Part I

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=Sciatica= is usually a neuritis of the sciatic nerve, although all painful affections of the nerve are termed sciatica. In some cases it is a neuralgia when the nerve is swollen and presents an interstitial neuritis.

=Osteopathic Etiology.=—This affection occurs more frequently in males than in females. The usual period for sciatica is from the twentieth to the fiftieth year and the principal causes are =vertebral lesions= of the lower dorsal and lumbar vertebræ, especially lesions to the fourth and fifth lumbar. Occasionally the lesion is a subdislocated innominatum, a downward displacement of a floating rib or a partial dislocation of the femur. Other causes are exposure to cold, contraction of muscles, gout, rheumatism and syphilis. Contraction of the pyriformis muscle may bring direct pressure on the nerve. Focal infections, arthritis of the articular processes of the lower spine, and sacro-iliac and hip-joint disease should not be overlooked. In a few cases there are intrapelvic causes, such as uterine and ovarian tumors, rectal accumulations and the fetal head during labor. Enlarged prostate may be a factor. It is possible for the roughened edges of the sacro-iliac joint, internally, to irritate the sacral plexus as it passes over and thus keep up the pain. This may explain the occasional failure of treatment.

=Symptoms.=—Pain in the nerve along its course is the most constant symptom. The pain is most intense back of the thigh and above the hip-joint. The pain radiates downward through the entire nerve; it is of an annoying character and walking is especially painful. In rare cases there is wasting of the muscles, cramps, herpes and edema. In a few cases the neuritis may extend to the spinal cord.

=Diagnosis.=—The diagnosis of sciatica is usually easy. Care has to be taken in the examination to determine whether the affection is primary or secondary. It is difficult, in some cases, to locate the origin of the disturbance, especially if it is in the lumbar vertebræ, as frequently a very slight deviation of a vertebra will cause the disease; or some focal infection may be difficult to locate; or malformation of the fifth lumbar may be present; or asymmetry of the legs or the body be a factor. Careful palpation, measurements, and the X-ray are of diagnostic importance. =Hip-joint disease= and =sacro-iliac disease= can generally be easily distinguished from this affection. The lightning pains of =tabes= may simulate sciatica, but then there are other well defined symptoms of the disease.

=Treatment.=—Sciatica rarely runs a very long course, though there are cases that last for years. The treatment almost wholly depends upon the cause. If the cause can be determined at once, the probabilities are that severe cases may be relieved by a few treatments. Correction of the vertebræ, to relieve impingements to the nerve fibers as they pass through the intervertebral foramina, usually constitutes the primary treatment. Carefully examine the pelvic organs for disturbances. Occasionally deep treatment over the iliac vessels will be of great help. The innominatum, if deranged, should be corrected and all troubles of the hip-joint that are found must be corrected.

Cases of rheumatism and gout should receive their separate treatments, besides careful manipulations of the affected leg. Rest in bed should be insisted upon; this will usually markedly lessen the duration of the inflammation. Adjustment of the special points found deranged and a thorough treatment, if conditions permit, of the entire leg will be beneficial. Hot fomentations applied along the course of the nerve, and an inhibitory treatment back of the trochanter will at least give temporary relief. Extension of the leg is effective. Placing a patient upon his back and flexing the leg and thigh upon the abdomen, at the same time keeping the leg straight and the foot flexed, is an effectual stretching method. As a rule, sciatica readily responds to osteopathy.

Neuralgia

=Neuralgia= means simply “nerve pain.” The term neuralgia should be restricted to such nerve pains as are not caused by structural changes in the nerves. In cases where the pain is due to organic changes in the nerves, the disease should not be classed as a neuralgia, although it is practically impossible to draw an absolute line between functional and organic disturbances for the one may gradually progress (pathologically) into the other. In neuralgia there is always =disturbance= of the =blood supply= to nervous tissue, which may be of the character of congestive irritation, ischemia or altered states of the blood wherein it contains toxic substances or is below normal quality. It is well known that osteopathic lesions are very common etiological factors.

=Osteopathic Etiology.=—Neuralgia is essentially a disease of adults. It rarely occurs before puberty or late in life. Women are more prone to neuralgia than men and the tendency may sometimes be hereditary. Sufferers from neuralgia often present a peculiar “nervous temperament.”

The exciting causes of neuralgia are impairment of general health; irritations of the nerve fiber or trunk by a displaced bone, ligament or muscle, which may affect the nervous tissue directly by mechanical irritation, or indirectly, by the disturbance of its blood supply, or toxic agents; exposure to cold or damp; overwork and worry; toxic influences of various diseases, as malaria, lead poisoning and alcoholism; irritation from carious teeth, and various septic foci.

=Symptoms.=—Pain, which is spontaneous and paroxysmal, is the most prominent symptom. It may be described as “darting,” “shooting,” “burning,” “stabbing,” “boring,” etc. The pain is usually unilateral, following the course of the sensory nerves, and there are generally tender points along the course of the nerve. Especially are there points of tenderness near the central end of the nerve, where the displaced structures are irritating it. After the pain has continued for some time the skin becomes tender, reddened and swollen. The redness and edema are supposed to be due to vasomotor changes. Muscular spasms, trophic disturbances, skin eruptions, herpes and grayness of the hair are of rare occurrence. The duration of an attack varies from a number of minutes to a few hours.

=Neuralgia of the Fifth Nerve.=—This is by far the most frequent variety of neuralgia, and it is generally due to a displaced =atlas= or =inferior maxilla=. The teeth sinuses, and other possible regions of focal infections should be thoroughly investigated. Anemia and products of metabolism may be underlying factors. All the branches of the fifth nerve are rarely involved. The =ophthalmic division= is most often affected; pain and tenderness being present about the supraorbital notch or foramen, the palpebral branch at the outer part of the eyelid, the nasal branch, and occasionally an ocular pain will be felt within the eyeball. When the =infraorbital branch= is involved, pain and tenderness are principally present at the infraorbital, nasal and malar points. When the =third division= is affected, the chief tender places are the inferior dental, temporal and parietal points. In nearly all cases of neuralgia of the fifth nerve, there is extreme tenderness in the region of the articulation of the atlas and the occipital, particularly the side on which the fifth nerve is involved. This tenderness in a few cases may be found as low as the second or third cervical vertebra. The pain may be so severe as to cause edema along the course of the affected nerve fibers, grayness of the eyebrows and locks of hair chiefly in the temporal region, and convulsive twitching of muscles.

=Tic Douloureux= is a vastly exaggerated neuralgia of the fifth nerve and is supposed to be a primary affection of the Gasserian ganglion. Starting in middle life from no apparent cause it increases in severity until it becomes unbearable and suicide is not an infrequent result.

Many methods to relieve have been tried including destruction of the ganglion but with various results.

Treatment should be the same as in the milder form of neuralgia but it will require critical examination to determine the causes which are liable to be obscure.

=Cervico-Occipital Neuralgia.=—This variety involves the =posterior branches= of the =first four cervical= nerves, affecting the region of the posterior part of the neck and head. The pain may extend as far forward as the parietal eminence and the ear. The chief tender points are about midway between the mastoid process and the spine, between the sternomastoid and trapezius (branches of the cervical plexus), and a point just above the parietal eminence. This form of neuralgia is chiefly due to =subluxation= of the =upper four= or =five cervical= vertebræ irritating the posterior branches of the spinal nerves. A draught of air or exposure to cold are common exciting causes. The pain is of a sharp lancinating nature or else it is heavy and tense. Tuberculosis of the cervical spine may be an underlying cause.

=Cervico-Brachial and Brachial Neuralgia.=—In these forms of neuralgia the pain is referred to the area supplied by the =four lower cervical= and the =first dorsal= nerves. The tender points are in the axilla along the course of the ulnar, the circumflex at the posterior part of the deltoid and points at the lower and posterior part of the neck. The =lesions= exciting this form of neuralgia are usually found in the upper dorsal and upper cervical spines, but they may be as low as the sixth dorsal or as high as the atlas. As far as neuralgia of the ulnar nerve alone is concerned, it can be traced to the seventh and eighth cervical and first dorsal, and the lesion may be found occasionally at the fifth dorsal vertebra or rib. How a lesion as low as the fifth dorsal affects the ulnar nerve, it is hard to say definitely. There may be fibers directly to the ulnar nerve as low as this region, the nerve may be reflexly affected, the vasomotor supply to the ulnar nerve may be disturbed, or possibly the lesion interferes with fibers of the deep layers of the back muscles and thus contraction of muscles for some distance above the lesion would affect the ulnar and other nerves. The scaleni may be affected and involve the plexus. A bursitis may be present (See Painful Shoulders