CHAPTER VI

LUMBAGO AND SCIATICA

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.

SCIATICA

Etiology.--What has been said of lumbago applies to a great extent also to sciatica. There are a number of different affections which have come to be grouped under the term sciatica. Here, much more frequently than in the lumbar region, the cause of the pain is a true neuritis. This may be of many forms. Occasionally it is syphilitic in origin; whenever the sciatica is double it commonly develops on a basis of diabetes, while in many cases it is of an infectious nature. There is no special reason to think that there is a rheumatic infection of the nerve, though inasmuch as rheumatic arthritis is probably due to infections by many different kinds of microbes, it may well be that some of these play a role in sciatica. There is no good reason, however, why the word rheumatism or the term chronic rheumatism should be applied either to lumbago or to sciatica. Certainly there is no reason in any definitely known etiology of the affections. Each individual case must be studied carefully. Always these are local and not constitutional conditions, and usually something in the patient's occupation, or in his habits of life, helps us to understand the development of sciatica or lumbago and gives the most valuable hints for treatment.

Men who shovel much and who bend one knee as they stoop in shoveling will often suffer, though more frequently in the leg which they do not bend than in the other. The same thing is true for men who use one foot to run a lathe or a small printing press, or anything of that kind. They must be taught to alternate in the use of their limbs.

_Pressure_.--Occasionally direct pressure upon the nerve is the cause of the disturbance. I once was asked to see in consultation an elderly lady who had complained very much, first of discomfort and then numbness in her legs, until finally she lost all power in them below the knees. The affection was considered to be some sort of creeping paralysis. I found that her favorite chair, an old-fashioned cushioned easy chair, allowed her to sink down so that the edge of the wood seat frame pressed upon her just where the sciatic nerve comes closest to the surface. As soon as the habit of sitting on this chair was changed her numbness and inability to use her limbs began to disappear.

_Alcoholic Neuritis_.--In both lumbago and sciatica one underlying factor is often present. This is the consumption of undiluted whiskey in considerable quantities. Outdoor workers are prone to take an occasional glass of whiskey, especially in the winter time, and a copious quantity of malt liquors in the summer. Both of these predispose to the development of a low-grade {405} neuritis in susceptible individuals. Alcohol is said to have an idiosyncrasy for the anterior tibial nerves. That only means, as a rule, however, that these nerves are more frequently affected by alcoholic neuritis than others in the body. The reason for this special location of the affection is that in people who stand and walk much, this constituting their main form of exercise, these nerves are much used. They are probably in such people (that is, if the intensity of impulses that pass through them be taken into account) the most used nerves in the body. It is this that makes them most susceptible to alcohol. In people who stoop much or who have to work hard in stooping postures, the nerves in the lumbar region and those that make up the sciatic trunk are over-used. This makes them more susceptible to pathological influences than others, hence the tendency for neuritis to develop in them.

_Intrapelvic Causes_.--Sciatica may be due to various pathological conditions within the pelvis. Women with fibroid tumors are particularly likely to suffer from it. Their removal by operation does not always assure against the occurrence of sciatic troubles. I once saw an obstinate case of sciatica in which there was a story of a fibroid having been removed years before and, though there were no signs of any recurrence of the growth of another, there were some adhesions in the region, and there was an obstinate constipation particularly likely to have as one symptom an accumulation of fecal material in the rectum until it was very hard. The keeping of the bowels open meant more than anything else for the relief of the sciatica. This patient subsequently died from what was diagnosed by a well-known French surgeon as rupture of the bowels. This was probably due to the adhesions that occurred after the old operation, done without any regard to the possible development of such a sequela, some twenty years ago. The sciatica was undoubtedly connected with the group of disturbed conditions within the pelvis.

_Position at Work_.--In this case, as in others that I have seen, the position assumed while at work seemed to have been an appreciable factor in the production of the pain in the limb. The lady made her living by writing and often wrote on a board resting on her knee--a feminine, not a masculine habit. This brought pressure to bear upon the right limb a little more than the other and then, when she crossed her knees in order to put the writing board on top of the knee, this side seemed to be used more than the other.

This question of the position in occupation, even though sedentary, is very important. I have seen a strikingly typical case of the so-called _neuralgia paresthetica_, the achy condition of the outside of the thigh with some anesthesia and paresthesia, occur in an old lady who still retained the girlish habit of sitting on her foot while she did crocheting. I have often seen achiness of muscles of the trunk develop in persons who read much in a cramped position because of the reading light being too low or otherwise wrongly placed for group reading. Whenever a patient has to stand much on one foot while doing something, it is important to remember that there should be alternation in the use of the limbs; otherwise sciatica and lumbar pains will often develop, usually on the side corresponding to the limb that is kept rigid.

Treatment.--_Mental Persuasion_.--The patient must be made to realize that his affection is not rheumatism, but is due to local conditions. Just as soon as a patient's mind is relieved by being made to appreciate that certain habits in his occupation, or certain local conditions that can be corrected, {406} are responsible for much of his discomfort, then that discomfort is much easier to bear. Even in cases where actual neuritis has developed, or where there have been changes in the intermuscular planes bringing considerable disability, the aches caused by these will be much more bearable if the patient's mind is set at rest as to the real significance of the condition. No condition should be called rheumatic unless at some time in the history of it there was an acute inflammatory condition with Galen's classical symptoms--_tumor, color, rubor_ and _dolor_. Pain alone is never sufficient to justify the diagnosis. Painful disability is usually due to local causes.

_Treatment of Acute Symptoms_.--For acute symptoms, the coal tar products may be used and usually afford distinct relief. They include all the old-fashioned salicylates as well as certain more recent compounds, such as aspirin. Phenacetin, however, though usually not thought of in this connection, is an excellent remedy for the discomfort. These drugs should be used freely so as to give relief from the painful condition. The fact that they afford relief, however, should not be taken as an argument that the condition is rheumatic. Rheumatism, as we know it, is an acute infectious disease and there is no reason in the world for saying that the salicylates or cognate drugs are specifics in this affection. They relieve the pain, but just in the same way they would relieve the pain of toothache or of any other painful condition. After the acute symptoms are removed, the condition that remains may be treated in various ways, by massage, by local applications, and by such manipulations as will restore the normal circulation of the part. Care must be taken, however, to distract the patient's mind from the local condition after a time, or mental influence, by interfering with the capillary circulation, may inveterate the symptoms. It is not good to keep patients at rest, though rest, of course, is always indicated if there is much discomfort. Sometimes, however, the discomfort is really due to the fact that muscles have not been used for some time and so are easily fatigued and may ache even under ordinary use. In this case, a gradual restoration of the muscles to normal strength by progressively increased exercise is important.

_Counter-Irritation and Its Suggestive Value_.--Personally, I have found the use of turpentine particularly efficacious in connection with suggestion. The old-fashioned system of ironing seems to do more good than any ordinary application of turpentine. For this a piece of flannel wrung out in warm water has some turpentine scattered over it and then is placed on the affected loins or back of the thigh and covered by another piece of flannel, and a hot flat-iron is rubbed over it. The physical effect is a considerable hyperemia, but the effect upon the patient's mind is especially interesting, the unusualness of the mode of application adding decidedly to the effect. It must not be forgotten, however, that there are some people who are over-susceptible to the influence of turpentine, and its use is followed by a rash.

_Lumbar and Sciatic Psychoneuroses_.--Many cases of lumbago and sciatica are really psychoneuroses. They develop exactly as psychoneurotic conditions do in the abdomen or in joints. Not infrequently there is some accident or injury, some sprain or strain, or exposure to dampness or draft, that serves as the occasion. The Germans group all these occasions together under the word "insult." The "insult" produces little physical effect but after some days or sometimes weeks, the slight discomfort present secures the center of {407} attention and then the patient suffers from what seems to be severe pain and often inability to move or use muscles. Even when there is true sciatica or lumbago, that is, a genuine low-grade neuritis of the lumbar or sciatic nerves, most of the symptoms may come from the associated psychoneurosis. This is proved to be so by the fact that such patients are often cured, for the time being at least, by some shock or fright or sudden excitement, that makes them move, forgetful of the pain and inability from which they suffered just before. Besides, such cases are often cured by inert remedies of many kinds, by local applications that have no specific effect, and by various methods of treatment which cannot be responsible for the recovery. The amelioration of the condition is due to the mental influence accompanying the methods of treatment and the reassurance of the patient's mind.

_Diversion of Attention_.--Almost anything that produces a continuous succession of sensations on the surface of the affected area that attract and hold the attention of the patient may prove a valuable therapeutic suggestion and even eventual relief from symptoms that have proved obstinate to more rational treatment. Liebault, the well-known founder of the Nancy school of hypnotic therapeutics, tells in his "Therapeutique Suggestive," that he has frequently cured lumbago by the simple recommendation of a rather stiff piece of paper to be applied over the patient's loins. The rationale of this treatment seems to be that the patient's attention is attracted to the skin surface by the sensations constantly produced by it and attention is distracted from other feelings deeper in the muscles. It often happens that after an acute lumbago has run its course, there is left a chronic achiness only partly physical and largely psychoneurotic. Some of it is undoubtedly due to the habit, formed during the acute period, of keeping the muscles quiet, in order to avoid the spasmodic pain that occurs on movement. Patients cannot, as it were, let go of their muscles, and their discomfort is largely due to holding them in a cramped position. The sensation produced by the paper on the cutaneous nerves distracts the attention and brings about relaxation of the muscles with decrease of discomfort and gradual relief of all symptoms.

The paper acts as a constant source of suggestion for the cure of the psychoneuroses when the affection is purely psychoneurotic. The mind has become concentrated on the idea of pain and discomfort in this region and needs another thought to occupy itself with so as to neutralize this. Wearing the paper with the assurance, for instance, that because of its impermeability to air it keeps the part more thoroughly protected from variations of temperature and from such possibilities of transudation as have before been possible, serves to lift patients out of themselves and affords relief. Whenever the sensation produced by the paper is noted, there is a renewal of the suggestion and its curative effects. There are many plasters that have obtained the reputation for curing lumbago. It is doubtful whether any of these have sufficient medicaments on them to be of any serious pharmaceutic significance. They are mostly rubber plaster. The presence of this and the consciousness of the sensation produced by it acts as favorably as does Liebault's sheet of paper.

_Mechanical Agents_.--It must not be forgotten, however, that a large sheet of adhesive plaster firmly applied may act as a mechanical therapeutic agent, somewhat in the same way that strips of adhesive plaster relieve the pain of pleurisy, or are helpful in a sprained ankle or a knee. The muscles may be {408} held rather firmly together and so there is no necessity for constant attention to prevent spasmodic pain. Undoubtedly some of the newer large-sized adhesive plasters produce an excellent effect in this way. If, besides, the patient has the feeling that they must be doing him good because of materials in their composition, the psychoneurotic elements are more readily relieved. The old idea was that such plasters drew out the pathological elements to the surface whence they were dissipated. There is no truth underlying this thought.

In the old days blisters were applied rather freely to these regions and the actual cautery was often employed. Both of these therapeutic processes are likely to do good in chronic cases, but much more from their psychic than their physical effects. The actual cautery is not used nearly so much as it ought to be in chronic muscular and neurotic conditions, for the mental effect of its application and the distraction of attention to the skin surface while the cauterized areas are healing are excellent remedies.

There are other counter-irritant procedures of the same kind that have been used with reported successes in many cases. Hot needles, for instance, if pushed deeply into the muscles, often have an excellent effect. Some years ago a distinguished surgeon insisted that both lumbago and sciatica might be cured in many cases by the insertion of needles deeply into the muscles. He argued that what happened was that these needles brought about an equilibrium of electricity in the muscular structures which had somehow been disturbed. Deep injections of water into the muscles also do good. Stretching of nerves has been applied with reported success. After a time all of these measures fail, however, because somehow after the novelty of the treatment wears off for the physician, the patient's mind is not sufficiently impressed and then the former results are not secured. Where there are actual neuritic processes present they will almost surely fail. So many of these cases are almost pure psychoneuroses, however, that it is little wonder that anything which produces a strong impression on the mind and leaves after it some condition that attracts attention and so furnishes favorable suggestion will almost surely cure even chronic conditions for which all sorts of physical remedies, employed on rational grounds, have failed.

Anything that modifies the circulation, even to a slight degree, or by causing a reaction in the local vaso-motor state, alters previous conditions, tends to enable the patient to control the affected part. These psychoneurotic conditions in large muscles help us to understand what happens in organic diseases. There is a physical element that must be modified, but unless a strong influence is brought to bear upon the mind so as to arouse all its capacity for control, the cure will not come. Anyone of a dozen things, however, may be used in this way and often when one fails another will succeed. In obstinate cases of lumbago and sciatica if necessary a number of these forms of treatment should be used successively.

_Hypnotism_.--How much pure psychotherapy may mean for many of these obstinate cases of lumbago and sciatica can be appreciated from the many reports of cures by hypnotism or by suggestion in a light hypnoidal state, or occasionally, under favorable circumstances, even in the waking state. One of these cases, indeed, is responsible to some extent for the French interest in hypnotism which attracted so much attention in the last quarter of the {409} nineteenth century. Prof. Bernheim of the University of Nancy had seen a case of sciatica in which every therapeutic means at his command had failed. As the result of disuse the leg was emaciated and possessed little muscular power. It looked as though the man would never be able to regain the use of it properly. Dr. Liebault succeeded in curing the patient by light hypnotic sleep, in which the suggestion that he would be better was given while the physician stroked the limb. After the first seance the patient was able to use the leg better and the discomfort was greatly decreased. Further seances with Dr. Liebault brought further improvement until finally the condition was cured. Prof. Bernheim, who knew how intractable these cases are, had the case called particularly to his attention and naturally wanted to learn more about the method by which it had been brought about. Liebault's methods had been quite contemned by the regular faculty before. After a series of experiences under Dr. Liebault's direction Prof. Bernheim became enthusiastic over the use of hypnotism as a curative agent and this led to the publication of his well-known work "De la Suggestion et ses Applications dans la Therapeutique." [Footnote 34] It was the interest aroused at Nancy that led Charcot to take up hypnotism, and while he came to very different conclusions, there is no doubt that the work at Nancy meant much for our knowledge of suggestion in both waking and hypnotic state in therapeutics.

[Footnote 34: On Suggestion and its Applications in Therapeutics.]