'5I Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from

SCIATIC PAIN * By H. LOVELL HOFFMAN, M.D., M.R.C.P. Honorary Assistant Physician to the Royal United Hospital, and the Royal National Hospital for Rheumatic Diseases, Bath There is no need for me to stress the chaotic operations, and its removal has relieved the state of our ideas in the past regarding sciatic symptoms. We also know that sciatica was pain. The fault lies undoubtedlv with those just as common before the discovery.of this who, from the depths of their armchairs, pro- condition, and that patients recovered without pounded theories based on inadequate operation. The inference to be drawn from pathological evidence, or succumbed to the this fact is that healing or reduction of the almost overwhelming temptation to adopt a lesion may in some cases occur without sur- simple explanation for all cases. To the latter gical intervention. Walshe has tritely replied in discussing this These are the causes of sciatic pain of which particular subject, ' Nature is not interested in we have no doubt. We must now consider simplicity.' other possible causes based on less certain Being faced with the task of producing for pathological grounds. you some order out of this chaos, it is my aim to steer a course midway between the Scylla of Less Certain Causes of Sciatica Protected by copyright. dogmatism and the Charybdis of sheer vague- ness. With regard to sciatic pain we need Sciatic neuritis or interstitial neuritis facts, and first I propose to mention briefly I have already mentioned that this may occur those which are incontravertible. when due to diabetes, alcohol, or arsenic. We know also that interstitial, neuritis of other nerves is not uncommon, ahd examples such as Proved Causes of Sciatica occipital or supra-orbital neuritis, and brachial It is quite definite that sciatic pain may arise neuritis may be mentioned. These con- when the nerve or its central connections are ditions may arise, like other rheumatic mani- affected by a pathological process such as festations, after exposure to damp or cold, and herpes zoster, tabes, new growth or the be part of what we have termed a local or

neuritis of diabetes, alcohol or arsenic; dis- general ' fibrositis,' although the pathological http://pmj.bmj.com/ seminated sclerosis is 'a very rare cause. It basis of this lesion is a rather vague one. may also be due to disease in the vicinity of the Although I feel sure that a true brachial nerve's course or central connections., and the neuritis or neuralgia of this nature does exist, following conditions may be cited as examples. many cases of pain in the arm with definite In the meninges, arachnoiditis, syphilis or root signs, have recently been proved to be meningioma. In the vertebral bodies, caries, caused by a cervical disc lesion, which need not osteomyelitis, Paget's disease and new growth. necessarily cause signs of cord compression. on September 26, 2021 by guest. In the pelvis, inflammation or new growth Our ideas regarding the symptom are there- either in the bones or viscera, or inflammatory fore falling more into line with our conception changes in the sacro-iliac joint. of sciatica. Spurling and Scoville (I944); It is also certain that sciatic pain may be Elliott and Krerner (I945). produced by herniation of the nucleus pul- It has been argued that an inflamed sciatic posus of a lumbar intervertebral disc. The nerve has rarely been seen and examined; lesion has now been verified at countless naturally there are few opportunities for this. * A PQstgraduate lecture delivered at the Royal National Hospital for Rheumatic Diseases, August, 1946. £52 POST-GRADUATE MEDICAL JOURNAL March, J947 Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from

-1- -2- -3- One case was described by Denny Brown found in the upper gluteal regior of cases with (I933) in a woman who died after oxygen had undoubted disc lesions, and I have confirmed been therapeutically injected into the thigh. this observatiop on several occasions. By The author found exudate under the per- electromyographic study of these spots he has ineurium of the individual nierve fibres, but found spontaneous motor activity in the

certain other changes which he discovered, muscle, and considers that they are due -to in- Protected by copyright. may have been due to the oxygen injection. voluntary spasm of small groups of muscle More recently Holmes and Sworn (I946) fibres, caused by irritation of the nerve root hiave found evidence of what was termed more centrally. He repeated Kellgren's experi- 'radiculitis ' at operation. 'I his consisted ment and in some cases found continuous either of swelling of a nerve root, or adhesions motor discharge from muscles in the area of around it, for whic4, they were unable to find a .referred pain. He therefore suggests that mechanical cause. localized, spasm can be induced through a The general impression, with which I reflex path which involves the anterior horn personally concur, is that sciatic ' neuritis ' or cells, and that the source of excitation may be rqdiculitis does exist, but is rare. It was res- in, or outside the nerve root. He has recorded ponsible for orly 3 per cent. of a series of cases similar motor activity in the so-called fibrositis z,ollhted by Jacksor in 1943 (vide infra). of the shoulder girdle associated with cervical osteoarthritis, and in the extensor muscles of http://pmj.bmj.com/ Referred sciatica and the role offibrositis the arm in brachial neuritis with or without Kellgren produced pain referred to the root signs. corresponding root distribution by injecting an This work is of great interest and importance irritant substance into the interspinous liga- suggesting a new conception not only of re- ments. It is certain that sciatic pain can be re- ferred pain, but also of that mysterious con- of sacro-iliac as in ' As the it is ferred from disease the joint, dition fibrositis.' regards latter, on September 26, 2021 by guest. early ankylosing spondylitis, or from osteo- fascinating to postulate a vicious circle, arthritis of the hip. Steindler (I940) states that initiated, perhaps, by cold or minor trauma, similar pain !may be referred from areas of producing muscle spasm and pain. By reflex trauma or ' fibrositis ' in the back and gluteal action through the cord, this pain may produce muscles, which are in the territory of the a motor impulse causing further muscle spasm posterior primary divisions of the spinal nerves, in the affected segment, and so on. Such a the anterior primary divisions of which go to reflex process could explain the sudden onset form the sciatic trunk. He further states that of fibrositis, so unlike an inflammation, and our relief is obtained by injecting novocaine into treatment at once becomes rational, breaking these myalgic areas. Elliott (I944), however, the vicious circle at various points. Heat and has pointed out that similar tender areas are immobilization. tend to reduce muscle spasm, March, '947 SCIATIC PAIN 153 Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from and nfvQQCaine injvtion relieves pain. Later, Diagno4iF. Number m4spage and manipulation will further free Doubtful ..2 the muscle fibres and encourage them to Fibrositis (local) ..c resume their normal activity. In a recent RuptuLred intervertebral dist. . 8 article which, inter alia describes myalgic Areas Hysteria .. .. secondary to visceral disease, Kelly (1946) Fibrositis and neurosis 8 favours a similar hypothesis, and suggests Congenital bony abnormaliti, 4 that.... nervous reflexes are instrumental in Fibrositis (generalized) .. 3 the causation of fibrositic lesions in general.' Sciatic neuritis 3 Malingering 2 It is not my intention to theorize further re- Sacro-iliac strain 2 garding the nature of fibrositis, in the absence Lumbo-sacrao strain 2 of rnore definite pathological proof. It should Spinal osteo-arthritis I.. be remembered that gout, gonorrhoea and Bony infection I focal sepsis may play a part in its causation. Neoplasm of cauda equina The condition has been said to produce Polyradiculitis ...... sciatic pain in two ways, either by reference Secondarv carcinoma .. from remote areas, or by direct spread to the Disseminated sclerosis. . I nerve itself. From what has already been Spastic paraplegia (? aetiology) . I stated it seems reasonable to assume that re- ferred sciatica may be so caused, but the con- IOO ception of fibrositis spreading directly to the Sciatica Pain due to Protruded Inter- nerve is more difficult to accept in the light of Protected by copyright. new theories. vertebral Disc The intervertebral disc consists of the The role of lumbar osteoarthritis annulus fibrosus which is weaker posteriorly than anteriorly, a cartillaginous plate above and Harris (I933) and Putti (1927) describe below, and the nucleus pulposus, which lies cases where the nerve roots are compressed at slightly more to the posterior part of the disc. the foramina by arthritis of the intervertebral As a result of trauma and degenerative changes, joints. A spine, however, may bristle with the annulus fibrosus may rupture partially, and osteophytes and yet produce no symptoms; the nucleus pulposus will herniate either in further, in advanced ankylosing spondylitis certain postures only, or permanently. If the sciatic pain is rare. Burt (1933) explained this annulus ruptures completely, the nucleus pro- fact by pointing out that the latter condition is lapses, and part or all of it will come to lie http://pmj.bmj.com/ a sclerosing arthritis, without effusion, which under the posterior longitudinal ligament. rapidly immobilizes the spine. It is probable Owing to the position of the nucleus in the that certain cases of sciatica are due to vertebral posterior part of the disc, and the relative osteoarthritis, especially in older subjects, and weakness of the posterior part of the annulus, that cold, damp and trauma play a part in these protrusions tend to occur posteriorly, the initiating the symptoms; but it is generally nucleus being squeezed like a pea out of a pod

agreed that the soft tissue changes of the when the spine is in flexion. Compression of on September 26, 2021 by guest. arthritis, not the bony ones, are responsible for a nerve root may result. The fifth lumbar root the pain. Great care is necessary in making is most commonly compressed by the fourth this diagnosis, as radiological signs of spinal disc, the first sacral root by the fifth disc and osteoarthritis are common in cases with proved so on. disc lesions. Th. clinical history and physical signs of The following table is reproduced from an the syndrome vary- from case to case, and if article by Jackson (I943). He states that, of certain possibilities are borne in mind it is the doubtful cases, seven were probably due to easy to see how these vaiiations may occur. I disc lesions, and the series gives a good idea of have already mentioned that the nucleus may the relative frequency of the causes of sciatica herniate temporarily and only in certain in Service personnel. postures. This accounts for the intermittent MEDICAL March ' 1 1154 POST-GRADUATE JOURNAL 947' Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from charactet of the symptoms in some cases. The L.4 Anterior crural to medial malleolus. figure shows the possible anatomical relation- IL.5 Posterior crural to dorsum and medial ship of the hemiation to'the' nerve root. It is margin of foot. easy to see that the nerve may slip off the S. i Posterior crural to sole- and lateral mar- herniation; this explains the relief of gin of foot. symptoms, which is sometimes brought about The pain is usually relieved only when the by spinal manipulation' or epidural injection of patient lies absolutely still. It is aggravated by saline and novocaine, the root being 'floated movement and by sneezing or coughing. This off' the projection. Further, it may be that aggravation is supposed'to be due to a rise in -the three possible positions account for the cerebrospinal fluid tension with consequent variability of the scoliosis in these cases. pressure on the nerve root, and has been con- Scoliosis may be either towards the affected sidered to be a diagnostic feature of root in- side, away from it, or alternating. In many volvement. I cannot believe that this is true. cases adhesions form between the nerve and On coughing, all the trunk and buttock the protrusion, in which case it would be muscles contract, and I am sure that it is reasonable to expect more intractable symp- contraction of the latter, including the pyri- toms. Flexion of the spine or straight leg formis in close relation to the sciatic nerve, raising puts the theca on the stretch and will which produces the exacerbation of pain. tend to aggravate pain by stretching the Paraesthesiae may be experienced in the same affected nerve root over the projection. distribution as the pain, and consist of tingling, Flexion, however, opens up the intervertebral numbness, pins and needles or a burning

foramina and may relieve pressure oni an sensation. Protected by copyright. oedematous nerve root. Extension of the spine has precisely the opposite effect, and Physical Signs may aggravate pain by causing increased These are orthopaedic and neurological, pressure on the root at the intervertebral both being of importance in the recognition foramen. Capener (i944). and lo'calization of the lesion. Orthopaedic. The normal lumbar lordosis Clinical History may be lost or diminished. Sometimes a slight A history of frank -trauma initiating the kyphosis is encountered in the lumbar region. symptoms was given by 23 per cent. of Macey's Scoliosis is common, usually to the side of the cases (1940). Bradford and Spurling (I94I) lesion, but may be away from it, or even vary give the figure as 50 per cent. The trauma from time to time in the same patient. Some-

may be an actual fall on the back, a strain times the scoliosis is not present when standing http://pmj.bmj.com/ caused by lifting a heavy weight with the spine erect, but becomes evident only when an' flexed, a false swing at golf, or similar sudden attempt is made to flex the spine. Movements movement. There may be no remembered of the lumbar region are limited, especially history of injury, or the patient's occupation flexion, which nearly'always increases the pain. may suggest that he has suffered repeated An important sign is the presence of tender- small strains over a prolonged period. Preg- ness, either in the mid line over the affected

nancy and labour are sometimes responsible interspace, or just lateral to it, on the side of on September 26, 2021 by guest. for the lesion. Usually the first symptom the lesion. This tenderness is best elicited by is a fairly sudden onset of backache, and it is firm pressure with the thumb. If, in addition fair to assume that this is due to rupture of to local tenderness, there is an exacerbation of the annulus fibrosus. Sciatic pain may develop pain in the corresponding dermatome, the at the same time or be delayed for days or evidence is strongly in favour of root com- months, occurring, most probably, when pression by a disc lesion, 'Little (I946). actual protrusion of the nucleus takes place and Neurological. There may be slight wasting compresses a nerve root. The distribution of of the buttock, posterior thigh, or calf muscles the pain varies according to which root is com- on the affected side, but this is not usually very pressed, and the areas affected may be sum- marked. Muscle weakness is most commonly marized thus, Connell (I946) found in the dorsiflexors of the ankle, but mav March 7 c SCIATIC PAIN 1947 I5.5 Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from be present' in any of the muscles supplied by jerk 'many be diminished or normal, while if the affected roots. Sometimes the only weak- the first sacral root' is involved the ankle' jerk ness discovered is in dorsiflexion of the great is usually lost or at least diminished. As in the toe and this sign should always be sought in sensory supply of the limb, there is con- suspected cases of disc protrusion. Sensory siderable overlap in the roots subserving the loss is not always present. It is,usually slight reflexes, and individual variations are res- in degree, consisting of blunting to pin prick ponsible for inconstancy both of reflex and or loss of sense of light touch. In my ex- sensory signs. Occasionally a disc protrusion perience it rarely involves the complete is so large that the cauda equina is compressed, dermatome as illustrated in the text books. in which case there will be signs as of a tumour This is because there is considerable overlap in this region, with bladder disturbance and and variation of the skin areas supplied by the' anaesthesia in the saddle area. spinal roots. Thus in a lesion of the fifth lumbar root, loss of sensation will occur in the Special Investigations area of skin supplied solely'by this root. The CSF. This may show a raised protein, picture is further complicated by the fact that especially if lumbar puncture is performed two nerve roots may be involved by a single below the level of the lesion, e.g. in the disc protrusion, Spurling and Grantham L.5-S.I interspace. As the nuclear protrusion (I940). Moreover the lumbo-sacral plexus is relatively small, conmplete spinal block with may be pre- or post-fixed, and it will thus be a positive Queckenstedt's test and Froln's seen that a reliable localization of 'the disc syndrome 'seldom occurs, but slight rise in lesion is not always possible from considera- protein up to 6o mgms. per cent. is a fairly Protected by copyright. tion of the sensory signs alone. The sciatic common finding. The reversed Queckenstedt nerve is often tender at its exit from the pelvis test is carried out with a manometer attached and in the posterior thigh. Other tender to a needle in the lumbar theca, whilz s4line is areas may be found in the gluteal region, the injected into the epidural space aKt -;he sacral significance of which has already been dis- hiatus. If the' pressure if,to xse in the cussed. Straight leg raising, or extension of manometer, a block may be assumed to exist the knee with the hip flexed to a right angle between the two needles. (Lasegue's sign) may be limited by pain on the X-ray. Straight X-rays sometimes show affected side. If these manipulations ate narrowing of the intervertebral space corres- stopped just short of producing pain, neck ponding to the affected disc, but this is not flexion or dorsiflexion of the ankle may cause usual. Developmental anomalies of it to appear. Neck flexion carried out in this the'lumbo-

sacral region are sometimes seen in cases of http://pmj.bmj.com/ way acts by stretching the affected nerve root disc protrusion; for example, .there may be or the theca, and if pain results, it is good sacralization of the fifth lumbar vertebra, evidence that a root lesion exists. Lasegue's unilateral alteration of the plane of the articular sign itself, on the other hand, is often positive facets, or spondilolithesis. These need not in cases of referred sciatica, and it seems necessarily be the direct cause of sciatic pain, reasonable to assume that this may be due, in as has previously been It seems part at least, to stretching of the spastic ham- supposed.

more likely that, by upsetting the spinal on September 26, 2021 by guest. string muscles. Naffziger's test for root in- mechanics, they can predispose to degenera- volvement consists of bilateral jugular com- tion of the annulus, and consequent nuclear pression, and is positive when pain or protrusion. It is important to realize that the paraesthesiae result in the affected area. The lumbar spine is an extremely complicated CSF pressure is raised, and further tension system of joints, liable to all the diseases and results in the compressed nerve root. If insults which may affect the other joints of the positive, the sign is of considerable diagnostic body, and that many different signs and value. symptoms may arise therefrom. It is also In lesions of the fourth lumbar root the important to view disc lesions in their proper knee jerk will tend to be diminished or absent; perspective. The disc is merely a part of the with a lesion of the fifth lumbar root the ankle joint, comparable to the fibro-cartillage ofother POST-GRADUATE MEDICAL JOURNAL Mar,ch, 1947 156 Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from joints; but it is also the focal point through to find a hy§terical prolongation of a previous which abnormalities of the spinal meehanics organic sciatica. Such cases are difficult to will most frequently produce gct4 nerve root assess because there may be residual neuro- compression, and so give rise to sciatica. logical signs as a legacy of the anteceedent Myodil is now being used for myelograhy attqck, It is most important in all such cases in place of lipiodol. It is a stable compound, to look for positive signs of hysteria rather than c'using little irritation and is slowly absorbed for negative signs of organic disease, and to by the spmal canal. It is of low viscosity and seek possible escapist motives, and unsettled can therefore be removed through a lumb4r compensation claim. These patients may punctige needle. I have no experience of show an exaggerated or even fantastwc limp. myelography in disc lesions; the technique They will, with great show of emotion, resist and positioning is complicated and time con- all movements of the limb, irrespective of suming, but many consider that it is of great those which should actually cause pain. Areas value in these cases. Personally I agree with' of anaesthesia may be. typically hysterical, in- those who hold that a disc lesion can be volving the patient's conception Qf a limb diagnosed and located on clinical grounds segment and bearing no relation to nerve or alone. root distribution; such areas, moreover, may easily be suggested to the patient. Occasionally Differential Diagnosis. it will be found that bending forward from the Sciatic Neuritis. It is almost impossible to erect posture or straight leg raising is bitterly differentiate with certainty between this con- resisted, as the patient has learnt from previous examinations that this should cause pain. Yet dition and a disc lesion. In neuritis one is Protected by copyright. more likely to see signs of involvement of the he may be induced, without complaint, to whole nerve than of its individual roots. bend forward and touch his toes while sitting Walshe (I946) states that single attacks of on a couch, showing that the movements, acute onset and relatively short duration are which are essentially the same in each case, more likely to be due to this cause. are really not painful at all. Root Compression from neoplasm. Here the signs are more insidious in onset and steady in Treatment progression. Weakness, wasting, and sensory In all cases of sciatica, unless there are sure loss are always more marked and bladder dis- signs ofcord or cauda equina pressure, then con- turbance more common. If the growth is servative treatment should first be tried. Rest malignant, there are likely to be signs of in bed is the first essential and should be main- cachexia. tained for four to six weeks if necessary. A Referred Sciatica. In referred pain there pillow under the affected knee may give relief, http://pmj.bmj.com/ will be no signs of actual nerve involvement; or the leg may be immobilized with sandbags thus, sensory loss, marked weakness or wasting, or a long Liston splint; weight extension is and absent tendon reflexes will not be found. often useful. During this period local heat in The pain of root compression is always felt in the form of hot water bottles, electric pads, the territory of that root, whereas referred pain radiant heat and mud packs may be employed. is far more diffuse and vague in its distribution. Analgesic drugs are usually essential in the Pain i eferred from osteoarthritis of the hip early stages, and aspirin, phenacetin, veganin, on September 26, 2021 by guest. tends to radiate to the anterior part of the or sonalgin may be used. In some cases, thigh, there will be limitation of movement of however, only morphia will give relief. If, at the joint, and percussion of the heel may cause the end of this time, pain is relieved, massage pain. X-rays of the pelvis should always be and exercises to the spine are carried out to examined carefully for lesions of the sacroiliac correct faulty posture which may have been joint such as tuberculosis or early ankylosing responsible for weakening of the annulus and spondylitis, which are important causes of consequent disc protrusion; these may, with referred sciatica. advantage, be carried out in a hot pool. IIysteria. Although sciatic pain or purely If rest is not successful, it is the practice of hysterical origin is rare, it is extremely common our orthopaedic department, under Mr. John March, I947 CAESAREAN SECTION IN MODERN OBSTETRICS Postgrad Med J: first published as 10.1136/pgmj.23.257.151 on 1 March 1947. Downloaded from Bastow, to give an epidural injection of 120 of this period, massage and exercises are c.c.s of half per cent. procaine in saline under carried out as above. Should these measures pentothal anaesthesia, followed by gentle not give relief, and other signs point to the rotatary manipulation of the spine, and straight presence of a disc lesion, laminectomy, with leg raising. A plaster corset is then applied removal of the prolapsed nucleus pulposus, is which is worn for three months. At the end considered. REFERENCES BRADFORD, F. K., and SPURLING, R. G. (I94I) 'The Inter- LITTLE, N. (1946), Med. _'ourn. of Australia, I, 33. vertebral Disc,' Springfield and Baltimore. MACEY, H. B. (1940), Arch. Surg., 40, 433. BURT, J. BARNES (1933), Proc. Roy. Soc. Med., 26, 1396. O'CONNELL, J. E. A. (1946), Brit. M1ed. j., I, I22. CAPENER (X944), 'Annals of the Rheumatic Diseases,' 4, 29. PUTTI, V. (1927), Lancet, 2, 53. DENNY BROWN, D. (933), Proc. Roy. Soc. Med., 26 I399. SPURLING, R. G., and GRANTHAM, E. G. (1940), Arch. ELLIOTT, F. A. (1944), Lancet, I, 47. Surg., 40, 375. ELLIOTT, F. A., and KREMER, M. (I945), Lancet, I, 4. SPURLING, R. G., and SCOVILLE, W. B. (1944), Surg. Gynaec. HARRIS, W. (x933), Proc. Rov. Soc. Med., 26, 1389. Obstet., 78, 350. HOLMES, J. MACD., and SWORN, B. R. (1946), Brit. Med. J., STEINDLER, A. J. (1940), J. Bone and Joint Surg., 22, 28. I, 946. WALSHE, F. M. R. (1946), 'Diseases of the Nervous System,' JACKSON, W. P. V. (I943), Ibid., I, 776. Edinburgh, E. and S. Livingstone.

THE PLACE OF CAESAREAN SECTION IN MODERN OBSTETRICS By JOSEPHINE BARNES, M.A., D.M., M.R.C.P., F.R.C.S., M.R.C.O.G. Assistant, Obstetric Unit, University College Hospital Protected by copyright. One of the most striking developments in judgment needed to decide when delivery by modern obstetrics has been the immense in- the natural passages is likely to prove crease in the number of women delivered by sufficiently dangerous to mother or child that Caesarean section. Two hundred years ago operative delivery is to be preferred. the Caesarean operation was regarded as the last resort in a desperate emergency when The Advantages of Caesarean Section delivery was possible by no other means. The mortality was exceedingly high-in fact re- It must not be assumed that because the covery from the operation was considered very operation of Caesarean is so easily open to remarkable. Smellie (eighth posthumous abuse that its wider employment is not, on the edition) wrote concerning the operation that it whole, a great advance, in midwifery. The ' might be occasionally indicated because the advantage of reasonably safe abdominal de- http://pmj.bmj.com/ mother and child have no other chance to be livery in cases such as those of severely con- saved, and it is better to have recourse to an tracted pelvis where natural delivery would be operation which has sometimes sufcceeded than hazardous, if not impossible, are self-evident. to leave them both to inevitable death.' The advantages of abdominal delivery may be Today the position is very different. It has summed up under two main headings. become necessary for eminent obstetricians to Firstly, it avoids the danger of delivery by warn their colleagues against the abuse of an the vagina and there are' many circumstances, on September 26, 2021 by guest. operation which, thanks to the development of as will be seen, where it is inadvisable even to anaesthesia, of aseptic and antiseptic technique, attempt such delivery, while in other cases the and to a lesser extent of chemotherapeutic course of labour may be seen to be so un- methods has become, in some hands, a means favourable that it seems unwise to allow it to of avoiding even the slightest difficulty in proceed further. Secondly, Caesarean section labour. These warnings are timely since no offers a rapid method of terminating pregnancy other procedure is more open to abuse. No and may thus be considered as an alternative high degree of operative skill is needed, to induction of labour. The methods of in- certainly not for the classical operation, but duction in current use, admirable though they only wide obstetrical experience can give the are in favourable cases, are all very uncertain