JAMES CYRIAX. REFERENCEs. 1 Cyriax, J., Brit. med. J., 1938, 2, 1367. ' Campbell, D. G., and Parsons, C. M., J. nerv. ment. Dis.,. 1944, 99, 544. 3 Cyriax, J.
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tests, which revealed abnormalities typical of chronic bronchitis. The full part played by smoking in the aetiology of chronic bronchitis is still conjectural. While it is clear that a great deal of chronic bronchitis is caused by smoking, there appear to be at least two other important contributory factors. First, there is apparently an individual (possibly genetic) predisposition: I found a number of heavy smokers whose P.F.R.s were as high as those of non-smokers of corresponding age and height, whereas some moderate smokers had a cough and low P.F.R. Secondly, the effect of seasonal climatic changes was shown by the finding of considerable variation in the P.F.R.s of smokers when tested on repeated occasions during the year: there was a striking tendency for the P.F.R. to be lower in the winter months. By contrast, the serial P.F.R.s in non-smokers were remarkably constant in summer and winter. Unfortunately there are, as yet, no agreed normal values whereby the P.F.R. of an individual patient may be compared with a predicted value for his age, height. and sex. It is clearly essential that such normal values be obtained from individuals who have never smoked. Closely linked with the problem of early diagnosis by the G.P. is the need to educate patients to recognize the earliest symptoms of chronic bronchitis. A great deal of evidence suggests that the condition begins with hypersecretion of mucus and only later does infection play an important role. This points to the conclusion that the earliest recognizable symptom of the disease is a " smoker's cough," especially when it is productive of even a minimal amount of sputum. It remains to be found out whether, once this stage is reached, abstention from further smoking will allay the hypersecretion of mucus and bring about improvement of ventilatory
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traumatic degenerative changes in the upper two cervical joints. The pain is then worst on waking, disappearing towards midday. Moving the neck about helps to ease the pain. When reference is extrasegmental the pain may come on suddenly with stiffness of the neck at first, either on waking one morning or as the result of injury, often a whiplash. Some of the movements of the neck and, usually, a cough increase the pain. Muscle lesions respond to deep massage and local anaesthesia; capsular contracture to manipulative stretching; disk displacements are usually susceptible of manipulative reduction (an entirely different technique). Your annotator rightly lists these measures, amongst others, but treats them as alternatives whereas each treatment has its separate indication, depending on which tissue in the neck is found at fault.-1 am, etc., JAMES CYRIAX.
London WA1REFERENCEs
1 Cyriax, J., Brit. med. J., 1938, 2, 1367. ' Campbell, D. G., and Parsons, C. M., J. nerv. ment. Dis., 1944, 99, 544. 3 Cyriax, J., Textbook of Orthopaedic Medicine, 4th edition, 1962, p. 136. Cassell, London.
Infection and Disk Lesions SIR,-I have recently been impressed by the frequent incidence of acute low-back pain of typical " disk-type " distribution, pain being referred down one or both sciatic nerves. The numbers involved have been in the region of a minor epidemic, and the interesting thing about it is that this has occurred at the same time as a minor influenza epidemic, and following upon a minor epidemic of streptococcal throat infection in the area. The frequency of these disk-type lesions appears more than would be accounted for merely by coincidence. All age groups have been affected, one a child of 10 capacity. had the typical referred pain, with sharp pain in While research by G.P.s on the above lines could, I years on dorsiflexion of the foot and on the lumbar believe, provide information of great value, there is a flexion of theregion neck. Incidence of trauma in these cases need to supplement such studies by detailed pulmonary was negligible. On occasions the condition has spread function tests on selected patients with early chronic in a family, as an infectious disease would. bronchitis. This should yield information which cannot I have asked medical friends whom or One two whom tests in these be obtained from the type of patient in lesions. noticed increase disk-type also this have are usually performed-the bronchitic with a severe me the possibility to suggest above observations The the which enormously complicates degree of emphysema swelling infection which causes a virus being there of disturbances of ventilatory function.-I am, etc., and inflammation of the disk, producing pressure on the IAN GREGG. London S.W.15. nerve root, and consequent pain, in the same way that the mumps virus selects the parotid gland for its attack, inflammation and pain in this region. Altercausing Headache and the Neck natively, as the incidence followed upon widespread SIR,-The writer of your annotation (March 9, p. 629) streptococcal throat infection with occasional scarlet performs a real service by drawing renewed attention fever in the community, may the swelling of the disk to this neglected phenomenon. Lack of recognition of with subsequent root pain be a reaction to the streptothis common source of headache is responsible for coccus, a mechanism similar to that which occurs when many lay-manipulators' cures of what has been mistaken swellings appear in the skin in erythema nodosum ? for, perhaps, hyperpiesic headache, and gives credence 1 would be very interested in any observations which to their unfounded claims that manipulation of the neck others may have, and for suggestions as to how one may relieves high blood-pressure. set about putting this theory to the test.-1 am, etc., Reference of pain from neck to head arises in two V. AINSWORTH. Rotherham, Yorks. ways: (1) Segmental reference within the relevant dermatome-that is, the scalp-from tissues developed within An Old Barts Custom the first and second cervical segments' 2; (2) extrato see Dr. R. I. W. Ballantine's was pleased SIR,-I segmental reference from the dura mater when pressure is applied to it at any cervical level, as the result of a letter (March 23, p. 822), as I have always been intrigued by the provision of brandy in operating theatres. During space-occupying lesion, most often disk protrusion. When reference is segmental the pain may arise from a period of over 40 years I have never seen it given to the posterior spinal muscles close to the occiput, and anaesthetists, surgeons, patients, or fainting dressers or comes on when the patient is tired. More often it is of nurses. The only clue I have is the observation that capsular origin, the result of osteoarthritis or post- the consumption is not uniform but invariably rises to
