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THE TREATMENT OF SCIATICA.
1169 where the efferent limb is unkinked and the stomach is able to pass its contents into the efferent limb. In the future I am fully determined to do only Roux’s operation. It takes longer, but is as far as I can see an absolutely safe kink-proof operation and the one I have done had perfect immediate and after results. While on the subject of gastric ulcer I would like to mention the treatment of perforated gastric ulcer. There seems to be a tendency now to treat perforation by suture and immediate gastroenterostomy. I cannot believe this to be anything but a pernicious doctrine. First, gastro-enterostomy is a big strain to put on a severely shocked patient and in the most competent and rapid hands will entail an addition of round about 20 minutes to the operation; and, secondly, the end-results of several years of experience as a general practitioner-surgeon do not seem to justify any addition to the technique of burying the ulcer by purse-string suture. On points like this the G.P.-surgeon may safely say a word. If he cannot quote hundreds of cases yet he has to live with his patients afterwards, and I can definitely say that as long as the perforation can be closed and the ulcer turned in without practically closing the pylorus, the end-results lasting in many cases for years, 15 at least, have been excellent. I have only once had to do a secondary gastroenterostomy after an operation for perforated gastric ulcer, and my experience is that involution cures the ulcer and the stomach rapidly accommodates itself to the deformity produced by this operation. In the case mentioned suturing produced so much pyloric narrowing that I had to do a gastro-enterostomy a fortnight later. I am, Sir, yours faithfully, R. LEONARD LEY, Assistant Surgeon, Great Yarmouth May 31st, 1926. Hospital.
However, even though no adequate explanation be given, we are no worse off theoretically than with most of the other methods, for there is no adequate explanation why ionisation, galvanism, or oxygen should give relief. The following are types of case can
which have been treated with benefit :-
l.-Admitted for treatment for bronchitis and for the last two years had been complaining of a left-sided sciatica. In 1924 he was treated at an infirmary for seven weeks without benefit. He was at home in bed for four months and then treated at another hospital for several months. On admission here in November, 1925, he He was complaining of pain was walking with a crutch. across the loins and could not put his heel to the ground, owing to the pain it caused in the whole limb. Within a week he discarded his crutch, walking with the aid of a stick only, and he soon discarded that too. He was in the hospital for treatment for his bronchitis and asthma for two months. During this period the treatment for sciatica was continued, both local and general ultra-violet baths being given. By the end of the two months he had made up a half inch wasting of the thigh and his sciatica had disappeared. CASE 2.-Contracted sciatica 1915. He had attacks at intervals till 1920, and since then he has been treated with radiant heat, massage, and electrical methods at one hospital or another every year. He was discharged from one hospital in March, 1925, but was readmitted to another in August. For two months he was on massage, radiant heat, and electrical treatment without benefit. When he came to the " Light " Department in October he was limping along with the help of a stick. He was tender to pressure along the course of the sciatic, and there was half inch wasting of thigh and calf. He also had a marked synovitis of the right knee. Within three weeks he discarded his stick and could walk three miles. Within two months the synovitis had disappeared, and also the wasting of the limb. He had CASE
asthma, but
10 lb.
weight and was discharged. Not all cases will respond, but of ten cases, with an average history of seven years, there have only been two failures. One of these was on treatment for a short period, but as he was showing no signs of improvement, the nerve was stretched- by the open method with considerable success, a previous manipulaTHE TREATMENT OF SCIATICA. tion having failed to give him relief. The other case also had the nerve stretched after a period of ultraTo the Editor of THE LANCET. violet treatment without benefit. It should be added SIR,-Dr. J. P. Martin in his article in your issue of that all these cases were also general ultra-violet May 22nd on the treatment of sciatica does not radiation as a general tonic.given I feel, however, that include the local application of ultra-violet rays as the effect was mainly due to the local treatment, as one of the methods of treatment for this condition. the symptoms disappeared in some of the cases before The method is extremely simple, simpler than any the general baths could have had an appreciable of the methods mentioned, and is free from any danger effect. I am, Sir, yours faithfully, shocks. convenient for or The most of burns lamp M. WEINBREN.
the purpose is the Kromayer (water-cooled mercury vapour) which is applied in contact with the skin. The applications are made over the nerve roots and along the course of the sciatic, giving one-two minutes (a third degree erythema, depending on the age of the lamp), particularly to points which are tender to pressure. Ten such points or more may be treated at one sitting, and others on succeeding days. Compared to galvanism, ionisation, or diathermy, it is much simpler, easier, and more rapid in its effects. One exposure to half-a-dozen areas has in some cases given considerable relief. This method has been used in chronic cases which have been treated by the older methods (including nerve stretching) without benefit for years, with striking results. I confess it is difficult to find an explanation for the effect of ultra-violet treatment in these cases. It is extremely unlikely that any of the rays penetrate to the sciatic nerve, so any direct action must be excluded. Prof. Dixon has pointed out the similarity between ultra-violet rays and the mustard leaf in the effects on the skin (Brit. Med. Jour., Sept. 19th, 1925). Counter-irritation alone, however, will not explain the results, for some of the cases still bore pigmented areas on their thighs as evidence of previous counLerirritants, which they stated had not given relief. Neither will a functional element serve as adequate explanation in the particular type of cases (pensioners) dealt with. The local analgesic action of ultra-violet rays will not explain the effect in chronic cases where the pain is probably due to adhesions and pressure on nerve-fibres within the sheath.
gained
I
The Queen’s Hospital, Frognal, Sidcup, Kent, June 2nd, 1926.
FILIGREE IN HERNIA OPERATIONS. To the Editor
of THE LANCET. article Mr. Percival P. Cole in THE SIR,-The by LANCET of May 22nd must compel attention to the use of the filigree in the operation for the radical cure His figures are so convincing of inguinal hernia. that they cannot be disregarded by those interested in the problems of hernia. They should silence once and for all the unfair criticisms levelled against the method in text-books of surgery and in monographs on hernia-criticisms not infrequently repeated by those who have not given the method a fair trial nor mastered the technique of the operation. Such results should embolden those who are restrained from the use of the filigree because of theoretical objections. Not uncommonly does theory mislead or misdirect It is regrettable that us in the practice of surgery. so simple, so effective, and so successful a method should not be more commonly practised. The published results of hernia operations with their usual 6 to 8 per cent. recurrence in oblique inguinal hernia and very much larger, one might say appalling, recurrence rate in the direct variety are based on cases selected for operation after numbers have been rejected as unsuitable either from the point of view of age, size, type, or duration of hernia. Mr. Cole has drawn his series from the same source
’
However, even though no adequate explanation be given, we are no worse off theoretically than with most of the other methods, for there is no adequate explanation why ionisation, galvanism, or oxygen should give relief. The following are types of case can
which have been treated with benefit :-
l.-Admitted for treatment for bronchitis and for the last two years had been complaining of a left-sided sciatica. In 1924 he was treated at an infirmary for seven weeks without benefit. He was at home in bed for four months and then treated at another hospital for several months. On admission here in November, 1925, he He was complaining of pain was walking with a crutch. across the loins and could not put his heel to the ground, owing to the pain it caused in the whole limb. Within a week he discarded his crutch, walking with the aid of a stick only, and he soon discarded that too. He was in the hospital for treatment for his bronchitis and asthma for two months. During this period the treatment for sciatica was continued, both local and general ultra-violet baths being given. By the end of the two months he had made up a half inch wasting of the thigh and his sciatica had disappeared. CASE 2.-Contracted sciatica 1915. He had attacks at intervals till 1920, and since then he has been treated with radiant heat, massage, and electrical methods at one hospital or another every year. He was discharged from one hospital in March, 1925, but was readmitted to another in August. For two months he was on massage, radiant heat, and electrical treatment without benefit. When he came to the " Light " Department in October he was limping along with the help of a stick. He was tender to pressure along the course of the sciatic, and there was half inch wasting of thigh and calf. He also had a marked synovitis of the right knee. Within three weeks he discarded his stick and could walk three miles. Within two months the synovitis had disappeared, and also the wasting of the limb. He had CASE
asthma, but
10 lb.
weight and was discharged. Not all cases will respond, but of ten cases, with an average history of seven years, there have only been two failures. One of these was on treatment for a short period, but as he was showing no signs of improvement, the nerve was stretched- by the open method with considerable success, a previous manipulaTHE TREATMENT OF SCIATICA. tion having failed to give him relief. The other case also had the nerve stretched after a period of ultraTo the Editor of THE LANCET. violet treatment without benefit. It should be added SIR,-Dr. J. P. Martin in his article in your issue of that all these cases were also general ultra-violet May 22nd on the treatment of sciatica does not radiation as a general tonic.given I feel, however, that include the local application of ultra-violet rays as the effect was mainly due to the local treatment, as one of the methods of treatment for this condition. the symptoms disappeared in some of the cases before The method is extremely simple, simpler than any the general baths could have had an appreciable of the methods mentioned, and is free from any danger effect. I am, Sir, yours faithfully, shocks. convenient for or The most of burns lamp M. WEINBREN.
the purpose is the Kromayer (water-cooled mercury vapour) which is applied in contact with the skin. The applications are made over the nerve roots and along the course of the sciatic, giving one-two minutes (a third degree erythema, depending on the age of the lamp), particularly to points which are tender to pressure. Ten such points or more may be treated at one sitting, and others on succeeding days. Compared to galvanism, ionisation, or diathermy, it is much simpler, easier, and more rapid in its effects. One exposure to half-a-dozen areas has in some cases given considerable relief. This method has been used in chronic cases which have been treated by the older methods (including nerve stretching) without benefit for years, with striking results. I confess it is difficult to find an explanation for the effect of ultra-violet treatment in these cases. It is extremely unlikely that any of the rays penetrate to the sciatic nerve, so any direct action must be excluded. Prof. Dixon has pointed out the similarity between ultra-violet rays and the mustard leaf in the effects on the skin (Brit. Med. Jour., Sept. 19th, 1925). Counter-irritation alone, however, will not explain the results, for some of the cases still bore pigmented areas on their thighs as evidence of previous counLerirritants, which they stated had not given relief. Neither will a functional element serve as adequate explanation in the particular type of cases (pensioners) dealt with. The local analgesic action of ultra-violet rays will not explain the effect in chronic cases where the pain is probably due to adhesions and pressure on nerve-fibres within the sheath.
gained
I
The Queen’s Hospital, Frognal, Sidcup, Kent, June 2nd, 1926.
FILIGREE IN HERNIA OPERATIONS. To the Editor
of THE LANCET. article Mr. Percival P. Cole in THE SIR,-The by LANCET of May 22nd must compel attention to the use of the filigree in the operation for the radical cure His figures are so convincing of inguinal hernia. that they cannot be disregarded by those interested in the problems of hernia. They should silence once and for all the unfair criticisms levelled against the method in text-books of surgery and in monographs on hernia-criticisms not infrequently repeated by those who have not given the method a fair trial nor mastered the technique of the operation. Such results should embolden those who are restrained from the use of the filigree because of theoretical objections. Not uncommonly does theory mislead or misdirect It is regrettable that us in the practice of surgery. so simple, so effective, and so successful a method should not be more commonly practised. The published results of hernia operations with their usual 6 to 8 per cent. recurrence in oblique inguinal hernia and very much larger, one might say appalling, recurrence rate in the direct variety are based on cases selected for operation after numbers have been rejected as unsuitable either from the point of view of age, size, type, or duration of hernia. Mr. Cole has drawn his series from the same source
’