Trouble arises sometimes in cases when X-ray examination reveals that one side of the last lumbar vertebra has become fused to the sacrum. Support would then be indicated in preference to manipulation. The same applies when the last lumbar transverse processes are so long that they impinge upon the ilium on either side. There may be a bursa or even an actual joint at the point of contact. The bony formation of the lower part of the spine varies within such wide limits in people who present no symptoms of "strain" or "locking," that X-ray examination must be regarded as confirmatory rather than as diagnostic.

There is, therefore, a place for both treatments in cases of lower back trouble: the choice may be doubtful, but, so far as reflection and superficial observation allow, I have tried to indicate the factors which should probably regulate the decision between them. Combined treatment may also be indicated. The types of case which seem to be chiefly benefited by treatment - support or manipulative - are those presenting pain in the lumbo-sacral region and referred pain down the leg in any position. Dr. William S. Baer reports 1 that evidence of sacroiliac "strain" is to be found in pain over a spot "just to the side of, and just below, the umbilicus," and considers that the position, when on the right side, is so close to McBurney's point that many operations for appendicitis have been performed in error. On the left side the tenderness might well be held to indicate inflammation or engorgement in the neighbourhood of the ovary. This "point" applies to sacro-iliac trouble only, and does not apparently indicate any defect in the lumbosacral region.

In attempting to distinguish between fibrositis and neuritis (other than pressure or referred neuritis) of the sciatic nerve, I think there should be definite indications. If the pain is due to "strain," "locking," or to "subluxation," there should be some definite distinction between the resistance in the muscles to be felt on the two sides of the lower part of the back; and, from the side on which the resistance is greater, there would therefore be unusual deviation. These variations from the normal will probably be found to be so trivial that only the closest and most practised observation will detect them. A fair guess should always be possible when observing a patient whose sacrum is unduly tilted backwards, as the lumbar curve would then be unduly pronounced in a forward direction. Very sudden onset of acute pain while making any unusual movement or effort is also suggestive; and, if this history is recent, should incline us to treatment by manipulation rather than by support. When, however, the pain starts as a dull, nagging ache which gets steadily and progressively worse, support is indicated either with or without manipulation as an auxiliary.

1 See report in the Lancet, September 29th, 1917, of an article in the Bulletin of the Johns Hopkins Hospital.

The history in any case of the type under discussion is of great importance. The patient who experiences acute pain in the lower part of the back when cranking a car, for instance, may be suspected of "strain" or "locking"; but when it follows lying on damp grass, myalgia, myositis or fibrositis - i.e., lumbago - should be given preferential consideration. In a true sciatica the pain should be limited to the course of the nerve, even when the cause of the irritation is fibrositis in the gluteal region. In cases of sciatic pain referred from the sacroiliac or lumbo-sacral region other nerves are almost sure to be affected.

How far various other evils are attributable to the "strains" or "lockings" I cannot judge. The evidence, as I encountered it, was so confusing and conflicting that it was impossible to form any opinion. Two points, however, are worthy of notice. The wearing of high heels must tend to increase the forward lumbar curve, and this must tend to the carrying of the sacrum in a position inclined unduly backwards. Although "strain" or "locking" may be insufficient to cause acute pain in the back or leg, it may, nevertheless, be sufficient to account for the "dull back-ache" so often mentioned, and possibly also for many of the abdominal pains commonly referred to the ovarian region. Lowering the heels and support, with or without manipulation, is, of course, worthy of trial.

I have nothing very much to guide me in my observations of "lesions" in other parts of the spinal column till we come to the thoracic region. I was put in receipt of indisputable evidence that chronic, irritating cough (in the absence of physical signs in the chest) can yield spontaneously to manipulation. I regard this observation as of great importance. The question of the occurrence of "strain" has not been raised, so far as I know, above the level of the fourth lumbar vertebra; so, in the region we are now considering, the "lesion" should consist of "locking" or "displacement." If either condition really exists, and if either can produce cough by reflex - as was proved to me in a manner I cannot fail to accept - then it is impossible to refuse to accept the conception that similar lesions in the lumbar and sacral regions might produce abdominal symptoms by reflex. One of the evils very commonly attributed to lumbo-sacral "lesion" is constipation. In Sweden, sacral beating is reputed to act beneficially; in America, the same claim is made by the cheiropractors for percussion of the spine and by the osteopaths for manipulation. It is not impossible that the teaching of all three schools may be of service, and that each method of treatment advocated acts in the same way, namely, by relieving some "locking" or "displacement."

In the cervical region manipulation has succeeded in curing many forms of chronic headache, and particularly in the occipital region; and several patients spoke of relief of what almost amounted to migraine attacks. There is another claim which is made for manipulation of the cervical region and which, in view of the relief unquestionably rendered in the lower part of the spine, cannot be dismissed without consideration. This is the assistance rendered in cases of brachial neuritis. I happened to see only one patient, so far as I can recall, who had sought relief from this treatment, and she found it. I should regard this evidence, taken alone, as negligible; but, when taken in conjunction with the relief frequently secured from manipulation of the lumbar spine, it cannot be ignored.