DR. F. W. LANGDON: The essayist has covered the ground so thoroughly that there is not left very much for any of us to say in the way of comment. There were, however, one or two brief references made by him which attracted my attention. The essayist as he went along spoke of some of the reflexes, but I do not think he referred to the Achilles reflex. If he did it escaped my hearing.

In the first place, I would say that sciatica and sciatic neuritis are practically synonymous, and that at the present time the so-called functional neurosis of the nerve is a very rare occurrence, if it occurs at all.

The probabilities are that the ordinary cases of pain which appear in this region are due to a neuritis, mild or severe, but a neuritis of an interstitial type. As a proof of this you will almost invariably find the Achilles reflex diminished more or less on the same side in which the disease appears, and is usually unilateral. This is true not only for the time that the disease is manifested by the pain and other symptoms which accompany it, but for two years after the affection is apparently well there is some diminution of the Achilles reflex, which is gotten, as we all know, by tapping the tibialis anticus after the leg has been extended, and the foot also extended, by grasping the sole of the foot. A diseased condition of the sciatic nerve is manifested by a contraction of the gastrocnemius. I think it was Babinski who first called attention to this alteration in the Achilles reflex in sciatica.

In the use of the hot-air apparatus I think that we have a distinct addition to our therapeutic resources for the treatment of this disease, but, unfortunately, we do

not all have hot-air apparatus, and occasionally we have to adopt some more simple methods, to one of which I will refer. It is an old-fashioned remedy, and very effective, and is nothing more or less than castor oil. I saw some time ago an article in a medical journal advocating the use of repeated doses of castor oil, two ounces daily before breakfast, as an effective agent in the treatment of sciatica. I had an opportunity of testing this drug in a number of cases, and they all got well in a period varying from one to four weeks. Of course, most of these patients had rest, but some were up and around, but they all received benefit from the start in its use. Whether the castor oil causes an elimination of toxins or what I do not know; I will have to let others more competent than I decide that point. For the purgation which results from its administration castor oil carries along with it its own remedy, for after the purgative effects have manifested themselves the astringent qualities of the drug check the bowel movements. Teis remedy is well worthy of a trial, and especially in cases where the conditions of the alimentary canal call for a drug of this nature.

DR. DAVID I. WOLFSTEIN: The paper which the essayist has presented to us tonight is certainly very practical, and covers the ground so completely that there is very little one can add. There was one point which occurred to me when the essayist was calling attention to the benefits to be derived from hot air treatment, and that is these cases are often as effectually relieved by the application of cold. A very important feature in the treatment of cases of sciatica, especially the acute form, is rest in bed, and incidentally in this connection I think that one of the greatest sins committed in connection with the treatment of this disease is that we do not insist upon rest in bed, complete rest in bed, and especially in cases of acute sciatica. In many of these cases the application of ice bags along the course of the sciatic nerve will yield most excellent results, and that applies not only to sciatica, but also to other forms of neuralgia and neuritis. Not long ago I treated a case of neuralgia in the arm where no medication except morphine would give any relief until cold applications were made to the arm. I gave the patient morphine for immediate relief and then ap

plied the ice bags, and in a short time the neuralgia was relieved.

I have nothing to say in the way of criticism in the treatment of this affection with hot air, and the results obtained from its employment are excellent, but that there is any particular virtue in superheated air over other therapeutic agents I doubt very much. I think we can often secure the same results in the use of oldfashioned remedies-for example, the remedy spoken of by Dr. Langdon.

One point along the line of diagnosis, although not of special importance, is the so-called Laségue sign. The affected limb is extended with the patient flat on the back. On the attempt to raise the extended limb up and flex the leg on the trunk there will immediately be manifested unmistakable evidence of pain when the leg has been raised to about 90°; but if now the leg be flexed on the thigh the pain disappears, showing that the pain was caused by tension of the sciatic itself.

The point I wanted to make in regard to the acute cases is this; if they are properly treated at the time of onset we could prevent many times the more chronic forms of the disease.

I can entirely agree with what the essayist said concerning drugs in the treatment of the disease. I have undoubtedly gotten good results from the prolonged use of the iodide of potash, and also from the salicylates. Sciatica is a peculiar affection, and there are so many remedies offered in its treatment that there is good ground for a certain amount of optimism in regard to any particular measure which has been employed. Under this head we might include the remarkable results we are seeing in regard to the treatment with the X-ray. I think the latest movement is to treat cases without the use of the Crookes tube. Now any one who uses the static current a great deal must be convinced as to the considerable degree of psychic power connected with its use, and he must also be convinced of the fact that he gets results in many cases which are quite unintelligible to him except on this basis. There are many cases which are relieved, I am sure I do not know how, and there are many other cases which do not respond to treatment of this kind. I do not allow myself to become so optimistic about it as a great many of the X-ray

specialists who claim to give relief in sciatica and allied painful affections after a few applications.

DR. R. C. JONES: I wish to compliment the essayist upon his excellent paper. There is one agent, not mentioned this evening, which helped me out of a difficulty in the treatment of sciatica in a very large fleshy woman with atheromatous degeneration of the arteries, who for a number of years had been troubled with recurrent attacks of the disease. I ran through the list of ordinary remedies with her, finally trying the deep injection of chloroform with only temporary benefit. About that time I saw in one of the journals an account of the excellent results accomplished in the treatment of sciatica by the administration of nitroglycerine. I tried the remedy in this case and it acted marvellously. She tells me that she keeps her little bottle of nitroglycerine constantly on hand, and whenever she has a recurrence of the disease promptly resorts to it, taking it three or four times a day, with the most gratifying results.

I have also had most excellent results in the treatment of sciatica with salicylate of soda. An old gentleman came to me recently in one of his recurrent attacks of this disease, and the salicylates relieved him promptly, as it had a number of times before.

DR. HORACE J. WHITACRE: There are two or three points in this connection of which I would like to speak. I am sorry that I did not arrive in time to hear that part of Dr. Bailey's paper which referred to etiology. It seems to me, in view of the fact that we have a neuritis, and particularly an interstitial neuritis, an inflammatory condition involving the connective tissue of the framework of the nerve, we must look for the causative factor in this inflammatory reaction. Dr. Langdon has said that good results may be obtained by the administration of castor oil. results are probably due to the elimination of toxins produced in the intestinal tract. When the intestinal tract is not responsible for the toxin, it would be reasonable to look to some other source of intoxication for an explanation of the condition. It seems to me that such etiologic factors should be considered in connection with the pathology of the disease.

These

A personal experience in the etiology of sciatica is furnished by a pelvic abscess

which I discovered in a patient suffering from persistent sciatica. An abscess springing doubtless from the Fallopian tube was pressing on the nerve. sciatica was relieved by the spontaneous opening of the abscess.

The

The application of a splint to these cases would seem to be directly in line with the pathology of the condition. We have an inflammatory reaction between the nerve fibres of a large nerve trunk. Nothing can contribute more completely to the relief of the pain than abolute rest, and this can be obtained only by the most perfect splinting. There must be not only an immobilization of the thigh, but likewise of the hip, of the knee, and of the ankle joint. This splinting, I know from personal experience, will give very decided relief to the pain.

I think I can second the statement of Dr. Ricketts to the effect that cocaine injections are the most efficacious in the rapid relief of the pain in sciatica.

were

Formerly the chronic persistent types of sciatica were treated by nerve stretching. I have seen this practiced in two cases. The results in the second I do not know, since the man passed from observation. The immediate and the remote result in the first case was perfect. Both we treated by open operation, the sciatic nerve was picked up in a vertical incision made directly below the gluteal fold and stretched with sufficient force to lift the leg of the patient from the table. In this successful case the disease had persisted for a long time as uncontrollable sciatica. It seems to me that this procedure should be classed among the valuable resources in the old cases that resist the ordinary methods.

Perhaps Dr. Bailey can control these cases by the application of hot air, and if so I would certainly like to try it before resorting to operation. I have had no experience with the method. Nerve stretching without cutting has been suggested. I have never tried this, but the method as described by Dr. Bailey for accomplishing such results does not appeal to me as altogether scientific. I feel that there must always remain an uncertainty as to just how much the nerve has been stretched, and feel that the hamstring muscles will always receive the major part of the stretching. Inasmuch as an efficient stretching will require an anesthetic, it seems much

more rational to make an insignificant incision, expose the nerve and stretch it with a degree of force that can be measured and in the direction that is desired.

DR. MAGNUS A. TATE: I think the paper presented by Dr. Bailey a very practical one and I have enjoyed it very much. Twelve to fifteen years ago a paper was presented to this Academy by the late Dr. Comegys on the treatment of sciatica in which he claimed that the injection of from fifteen to thirty minims of ether along the inflamed sciatic region gave him better results than any other form of treatment. He also claimed this a substitute for hypodermics of morphine. I have had a few, not many, cases of sciatica to treat and the injection of ether with rest in bed has given me good results.

DR. B. M. RICKETTS: I speak from the standpoint of the surgeon. Causes of sciatica to which I wish to call attention are injury, osteophitis and narrowing of bony openings in sacrum. In 1887 or 1888 I had a case which was due to trauma. In that I made an excision of the nerve (one inch and three-quarters). The patient before the operation was a confirmed morphine habitue. He took but little after operation.

In regard to oleum ricini as an agent for the cure of sciatica, I was probably the first to speak of it in the medical journals of this country. I had just come from Chicago, and Dr. Ochsner had been. using it with success for tic douloureux, and I thought it would be a good thing for sciatica. As to the modus operandi of this drug, that has not been determined. Refined castor oil will not give good results in sciatica that the crude oil does; it will move the bowels freely, but the good effects of the crude oil in this disease are wanting. It is supposed that there is some constituent in this agent which combines with the blood and in that way relief is given.

As to the injection of the sciatic nerve, it is a very simple thing to reach it through an incision in the gluteal fold. Two or three drops of a 1 per cent. solution of cocaine will relieve the sciatica. That is the most efficacious, the quickest and the easiest of all the injections of which I know, and especially in thin persons where there is not much fat. times the anterior crural nerve is involved and then it is best to inject that also.

Some

Injection of simple water is not as efficacious as cocaine, as it is impossible to amputate a leg or arm by injecting the nerves or their sheaths with simple water. It can be done with cocaine, however.

DR. BAILEY: I wish to thank the members of the Academy for the interest which they have displayed in the discussion of my paper. It was with a great deal of fear and trepidation that I attempted the subject of sciatica, but it seemed to me one which would be of interest to every one in the profession, and especially to the general practitioner. I wish to thank Dr. Langdon for his mention of the Achilles reflex, which I did not mention specifically, but which was included in the statement that the reflexes of the lower limb were diminished.

I did not wish to infer that the hot air is a cure-all for all cases of sciatica, or that the use of drugs is to be tabooed entirely. I have found the use of hot air to be of great service in the relief of the pain, and that it will also markedly shorten the length of the attack. Various drugs are certainly of great service in sciatica which is a complication or symptom of other diseases, e.g., rheumatism, gout, syphilis, typhoid fever, influenza, etc. All of these diseases may give rise to sciatica. Such conditions certainly require medication, and lots of it. The hot-air treatment is only used as an adjunct in these cases. I have had no experience in the application of cold in the manner mentioned by Dr. Wolfstein, but I have no doubt it would prove just as efficacious as heat in certain cases.

I

I agree fully with the statements in regard to the necessity of rest in bed; in fact, in an acute case of sciatica the patient can do nothing else but rest in bed. think one reason there are so many cases of chronic sciatica is that patients do not rest long enough in bed, getting out before the inflammation of the nerve has entirely disappeared.

I have also used hypodermic injections into the sciatic nerve, as suggested by several of the speakers this evening, and have found water just as efficient and certainly a more simple and safer remedy than ether or cocaine. It seems to me that in an inflammatory condition of the nerve ether would do more to increase the irritation, and while we may get material relief from the pain, it would increase the in

flammation, and so prolong the ultimate recovery.

Dr. Jones has mentioned nitroglycerine as a remedy in sciatica. That certainly would be of use in cases where there were atheromatous changes in the arteries, and where the general circulation was impaired.

As far as the etiology is concerned, the fact that sciatica accompanies so many of the acute diseases seems to me direct evidence that it is due either to an invasion of the nerve itself by bacteria, or to the toxins produced by these organisms. The benefits derived from castor oil are an evidence that sciatica is often of toxic origin, and the fact also that sciatica sometimes accompanies habitual constipation would certainly be an indication for its use in such cases.

the

Nerve stretching by the open method seems to me to be the method of last resort in all of these cases. It appears to me that the same results can in most instances be obtained by the bloodless method, upon which Dr. Whitacre comments, viz., extending of the leg from the thigh and then flexing the thigh upon the abdomen. The feelings of the patient and the overcoming of the contraction are the only evidence that the nerve is stretched, but this procedure is never carried on with such force as to tear the hamstring muscles. The patient's feelings are a guide as to the amount of stretching which may be accomplished. The other method of grasping the thigh deeply and pulling and pushing the thigh muscles is also an efficient means of stretching the nerve, especially in cases where we have an atrophy of the muscles on the posterior aspect of thigh.

As far as reflex conditions are concerned, it has come to the notice of the most of us that sciatic pains may follow as reflexes, inflammation occurring in any of the organs of the pelvis. Prostatic inflammation is followed at times by pains shooting down the sciatic nerve; in posterior urethritis we occasionally have pain running down the leg; in pelvic tumors, in hemorrhoids, etc., we have the same thing occurring occasionally; in fact, as stated above, almost any inflammatory condition about the pelvis may give rise to pains which shoot down the leg, but these pains are not due to sciatica, nor is this condition apt to be confused with true sciatic neuralgia.

A Weekly Journal of Medicine and Surgery.

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MEDICAL ACTIVITIES IN CINCINNATI.

With an incoming of a new municipal administration in Cincinnati there has come with it a reorganization of many features pertaining to interests which are more or less medical in character. Chief among these changes is a reorganization and proposed rebuilding of the Cincinnati Hospital, which includes a new building in a new location, all of which is to be commended. The old hospital has had its day, and is no longer desirable as a building in which to send patients for treatment. The old location is excellent and central for the purposes of a small emergency institution. In addition to this emergency institution, there is a positive demand made for a large structure which should be erected on what is known as a cottage plan of buildings. Such plans are preferable, all other things being equal, for all eleemosynary institutions, including hospitals, insane asylums, infirmaries, and may be judiciously extended to the construction of universities and public school buildings. There has been too much crowding of buildings of this character, because of an erroneous idea that they were capable of being operated more eco

mistake. The cottage plan institutions are managed with a corresponding or less. outlay of money than the old aggregate caravansary structure. In fact, it is not altogether clear in the mind of the writer that three or more public hospitals would not serve the public interests of Cincinnati more advantageously than a great institution, even though it were constructed on the cottage plan.

Cincinnati as a city is expanding at a galloping rate and already has one branch. hospital on a western hill. This has been used heretofore as a hospital for contagious diseases. In connection with the branch hospital there are more than fifty acres of ground, sufficient for building space for an emergency hospital for all comers in the west end of Cincinnati. There is no good reason why there may not be a similar construction of hospital buildings in the east and north end of the city, in the vicinity of Norwood or Delta. Such a plan and movement commends itself as being the very best for the accommodation of the people. The medical profession has a claim upon all public hospitals so large and so great that it cannot be ignored. For that matter there is no evidence that anyone desires an ignoring of these conditions. In order to have an educated profession there must be, first of all, hospitals for a training of young men who desire to fit themselves for the practice of medicine. This can only be done in suitable accommodations for clinic purposes. So far as known in this city the people are inclined to recognize these professional claims, and obstacles are not put in the way. The medical schools have at their head men of large views, and their future may wisely be left in their hands to work out their own salvation.

THE POLICE AND FIRE DEPARTMENTS.

The Police and Fire Departments have been re-organized, and in the re-organi