Any affection involving discomfort, pain, ache, or disability of the large muscles in the lumbar regions is likely to be called lumbago, not only by patients but by physicians. Any condition that makes it painful to use the upper part of the lower limb and especially the group of large posterior leg muscles just below the nates is called sciatica. These are commonly supposed to be typical "chronic rheumatisms." Anything in this region that is the source of discomfort on rainy days and comes especially to the working man who has been exposed to the elements, or that follows a wetting or the wearing of damp clothes, is confidently classified as a chronic rheumatic condition. Almost needless to say any such conclusion as to the heterogeneous groups of symptoms that occur in these regions, far from adding to our knowledge, rather confuses the situation. There is an assumption that we know something about them when we call these conditions either lumbago or sciatica, but unless each individual case is carefully investigated and its conditions studied so as to get at their true etiology, it is almost impossible to treat them successfully. While the general practitioner of medicine of the regular school often fails in his treatment of them, these affections are among the most fruitful sources of revenue for the irregular practitioners.

It was particularly for pains and aches in the back that St. John Long's liniment proved so efficacious about a century ago. So-called lumbago and sciatica patients were among the most frequent callers on Perkins in the days of the famous tractors and many of them received great relief. In our own time these constitute a class of patients who go from physician to physician and who finally are cured or relieved by some irregular practice which we know contains nothing especially remedial, but the advocates of which somehow succeed in persuading these patients that they must be better than before. Most old people have some aches and pains in either the lumbar muscles or the large muscles at the back of the thigh. Many of them are relieved by massage, but still more of them find relief in the rubbings and manipulations of the osteopaths, and they are great advertisers of the relief that has been afforded them and they have helped much in securing such state recognition as has come to the systems they thought curative in their cases. Eddyism has been helpful to a certain number of them. Fads of various kinds catch still others. Evidently these intractable cases deserve to be studied from the standpoint of what mental influence can do for them.

Conditions Mistaken for Sciatica or Lumbago.—Needless to say, a large number of conditions occur which may be called sciatica or lumbago, but which are due to the most varied causes. An affection of any of the joints in this neighborhood will produce pain to which is often added tenderness and occasionally swelling, and nearly always disability. Disease of the lower part of the lumbar spine due to tuberculosis is often in its earlier stages called lumbago. Indeed, without careful investigation showing that there is a special point of tenderness, some irregular fever and that the muscles are in spasm {403} to protect the underlying joints from use, it is difficult to decide just what is the affection in a particular case. I have seen three physicians diagnose a one-sided tenderness and pain in muscles with disability as lumbago, when the course of the disease proved that it was tuberculosis of the sacro-iliac joint. Any of the bones or joints in this neighborhood may give rise to pain, tenderness and spasm of muscles and it is important not to make the facile diagnosis of lumbago, unless careful investigation has eliminated all underlying organic conditions.

There are other conditions not infrequently mistaken for lumbago or sciatica which are interesting. Needless to say unless they are definitely recognized there will be no relief afforded for any discomfort of a permanent character, though the coal-tar products will give temporary surcease of pain. Occasionally internal hemorrhoids produce an achy discomfort in the lower part of the back that is described as lumbago, and unless the physician is careful to investigate he may tentatively accept that diagnosis. Proper regulation of the bowels and the use of gluten suppositories will often practically cure the condition, though there will be relapses whenever constipation returns. Chronic posterior urethritis sometimes simulates painful conditions very low down in the back or in one hip or the other. Usually in that case there is a chronic inflammatory condition in the seminal vesicle on the side to which the symptoms are referred. Occasionally over-distention of the seminal vesicles, as seen in widowers who have been accustomed for many years to regular evacuation of them, may cause so much pain and disability in the region of the hip on one side as to be mistaken first for lumbago and then even for tuberculous hip joint disease. Artificial emptying of the seminal vesicle by milking through the rectum will usually afford relief. In all of these cases as soon as the exact diagnosis is made, the patient's mind is relieved of a serious burden of anxiety and it is usually not difficult to bring a great measure of relief.

Old Injuries and Discomfort.—Many of the painful conditions described as lumbago are due to old injuries, to wrenches and sprains in this region due especially to heavy lifting and to the laceration of ligaments from over-exertion.

Typhoid Spine.—Protracted cases of typhoid are sometimes followed by pain in the lumbar or sacral regions, developing usually after a slight jar or shock, sometimes after a fall or even following a severe injury, which are really the result of the physical condition of the patient. Stiffness, aching discomfort on movement and sometimes tenderness on pressure are present. Often there are associated neurotic symptoms of various kinds. This used very commonly to be considered rheumatism and occasionally one still sees cases so labeled. On the other hand, much more serious conditions, as Pott's disease, abscess of the liver, or some form of spondylitis, may be suspected. Absence of temperature is almost the rule and usually is the pathognomic differential against these. The whole condition is usually a neurosis though there may be some perispondylitis. The treatment is to increase the patient's nutrition, which has usually suffered to a marked degree, and get the mind off the condition in the back. Concentration of attention on it will make it very uncomfortable, so that even heavy doses of opiates will scarcely relieve the discomfort, and this emphasis of attention will further disturb the mind and develop neurotic {404} symptoms. Diversion of attention, gentle movements, plenty of air, and regulation of the functions of the body will bring about a cure.

Stooping Occupations.—Occupations are especially important in lumbago and people who have to stoop much, above all those who do hard work in a stooping position—lifting, pushing, sawing, planing, and the like—are particularly prone to suffer. Miners working where the height of the vein does not permit them to stand up are commonly subject to it. Any one who has to assume, or has the habit of assuming, a stooping posture for long hours may suffer from lumbago. Constrained position predisposes more than hard work. Tailors, though in a sedentary occupation, often suffer from it.