thoseof the back and outer side of the leg. The pain wastypically a deep one and was felt in the muscles. Thereappeared to be tenderness along the course of the nerve,but it was doubtful whether this really indicated that thenerve was tender. The muscles were tender, and he hadfound that the muscles on the outer side of the leg mightbe tender when there was no tenderness of the commonperoneal Aerve at the neck of the fibula. He thoughtthat the pain excited by extension of the limb wasprobably due to stretching of the hyperalgesic muscles.It had been attributed to stretching of the inflamednerve, and even to adhesions ; but in some cases ofreferred sciatic pain it could be abolished by anaesthetisa-tion of the exciting focus, so that it could not be due toinflammation or adhesions. The causes of sciatic painfell into two groups : disturbances affecting the nerveitself, or one of its roots, and causes producing painreferred to the distribution of the nerve from a focus-that might or might not be within its territory. Thereferred pain was the commoner. Mackenzie’s con-

ception that referred pain was due to an irritable focusin the spinal cord had stood the test of time andhad received support from Sherrington’s demonstrationof a " central excitatory state " affecting. motor cellsin the cord. The cells concerned with referred painwere those in the posterior horn of the grey matterand they formed a continuous column which wasnot segmented. Referred pain was not, strictly speak-ing, segmental, though it might be so with a moderatestimulus. All the structures within the affected territorywere hyperalgesic. Referred pain could not impairfunction or abolish reflexes. The chief sources fromwhich pain was referred into the sciatic distribution werefrom arthritis and periarthritis of the hip and lumbarspine. Malignant disease of the lumbar spine mightcause sciatic pain at a time when no abnormality couldbe made out in the X-ray films, and as there was at thatstage no impairment of the functions of the sciatic nervethe pain was probably referred from the diseased bone.The treatment of referred sciatic pain was to treat theprimary focus. Harris was using the method of localinjection in suitable cases 20 years ago, employing quinineurea, and later very small injections of alcohol, and in thelast few years J. H. Kellgren, using procaine preparations,had made this method his own. Disturbances whichmight affect the nerve itself or -its roots were many.The protruded nucleus of a broken intervertebral discusually caused an irritation of a single root. This wasundoubtedly the same as the " radicular sciatica " ofDejerine and others, and the exponents of protrudeddiscs had not so far added anything to the symptomsdescribed by Dejerine. We were still somewhat weak inthe diagnosis of these cases. Like any other neurologicalproblem, it could be divided into : " where is the lesion "and " what is the lesion ? " The distribution of thepain and any sensory or reflex impairment indicatedwhich root was affected. For the answer to the secondquestion we were dependent on signs elsewhere, specialinvestigations and the history. The pain in the backwas probably referred from the damaged disc or liga-ments under stress. The simple X-ray appearances andthe C.S.F. findings were not very helpful in differentialdiagnosis, and we had to use X-ray examination withcontrast media, of which air was the best; Lipiodol ’

should not be used lightly. He believed we wouldeventually be able to diagnose. these cases clinically whenwe got to know the syndrome caused by the lesion of thedisc itself at whatever level, and in fact we might do itbetter than with contrast media, because there must besome cases in which no constriction of the theca wasproduced. Dr. Martin declared that a sciatic neuritisexisted-an interstitial’ neuritis analogous to thosewhich affected other nerves-though there was littlerecent pathological confirmation. Its signs were absenceof the ankle-jerk and wasting of the calf muscles. Somepatients had only one attack and others recovered in afew weeks. The outstanding symptom was pain, andthere were signs of interference with the nerve function,but paralysis was unusual and generally associated with agross lesion. The signs and symptoms were not localisedto the distribution of a single root, but there were usuallysigns of more widespread inflammation. There wasnearly always a point of tenderness below the iliac creston the upper and outer part of the buttock.Mr. V. H. ELLIS said that neurologists were now reach-

ing a conception that in sciatica there was usually nothingmuch wrong with the great sciatic nerve trunk, nor wasthe pain referred to its cutaneous distribution. Intheory, sciatic pain might arise within the nerve or

its central connexion, or might be due to irritationof the nerve or its roots from outside, or to stimulationof nerve-endings of similar segmental distribution inother regions, from which the pain was referred to thesciatic area. Sciatic neuritis was extremely rare and hehad never seen hyperaesthesia referred to the dorsum ofthe foot in sciatica, though the whole of the cutaneousdistribution of the nerve ought to be affected by aneuritis of the main trunk. Irritation of the nerve or itsroots might be caused not only by lesions of an inter-vertebral disc but also by an intraspinal tumour, sub-arachnoid adhesions and possibly by spinal osteophytesor tumours of the pelvis. Seddon had ascribed sciaticpain to tuberculous caries of the sacro-iliac joint. Toproduce pain in a nerve, movement was generally re-quired as well as pressure ; this fact might explain whysciatic pain was sometimes intermittent and why certainforms of treatment gave no relief. Rupture of an inter-vertebral disc suggested a severe traumatic strain on anintervertebral joint, and hypertrophy of the ligamentumsubflavum suggested a similar aetiology. He doubtedwhether protrusion of the disc was always the onlylesion present, and asked whether it might not be associ-ated with a strain of an intervertebral joint. Movementwas required to elicit pain when any of those threelesions was present. Sciatica could nearly always berelieved by immobilisation of the lumbar spine ; fusionof the lumbar spine relieved symptoms caused by discprotrusion, but prolapse of the disc was not the onlyfactor responsible for pain. Fusion after laminectomygave better results, and Watson Jones recommendedposterior root division as well as removal of the disc,which by itself seemed not always to produce a permanentcure. It therefore appeared that sciatica might bedue to intervertebral strain, a wide class of injuries ofwhich rupture of the disc might be merely a complication.In treatment, the lumbar spine might be immobilisedby methods varying from rest in bed to fusion of the spine.Application of a plaster jacket in suspension, possiblyprolonged into a short hip spica, would give relief evenin a case of protruded disc, but not permanently. Aprotruded disc might be reduced by alteration in theposition of the lumbar spine, but it was not likely thatthe ruptured fibrous ring would heal and fix it permanentlyin place. Spontaneous reduction, however, probablyaccounted for some of the remissions. He had broughtabout permanent relief in non-fibrositic cases by immo-bilisation and by simple traction on the affected limb withthe patient recumbent. Manipulation of the spinesometimes gave relief but was dangerous unless a ruptureddisc had been excluded.

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Dr. F. A. EmoTT pointed out a gulf between ortho-paediG and neurological views on the cause of sciatic pain.He analysed an unselected group of 115 cases admitted tothree emergency hospitals. Of these 84 had pain oftrue sciatic distribution ; 16 were obvious cases offibrositis. Interstitial neuritis, comparable to brachialneuritis, was present and obvious in 3, and was quiteunlike any type of fibrositis ; the ankle-jerk was absent

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and recovery was very slow. Radiculitis was diagnosedin 2 young men who apparently had sciatic neuritis butwhose cerebrospinal fluid had a protein content above100 mg. With osteo-arthritis of the 4th and 5thlumbar vertebrae there was localised inflammation withgross lipping, and the question arose whether the highsciatica was caused in any way by the osteo-arthritis.If the root was anaesthetised in the canal the pain wascompletely relieved for 2-3 hours. Osteo-arthritis of thehip’was diagnosed in 8 cases ; the fact that pyogenicor tuberculous disease of the hip does not usually cause‘

sciatic pain was a warning that osteo-arthritis hereshould not be accepted as the cause of a sciatica withoutmore evidence. Sacro-iliac arthritis was difficult todiagnose because clinical signs were unreliable. Subacutearthritis of the sacro-iliac joint accounted for 5 casesin his series, Pott’s disease for 4 or 5, and malignantsecondaries for 4 or 5 more ; 3 cases were due to tumoursof the cauda equina, 2 to herniation of the nucleuspulposus, 1 to protrusion of an intervertebral disc ; and1 patient was a malingerer who had suffered from-sciaticabefore and was reproducing his earlier symptoms.Sciatics of long standing tended to develop a neurosiswhich was either a hysteria or a true anxiety state duepartly to long-standing pain and partly to long discussionsround the bedside during which the patient began to’realise that his doctors were not very sure what was thematter. An anxiety state did not indicate that thesciatica was spurious, but it was a definite complication.

Mr. JOE PENNYBACKER doubted whether significantadvances would be made until Dr. Martin’s definitionwas accepted. Diagnosis of protrusion of an interverte-bral disc usually rested on the history, which began witha strain-as a rule a minor strain in flexion. The patientmight be so obsessed with the sciatic pain that the causewas only revealed on direct inquiry. Diagnosis fromneurological signs would vary with the diligence of thesurgeon in seeking them. Love had reported neuro-logical abnormalities in 85% of cases. One of the com-monest signs, and one generally missed, was muscularweakness : when the power of dorsiflexion of the footwas tested against resistance, there was a definite weak-ness on the affected side, but complete sensory loss wasrare ; more commonly there was slight hypo-aesthesia,loss of the sense of tickling and slight impairment ofresponse to pin-prick. Abnormalities of reflex varied.The cerebrospinal fluid was normal or had a slightincrease of protein. Lipiodol had become somewhat

dangerous because old stocks were now being used whichcontained relatively large amounts of free iodine. Mostpatients responded to rest, but if this could not bearranged for and the pain was not disabling, the sciaticacould sometimes be relieved enough by an extensionplaster jacket for the patient to return to work. Localinjections were harmless, but their results were notvery impressive. Operation should only be advised ifresponse to rest and immobilisation was not satisfactory.Spinal manipulation might cause obstinate cauda-equinalparalysis. Further advances would come throughorthopaedists and neurologists seeing cases together andcommitting themselves in writing to a definite diagnosisand suggestions for treatment. It was necessary toknow the reason why explorations had proved negativeand to be. sure that the lesion had not been missed.Proper follow-up, as yet rare, was essential.The PRESIDENT observed that diagnosis was the crux of

the matter and ought to precede any form of treatment.The profession should discard the notion that sciaticahad a simple pathology, and he thought that to give itanother name-such as posterior crural pain-mighthelp. He confirmed the need for a really scientificclinical investigation by a team consisting of neurologists,orthopaedists and physiotherapists, with a proper follow-up.

Dr. P. P. DALTON stressed the importance of the vege-tative nervous system as the site of minute points of painwhich would cause sciatica. The referred pain, he said,was often accompanied by other symptoms of neuraldisturbance, and in some cases vasomotor reflexes wereexcited when the painful point was injected. Thepattern of the painful spots was similar to that of theunderlying deep blood-vessels. Oozing of blood fromthe needle punctures was far more common than wouldbe expected, which confirmed the belief that the spots

lay in highly vascular areas-that was to say, in areas wellsupplied with vegetative nerve-fibres. The sensationof cold in the affected limb was due to vasoconstriction.He had produced pain or a sensation of extreme colddown the sole of the foot by injecting spots some two anda half inches deep lateral to the superior surface of thefirst lumbar vertebra ; this result would be anatomicallyimpossible if the path of the stimulus were along thecerebrospinal nervous system. Disturbance of the vege-tative nervous system was the only pathological statewhich fitted all the facts, and was one of the commonestcauses of sciatica and other reflex pains.Mr. L. S. MICHAELIS suggested that local and acutecooling-for instance, by lying on a wet lawn betweengames of tennis-might be one cause of sciatica. Heurged that before more drastic remedies were tried, thepatient should be given analgesics and vitamin B and beencouraged to move as soon as possible.

Dr. JAMES OYRIAX said that 15% of all cases were dueto adhesions affecting the sciatic nerve. The sciaticpatient always had pain on some movement, and if paincould be shown to be due entirely to the stretching of thenerve structure, the nerve sheath was obviously involved.If the sheath alone were involved and epidermal injectioncould be given at once, the patient could then usuallyreach another 8 in. down his leg and the diagnosis wasconfirmed. If the improvement was transitory, clearlythe condition was a sciatic perineuritis, but not of thesort that could be cured by local anaesthesia ; there must,in fact, be a frictional cause, usually a protruding disc.This was present in about a tenth of the cases of diffusepain felt down the thigh and in the leg. Diagnosis ofprotrusion of a disc could therefore be made purely on theresponse to local anaesthesia. The absence of signs otherthan loss of ankle-jerk and wasting of the glutei sug-gested a disc lesion, and weakness of dorsiflexion of thefoot was typical of it. Most patients with pain down theleg, however, were suffering from referred pain whichmight come from any deep-seated structure proximal tothe segments from the 4th lumbar to the 2nd sacral.Diagnosis. could nearly always be made from observingwhat movement hurt. Local anaesthesia could be usedto corroborate, and treatment was nearly alwaysphysiotherapy applied to the source of pain. The treat-ment of sciatic perineuritis was not physical, but con-sisted of local anaesthesia ; a protruding disc shouldnearly always be removed.

Group-Captain C. P. SYMONDS said he had very littleto retract from what he had said three years ago when Dr.J. G. Love had addressed the section. The syndromein patients with proved protrusion of the disc appearedidentical with that seen in scores of others who hadrecovered with rest and warmth alone. If prolapse ofthe disc had any substantial incidence, it must oftenbe capable of spontaneous repair. He added, however,from later experience that in healthy young people pro-lapsed disc was by far the commonest cause of sciatica.Prolapsed disc. could be diagnosed with considerablecertainty if recurrent lumbago were followed by recurrentsciatica in a healthy young person. He was not preparedto advise operation in any case. If rest had been triedfor a reasonable time and failed, the Service patient shouldbe invalided out. Results of’surgical intervention hadbeen deplorably unsuccessful.

Dr. HENRY WILSON spoke of 80 cases of sciaticaadmitted to the London Hospital in the last 5 years. Inno less than 25% the house-physician or registrar hadnoted a slightly abnormal mental attitude. He did notinclude the word " anxious," for any patient with serioussciatica might be anxious ; nor had he included" exhausted." These reactions were probably frequentbecause of long inactivity ; such patients ought to begiven suitable employment for their upper limbs andtheir minds. Possibly pain which continued after 3months was really hysterical in origin. If a patient didnot react to ordinary treatment after a reasonable time,a psychiatrist might be called in to inquire Whether anescape mechanism was prolonging the symptoms.-Major G. D. EEBSLBY said that strict immobilisationshould always be tried before operation was considered ;for Service patients he would not consider operation atall.-Mr. HARVEY JACKSON declared that hernia of thenucleus pulposus had been given undue importance ;by itself, it did not produce sciatica.. He asked how long

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would elapse between injury to the back and evidence ofnuclear herniation. If the lesion could remain quiescentfor 2 years, it was difficult to evaluate fixation. Clinicaldiagnosis was not possible; an impression only could begained ; accessory means were needed to make certain.The patient must be incapacitated from work beforeoperation was justified. Nuclear hernia sometimes pro-duced a neuritis and sometimes not. The ligamentumsubflavum played no part in sciatic pain : intermittentstrain always produced hypertrophy, which in thisligament was merely a result of the deformity.

Reviews of Books

Foundations of Neuropsychiatry(2nd ed.) STANLEY COBB, M.D. London: Bailliere,Tindall and Co. Pp. 231. 14s.

A RECENT controversy about the neurological approachto mental disorder showed how easily and vehementlythe connexion between neural and psychological func-tions can be denied, or belittled, by those who are mind-ful of past crimes of omission and commission on bothsides. In America they seem readier to accept. theconnexion, and Professor Cobb’s book, now in its secondedition, takes it for granted. By describing the presentstate of knowledge in the anatomy, physiology andpathology of the nervous system, he demonstrates thatpsychiatry can-indeed must-eat also at this table if itis not to become swollen with wind and rank mists. Inhis introductory chapter, Cobb recognises that themental sciences are separated from their foundations inanatomy, physics, chemistry, physiology, neurology andexperimental psychology by a gap in our knowledge thatis at present filled by theories with little support in scientifi-cally controlled observations. But he sees no reason forassuming that accurate controllable methods will neverbe applied to the observation of human behaviour: " it isbecause the science of psychiatry is young that it seemstoo complex for quantitative analysis."The book is mainly, as in the previous edition, an

exposition of the facts and correlations needed tounderstand the simpler workings of the central nervoussystem, whether in health or disease. Recent work isincorporated, and general principles made clear whereverpossible. The chapters on the autonomic nervous

system, the cerebral circulation, and epilepsy, have beenlargely rewritten, and a chapter on psychopathologyadded. This last is brief and schematic, and containscontroversial statements such as that one must takeschizophrenia and affective psychoses as fundamentallyone-the " schizo-affective group." This is the leastsatisfactory chapter, because uncritical and misleadinglysketchy. The book as a whole, however, is ideal forintroducing the medical student to the combined dis-cipline ; it gives him a sound basis for his further studies.

Science for the ProsecutionJuLius GRANT, M.Sc., Ph.D., F.I.C. London : Chapmanand Hall. Pp. 302. 15s.

A SUBJECT so new, so fluid, so various and so muchhampered by the lack of an English journal as contem-porary forensic science .takes some presenting; butthere has long been a space waiting on the shelf forDr. Grant’s book. He describes the forensic uses ofchemical analysis, serology, and the forms of radiation-from X rays to the infrared-which may be harnessedby means of the camera, the microscope, the spectro-scope, or the naked eye ; and in a final chapter hediscusses the psychological examination and treatmentof the offender. Thus he has certainly covered theground, though he might have opened up a little moreabout the comparison microscope, the use of obliqueillumination in deciphering impressions of writing, andabout ways of restoring erased markings to materialsother than paper. The arrangement is rather woollyand a few good diagrams might well replace the explaiaa-tion of the action of the spectroscope, which will be almostincomprehensible to the lay reader. , The book is alsomarred by some minor misstatements. Neverthelessthe various people to whom it is addressed-the scientist,the social worker, the lawyer, the policeman, and thegeneral reader-will be able to find the facts in it evenif they take a little hunting out. -

Recent Advances in Medicine

(10th ed.) G. E. BEAUMONT, D.M. Oxfd, F.R.C.P.,and E. C. DODDS, M.D., D.Sc.Lond. London : J. and A.Churchill. Pp. 440. 18$.DESPITE the war, Dr. Beaumont and Professor Dodds

have had much new material to incorporate in theirtriennial new edition. The expanded chapter on thesulphanilamide drugs now includes sulphathiazole ; butit is not made clear that the nausea and depressionproduced by this drug are usually much less than thosecaused by sulphapyridine. Other new material relates.to vitamin P, stilbcestrol and hexoestrol, electro-encephalography, sodium diphenyl-hydantoinate, lipo-caic, sternal puncture, heparin and plasma transfusion,and the estimation of prothrombin. The sections onvitamin B, Addison’s disease, and the macrocyticanaemias have been radically revised, and the chapteron basal metabolism has been dropped : one sighs tothink how important it seemed fifteen years ago.Though the diabetic section has been much improved,the diets are still calculated in grammes to the seconddecimal place and have not been adapted to our rationingrestrictions. In the chapter on liver-function tests, thevalue of a galactose test and a phosphatase determinationin helping to distinguish between obstructive and hepatiticjaundice finds no place. In other points physiciansfamiliar with a disease under discussion may differ fromthe authors ; for example, they say that hypertensiveneuro-retinopathy " may " occur in malignant renalnephrosclerosis, while most observers regard it as

essential to the clinical diagnosis. Why should a diabetic,just out of coma, be given an enema ? How manymoderns treat acute nephritis by cupping and hot-airbaths ? But some idiosyncrasies are bound to showthemselves where two men, however widely experienced,survey the whole field of medicine. Their book remainsboth popular and valuable.Schizophrenia in ChildhoodCHARLES BPADLEY, M.D., medical director, Emma PendletonBradley Home, East Providence, Rhode Island. London:Macmillan Co. Pp. 149. 10s. 6d.Tsis conscientious study is a satisfactory introduction

to the published work on psychoses in children and thebibliography makes it useful as a book of reference.But it will disappoint those who would have liked tolearn the outcome of Dr. Bradley’s observation of schizo-phrenic children over long periods. The cases quotedhowever add little to what has already been observed.in child schizophrenics elsewhere ; they serve to illus-trate those traits which he picks out, but accounts ofchildren’s play and fantasies are lacking, and there is noreal picture of their relationship with parents or siblings.When he comes to likely ages for onset, he avoids discuss-ing puberty and the early negative phase lest he should beled too far afield. Psychological and physical factors aspossible causes of schizophrenia in children actuallyunder observation have not yet, he says, been systema-tically studied. With the unparalleled opportunitiesavailable at the Bradley Home, we may hope he willsupply some studies of the kind himself.The March of MedicineNew York Academy of Medicine Lectures to the Laity,1940. London : Humphrey Milford, Oxford UniversityPress. Pp. 144. 13s. 6d.

THE New York Academy of Medicine annuallyarranges a course of lectures in which medical progressin various fields is expounded in non-technical languageby a team of experts to the laity. The recently publishedseries for 1940 consists of six lectures. Dr. AbrahamMyerson discusses the inheritance of mental illnessand Dr. Perrin H. Long chemical warfare againstdisease : Dr. Paul Reznikoff tells the story of our know-ledge of the blood and Dr. Thomas M. Rivers that ofthe viruses ; the ascent from Bedlam and the evolutionof modern psychotherapy are described by Dr. Richard H.Hutdhings, and the romance of bronchoscopy by Dr.Chevalier Jackson and Dr. Chevalier L. Jackson. Thosewho heard these lectures delivered may count themselvesfortunate, for it would be hard to find more lucid or morelively expositions. Though designed for the layman, nodoctor need think it beneath his dignity to read them, forhe can hardly do so without pleasure and profit.