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.