Article V.- -On Oil of Turpentine in Sciatica. By W. Allan V - PDF Document

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  1. Article V.- -On Oil of Turpentine in Sciatica. By W. Allan V Jamieson, M.B., M.R.C.P., Edin. A medicine which has been employed in the treatment of sciatica from the days of Galen downwards would seem scarcely to need anything further said in its favour; the observations I am about to make are an attempt to define more accurately the cases in which oil of turpentine may be used with most advantage. While our methods of investigating into the nature and natural history of diseases are day by day becoming more precise, and, as a neces- sary consequence, our knowledge of morbid states of the system,

  2. [MARCH 788 DR JAMIESON ON OIL OF TURPENTINE IN SCIATICA. and of the finer shades of distinction between each, is continually growing more perfect, the exact treatment of the varying forms is built up more slowly, and to some extent less satisfactorily. Even in the wards of a large hospital, cases of the same disease pre- senting a moderate degree of parallelism are not of constant occurrence, so that the experimental method of research into the action of one particular remedy in one special variety of disease, has often to be carried on for years before an induction which is worth anything can be drawn. In private practice long intervals of time frequently elapse between instances of disease similar in kind, while it is more difficult to ensure that the mere surroundings of the patient may not injuriously affect the observations. Sciatica, in our cold and damp climate, is common enough; it varies with the age, temperament, and diathesis of the person affected, while its treatment as yet is almost entirely empirical. Adopting Dr Anstie's classification, three main groups may be recognised. The first of these is that occasionally seen in young persons, most commonly females, though by no means unknown in men. While the constitution of these patients partakes more or less of the hysteric character, the exciting cause may be often found to exist in some peripheral irritation of branches of the sacral plexus, more especially of those distributed to some part of the sexual apparatus. cannot at present recall a very typical instance in my own prac- tice. Perhaps the following case is the best illustration which has come under my notice :? M. S., ?et. 24. Domestic servant. Of a reddish-fair complexion. Has been for more than a year in the service of a family in Edin- burgh, who took her with them to an elevated situation a few miles from Dunbar in the beginning of August. For three months before I saw her, on the 19th September 1876, she had experi- enced pain along the right sciatic nerve. attended her soon after it began, gave her temporary relief by subcutaneous injections of morphia. endurable, and she went on with her duties, but it gradually became worse, preventing sleep, and incapacitating her from work. She was sent in to a sister in town, at whose house I visited her on the date named above. She then complained of severe pain in sciatic notch at knee and outer ankle, but, contrary to what is usually observed, she seemed unable to keep the limb still in bed, and the pain on pressure behind the trochanter was elicited by slight contact. Her evening temperature was 98*8?, and her state otherwise normal. I injected ? grain of acetate of morphia deep into the gluteal muscles, and ordered her? ]?. Olei terebinth inae, 3ij. Olei ricini, 3iv. Mucilaginis, 3iv. Aquam ad, 3ii. The draught to be taken early next morning. It is not a common form of sciatica, and I A medical man who For a time the pain was

  3. 789 1877.] Dll JAMIESON ON OIL OF TUltPENTINE IN SCIATICA. When seen on the afternoon of the 20th September, the morphia had given little relief, while, though the medicine prescribed had acted freely on the bowels, the pain in the sciatic was as great as ever, and the restless movement of the limb even more so. As her sister was from circumstances unable to wait upon her, she was admitted the same day into the Hoyal Infirmary, under Dr Hal- dane's care, where her case proved a tedious one. here no history of rheumatism, nor of any such exciting cause as cold or damp, while the age of the patient and character of the pain raised at least a suspicion of an hysteric element, so that the failure of oil of turpentine to afford relief scarcely astonished me. The features of the second form are well marked. ally that connected with the period of tissue degeneration. comparatively rare in my experience before fifty, though cases much resembling it are occasionally met with in persons between twenty and thirty. 1870, have been exactly divided between the sexes. experience of all cases of sciatica prove it rather more frequent among men. Pain often commences first in the lumbar and sacral regions, and then after a variable time creeps downwards into the parts more immediately supplied by the great sciatic nerve. Points tender to toucli also manifest themselves successively from above downwards. Thus, those which first appear correspond with the terminations in the skin of the posterior branches of the sacral nerves; then the coccygeal, and perhaps the vesical branches, are next affected, and nearly simultaneously with these a fibular point over or near the head of the fibula; and, lastly, an external malleo- lar. This last is very persistent, continuing even when those higher up in the chain of distribution have almost or altogether faded away, ?so much so that I have frequently seen sinapisms and even blisters applied over the external anlde in the vain hope of thus mitigating the pain there. in the centre of the calf. Cutaneous anaesthesia is also a symptom, but is often masked in the early part of the disease by the tender- ness of certain portions of the skin becoming a prominent feature during its decline. The motor branches of the nerve are often, indeed, usually affected, locomotion being impaired quite independ- ently of the pain resulting from use of the limb, and consequent pressure on the nerve and its branches by muscular contraction. The predisposing cause is in many cases long-continued pressure on the sciatic nerve?in females who sit much and take little exer- cise?in males whose occupation is sedentary, though not neces- sarily one within doors. in sitting may determine which nerve is affected. more common than for an individual in a family to have his or her own seat, by one side or other of the fire it may be. one nerve is likely to suffer more from pressure than the other; and so, from local anaemia thus induced, or depression of functional There was It is especi- It is Ten examples, of which I have notes, since General (Sometimes a painful point is developed I am inclined to think, too, that position Nothing is In this way,

  4. [MARCH 790 DR JAMIESON ON OIL OF TURPENTINE IN SCIATICA. activity, to be easily influenced by such an exciting cause as damp cold. Exposure to this latter is usually the immediate precursor of an attack. In one of my cases the seizure was brought on by a long drive in an open gig on a raw cold evening, across a bleak Northumbrian moor, followed by a night spent in a draughty room with insufficient bedclothes. In another, a miller caught an attack by getting wet while assisting to drive a horse and cart out of the Whitadder, and subsequent carelessness in changing his clothes. While no temperament or diathesis can be said to be free from liability to an attack, the class of persons most subject to this form of sciatica, and who derive most benefit from oil of turpentine, are those who present the following appearances:? Usually middle-aged ; they look older than they ought, and have hair, as Anstie so well phrases it, prematurely and permanently gray. The complexion may be pale or fresh, but it nearly always exhibits a peculiar ashy gray or stone-coloured aspect?a point to which 1 attach much importance. The proof of tissue degeneration may be more conclusively shown by rigid radial arteries, possibly by arcus senilis. The following case, which was first seen by me on the 26th August 1870, illustrates many of the particulars stated remarkably well:? Mrs W., jet. 56, a lady in comfortable circumstances, who had a family of six children, and up till then had not had any severe domestic trial or worry. She had, however, occasionally of late, attacks of the neurotic form of angina, and one of her daughters subsequently had neuralgia of a severe type in various groups of nerves. She was tall and stoutly made, rather pale, her complexion having the ashen hue which I have already mentioned. Her hair became gray early in life, and continued so. or rheumatism. I afterwards observed that, when at home, Mrs W. always occupied a large arm-chair, so that her right side was next the fire. On the 11th August 1870 had a smart seizure of choleraic diarrhoea, which lasted all night and left her weak. She was then living on the banks of the Tweed in a rather damp and relaxing situation. On the 22d she began to have pain in the back, and along the course of the right sciatic nerve; three days after she was quite lame, so she returned to her home in Berwick, and I saw her on the 26th. I found her with a clean tongue, but marked with many deep cross fissures ; appetite fair; bowels, now perfectly regular. 60, equal, of good strength. course of the right sciatic nerve, paroxysmal in character, and when the attacks came on, there was also pain in the urethral branches ; urine normal as regarded quantity and quality. A blister was applied behind the great trochanter, and rest in bed enjoined. 29th.?Pain very intense, felt chiefly in calf and outer ankle. One twenty-fifth of a grain of sulphate of atropia was injected She never had gout Pulse There was severe pain along the

  5. 791 1877.] Dll JAMIESON ON OIL OF TURPENTINE IN SCIATICA. subcutaneously, which produced distinct physiological effect, and afforded temporary relief. 30tli.?Repeated atropia. 31 st.?Pain less ; 15 grains of carbonate of iron twice a day. 3d September.?Pain still continues; 5 grains of iodide of potas- sium, with 8 minims of tincture of colchicum, were prescribed, to be taken three times a day; and as the nights were sleepless, half a drachm of chloral at bedtime. diarrhoea and tormina ; the colchicum and chloral were omitted, but the iodide was continued till the 11th, when, as it appeared to be doing no good, it was given up, and the carbonate of iron resumed. 17th.?Passed a very bad night; did not sleep, and suffered much pain in coccygeal, vesical, and malleolar branches. Injected ? grain of acetate of morphia, which relieved, but gave rise to much nausea. 40 grains of chloral at bedtime. 18^.?Slept well, but pain undiminished. The chloral draught was repeated, and the following mixture directed to be taken early in the morning :? On the 6th there was some 01. terebinth., 5ij. 01. ricini, $iv. Tinct. cardam., co., si. Mucilag. et aq. ad Jii' ]?. 19^.?The medicine acted freely; the pain is much abated?so much so, that Mrs W. can now lie on her side. repeated on the 21st, and again on the 25th. Next day the pain was so nearly gone that she could sit comfortably. A slight degree of numbness persisted for some time ; but recovery was uninter- rupted and complete, no fresh attack having since occurred. In this instance the effect of the oil of turpentine was so real, as compared with that of all the other means which had been tried, that my patient, when I visited her after the first dose had acted, accosted me with the exclamation, that medicine at first ? " Its nauseousness had in fact deterred me, but I learned a lesson not to hesitate in ordering it 011 that account. Since then, I have employed it as the first remedy in eleven cases, all of them presenting in greater or less degree the characters of the class detailed above. In ten of these, relief from pain was immediate, not in any, entire or complete after a single dose, but such an amelioration as to render lying on the side affected, or even sitting up, quite possible. A second or third, in several even a fourth dose, was required to reduce what was previously intense suffering to a state of slight numbness. cure, though his case seemed well suited for its employment. T. S., jet. 61, was seen by me last March, after he had suffered from sciatica in the right leg for some weeks. He was a man of by no means temperate habits, and was employed in a large wood- The mixture was " Why did you not give me In one man it failed to

  6. [MARCH 792 DR JAMIESON ON OIL OF TURPENTINE IN SCIATICA. yard. He presented both the gray hair and ashy expression. Turpentine gave him temporary relief, but the pains recurred. Blisters, acupuncture, iodide of potash, iron, and strychnia were tried in succession, without effect, but the pain finally yielded to subcutaneous injections of morphia, at first daily, then every second day. was one of the most obstinate I have met with. Oil of turpentine has been long recommended as useful in some forms of sciatica, but if we are to judge from what one of our latest writers on therapeutics, Dr Phillips, says, that in which it may be advantageously administered has, up to the present time, been obscure. Dr Phillips endorses the opinion of Nothnagel, that the indications for its use are quite uncertain. son suggests that it may be most serviceable in cases where the irritation of the nerve is connected with a disordered state of the kidney, but there was no alteration in the urine in several patients under my care, where, nevertheless, turpentine cured. Dr King Chambers, who has in his Lectures, chiefly clinical, written more fully on the subject than any author with whose works I am acquainted, taking into consideration the proximity of the caacum on one side and the rectum on the other to the trunk of the sciatic within the pelvis, thinks that while disorder of these viscera may lead to the production of sciatica in some cases, turpentine given either as an enema or by the mouth exerts a direct local action on the nerve. Dr Anstie, in his classic work on Neuralgia, does not once mention turpentine as an internal remedial agent, although in his previously published article in the System of Medicine, he briefly alludes to it as worth trying in the more obstinate cases of this disease, in ten minim doses thrice a day. I have employed it in this way without any benefit in cases which were at one relieved by a purgative dose. And here I may also combat an objection which may be raised, viz., that the good results obtained from turpentine are due solely to its drastic action; a full dose of compound jalap' powder has no effect in moderating an attack of sciatica, however completely it may evacuate 'the bowels. In this opinion I find myself to be at variance with that of a very distinguished clinical teacher and accurate observer, the late Dr Warburton Begbie. In an exhaustive paper on the Thera- peutic Actions and Uses of Turpentine, published by him in the July number of the Edinburgh Medical Journal for 1871, for recalling my attention to which I am indebted to the kindness of Dr Muir- head, there occur the following remarks:?" The modus operandi of turpentine in neuralgia, and particularly in sciatica, is, I am dis- posed to think, not unfrequently connected with its action on the intestinal mucous surface, with some irritation of which the painful nerve-affection is not unfrequently connected. In illustration of this I may refer to an experience by no means uncommon, that after a brisk action of a cathartic?and for this purpose none is I think in his case there was a rheumatic taint; certainly it Sir Thomas Wat- I may remark that

  7. 793 1877.] DK JAMIESON ON OIL OF TURPENTINE IN SCIATICA. more suitable than the combination of turpentine and castor-oil? a severe attack of sciatica lias been entirely removed." Turpentine belongs to the narcotic stimulant class of remedies, and I agree with Dr Chambers in thinking it acts locally, just as its action is also probably local on the unstriped muscular fibres of the intestines when, administered in the later weeks of enteric fever, it so rapidly and effectually reduces the tympanitis so dis- tressing and dangerous. Turpentine, then, to do good in the sciatica of the period of tissue-degeneration, must be given in doses of at least two drachms, combined with half an ounce of castor-oil, suspended in mucilage, and rendered more palatable by the addition of an ounce or so of cinnamon-water. The draught is best taken early in the morning. The dose generally acts power- fully two or three times, but its action is not followed by exhaustion at all commensurate with its effect on the bowels. Sometimes there is considerable difficulty in keeping the mixture down; usually, however, this is less urgent when cinnamon-water is em- ployed as the vehicle. absolute rest in bed must be maintained, not only while the pain continues, but for some time after it is gone. difficult, as patients rebel against what they consider an unneces- sary restriction. The following, among others, is an instance where I had reason to regret the neglect of this precaution. J. B., aged 25, a masculine-looking female, an outworker on a farm in Berwickshire, began to suffer from sciatica in February 1875. I saw her on the 20th March, when the pain was so severe as to confine her per force to bed. draught, and on 24th March received a letter stating that this had at once relieved her, and she had gone to work. She sent for me on the 28th, and was found worse than ever. The turpentine was repeated on the 29th, and on the 1st and 2d April, and this time, warned by her previous experience, she rested longer, and got quite rid of her troublesome enemy. Commonly the dose does not need to be repeated oftener than every third or fourth morning. produced by its use in sciatica, nor indeed any unpleasant con- sequences. Lastly, there is a third group of sciaticas, in which the sheath of the nerve probably suffers from the action of a specific blood- poison, be that gouty, rheumatic, or syphilitic. last forms I have seen no examples. The rheumatic has been fully treated of by Dr Fuller, who, however, names so many reme- dies as to lead to a doubt which is the right one. seen in persons long subject to rheumatic pains in various parts of the body. A collier, who supplemented his earnings more legiti- mately made, by lying behind dykes and under hedges, and having a shot at any chance hare or rabbit which might come his way, came under my care a few years ago with a severe attack of sciatica. VOL. XXII.?NO. ix. In the treatment of all forms of sciatica, This is oftentimes I ordered her the turpentine I have never seen strangury Of the first and It is the form I 5 II

  8. 794 [MARCH DR JAMIESON ON OIL OF TURPENTINE IN SCIATICA. have no notes of his case, but I remember that after every remedy 1 could think of?turpentine included?was tried ineffectually, he went into the workhouse, and came out crippled with his prolonged illness, but with his pain relieved by almost parboiling him in a hot bath. This group includes some of the very worst cases, which tax their attendants' patience and resources to the utmost. My object in this paper has been to point out the variety of sciatica which has appeared to me to be almost invariably benefited by oil of turpentine; and I now respectfully offer the results of my ex- perience to the kind consideration of this Society.