THE TREATMENT OF SCIATICA
1915
The Lancet
appear in the Medical Record <New York) of Feb. 6th. The perineural infiltration method was first brought prominently to the attention of the medical profession in 1907 by Dr. J. Lange, of Leipsic. It consists in the injection of a 'large quantity of fluid under pressure directly over the sciatic nerve. Prior to that date injections of sterilised air, similar in principle, had been given with conspicuous success in cases of sciatica, lumbago, &c., in France and elsewhere. For a long time
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... sly, too, injections of cocaine and analogous medicaments had been used in sciatica with good results. The idea of the injection of air, or of fluid in quantity, is that thereby adhesions in the neighbourhood of the nerve are loosened or stretched or broken down. Dr. Leszynsky is of the opinion that, since prompt relief can be obtained in acute and recent cases, where the formation of adhesions can scarcely have taken place, the relief of pain must be due either to blocking of sensory conductivity or to the pressure and absorption of the fluid producing changes in the circulation and nutrition of perineural structures. The technique of the method is simple enough. With the patient lying on his face with legs extended, and a firm pillow under the lower part of the abdomen, the point of exit of the great sciatic from the pelvis is determined in one or other of the usual ways, the skin is painted with iodine, and then the needle of a syringe is pushed in perpendicularly till the sciatic sheath is reached, when the patient will experience a sharp pain radiating down the thigh, or in the heel, or there may be a twitch of the leg or calf. Sterile warm (95° to 100'F.) physiological saline solution is then injected by the syringe, in quantity ranging from 80 to 120 c.c. There may be aching or heaviness or numbness in the limb afterwards, but this rapidly passes off. The interval following the first injection, before another is given, naturally varies according to the degree of relief obtained. Sometimes only one injection is necessary. Dr. Leszynsky is in the habit of waiting from 36 hours to one week before repeating the injection. It is most important to note that it is not intended that the nerve sheath should be entered by the needle, otherwise the forcing of a large quantity of fluid into the nerve trunk may result in a traumatic neuritis. It is recommended that a blunt stylet, projecting 1 millimetre beyond the cutting point of the needle, should be inserted when the latter is once through the skin, to obviate puncturing a blood vessel or the nerve sheath. Dr. Leszynsky does not advise this perineural treatment in every case, but mainly for subacute and chronic intractable cases, and he has used it with success some 160 times. As for the epidural method, Dr. Cathelin, of Paris, recommended it originally, and employed it in various conditions with uniformly good results. For the purposes of epidural injections the epidural space begins at the first sacral vertebra, where the dura mater ends, and it extends down to the sacrococcygeal articulation, where the injections are made. The opening into it is bordered laterally by two prominences, the cristæ sacrales laterales, which are usually easily felt by the finger, and it is covered by the dense ligamentum sacrococcygeum. It lies generally about two centimetres above the end of the gluteal fold. Dr. Strauss has his patient lying on the side, with knees and thighs flexed. After anaesthetising the skin over the foramen with novocaine he pushes through the ligament and into the foramen a strong needle, 1 mm. in calibre, for a distance of about 6 em., to reach the second sacral vertebra. The injection consists of warm saline. To the first 10 or 20 c.c. of saline is added 0'3 c.c. of novocaine with adrenalin and a few minutes allowed to elapse. Then some 60 or 80 c.c. in all are injected. As a rule the patient feels merely an uncomfortable pressure in his lower spine. In some 19 cases Dr. Strauss has obtained excellent results. He also recommends it mainly in subacute and chronic cases, and holds that it is preferable to perineural infiltration, inasmuch as no injury to the nerves has been reported following on epidural injection. He considers that many cases of sciatica are really due to a root neuritis, a " radiculitis " of the roots of the nerve, and these are the cases more particularly where epidural injections are indicated. A NEW METHOD OF DIFFERENTIATING BETWEEN EXUDATES AND TRANSUDATES. HITHERTO the method most usually adopted to distinguish between these two classes of fluids has been that of Rivalta. This observer showed that if a drop of a transudate, which is of a lower specific gravity and contains less cellular elements and less albumin than an exudate, be added to a 2 per cent. solution of glacial acetic acid, the fluid remains clear, but if an exudate be added a bluish trail like a puff of cigarette smoke is seen as the material makes its way down through the fluid. In the last number of Annali dell' Istituto Maragliano Dr. F. Morelli describes a new method which seems to Morelli describes a new method which seems to yield much more certain results when compared with those obtained by using Rivalta's reaction on the same fluids. This new method is based on the reactions between mercury and different forms of albumin, causing precipitates and forming corresponding metallic albuminates. Dr. Morelli noticed that when drops of fluid obtained from a serous cavity were let fall on a saturated aqueous solution of corrosive sublimate the characteristics of an exudate were shown by the formation on the surface of the solution of a dense, compact coagulum of albumin, yellowish in colour, often remaining adherent and suspended, but sometimes falling in a mass without disintegrating. When, on the other hand, the fluid was of the nature of a transudate a coagulum of albumin formed on the surface which very quickly split up into small particles and fell ta the bottom. The only exception to this rule was in the case of pleuritic exudates of a tuberculous nature in which the reaction was always negative, and this uniformly negative reaction furnishes an important indication in etiological diagnosis. Rivalta's reaction did not show this difference I
doi:10.1016/s0140-6736(01)65861-6
fatcat:bjmgnu25evcbzlq4mlyp4tuopi