Number 13
told that she should consult an orthopedic surgeon but that her many specialists should be under the control of a neurologist whom she should see frequently and persistently; referred to Dr. J. J. Putnam with consent of Dr. Chandler with written opinion to this effect; referred by Dr. Putnam to R. W. L.
Examination by R. W. L. showed that the patient stood with slight left lateral curve and in a general "stumped" attitude. The lumbar region was flat, the dorsal region rounded and the knees were inclined to be held slightly flexed. She complained that she felt as if her back were not hollow enough; and to get relief she assumed a position with more lumbar curve in which the knees straightened. She showed marked tenderness over the left sacroiliac joint and felt some pain in the left leg. A radiograph showed that the sacroiliac joints were normal.
She was provided with properly fitted therapeutic corsets giving marked support in the lumbar region and which were tight around the pelvis, and was started on exercises. She was not markedly improved by this treatment at the end of a month.
Orthopedic treatment having failed to afford relief, Dr. Putnam put the patient under general rest-cure methods in a hospital. His observation there convincing him that the left-sided pain was genuine and persistent, and its catamenial exacerbation pronounced, he requested another examination from E. R. Examination without anesthesia was again negative, but under anesthesia the presence of a slightly enlarged, hard, non-tender left Fallopian tube was demonstrated, and a few days later the abdomen was opened. The left tube proved to be straight and patent, but with much thickened and indurated walls; the corresponding ovary slightly enlarged, sclerotic, and containing a very large number of small tense cysts scattered through it like a charge of birdshot. The left ovary and tube were removed, and abdomen closed. Normal convalescence. Patient declared that all abnormal sensations in left side had disappeared. On getting up there was, however, some left-sided sacroiliac backache, relieved by a therapeutic corset. Patient returned to Dr. Putnam's care. When last heard from, one year after operation, she considered herself well.
In this case the essential factor was at first missed and the case considered orthopedic. After longer observation the detection and cure of the abdominal lesion resulted in spontaneous relief of the apparently static symptoms.
CASE 4.—Patient of R. V. L., a healthy and well-developed young woman, a professional teacher of gymnastics, at the end of a very hard year developed severe sacral backache for which advice was sought. She was at the time wearing a small girdle. She was treated by corsets and one of Cook's back splints. The pain disappeared immediately and an observation was made showing that the center of gravity had been moved back 1½ inches. This change was so great that a second observation was taken a week later for purposes of verification with identical results (Fig. 11).
The relief was permanent and the case was evidently one of pure back-strain induced by overexertion and therefore relieved by the change of balance and consequent relief to the posterior musculature without further treatment.
CASE: 5.—Patient of R. V. L., a married woman, 34 years old, of rather less than average physique, had been fairly well until her confinement a year and a half previous. Shortly after getting about she began to have pain in the back and in one leg, and standing was accompanied by great discomfort. She had lost flesh and was very nervous and apprehensive. Examination indicated that the backache was apparently static. She had heen treated by osteopathy without success, and later the diagnosis of a relaxed sacroiliac joint had been made. For this a plaster-of-Paris jacket had been app1ied and worn without any relief of the pain. When she was seen she wore a steel back-brace and a neutral corset. An attempt was made to throw the center of gravity backward by means of a properly made corset reinforced by a light tempered steel back brace to throw her balance back; this gave immediate comfort, and gentle exercises were begun. In three weeks she was pracically free from pain, had gained in flesh and was improving as to her nervous instability.
In this case of evident back-strain the use of the onlinary appliances to splint the back did not give relief, which was obtained by changing the body balance by corsets.
APPLICATION OF EXPERIMENTAL DEDUCTIONS TO CLINICAL CONDITIONS
It becomes evident from the most casual consideration that in this class of cases there exist two elements, the gynecologic and the orthopedic, and an analysis of the probable primary cause of the pain, therefore, becomes necessary.
That forward displacement of the center of gravity induces increased effort of the posterior musculature (back-strain) has been demonstrated in our experimental section. That such excessive or prolonged muscular effort may be translated into pain, spasm and irritability is not only more or less a matter of common information, but may be supported by quotation of certain well-known analogous instances. If the arm is held out horizontally, after two or three minutes the muscular effort is translated into an ache. The spasm and irritability of the ciliary muscle which is overstrained to accommodate for astigmatism is well known. The pain and dragging in pronated and flat feet is generally admitted to be due to muscular and ligamentous strain.
That back-strain sufficiently long continued, induced by an unduly forward position of the center of gravity may be translated into backache seems evident. The unduly forward position of the center of gravity which induces backache we believe to be usually caused by one of three factors:
- Peculiarities in the form and proportions of the skeleton (not necessarily outside of normal limits) resulting in a type of figure with a center of gravity markedly far forward.
- General muscular relaxation leading to a "slumped," relaxed attitude.
- Tenderness of intra-abdominal or intrapelvic organs inducing the patient to assume a stooping or other strained position to relieve intra-abdominal or intrapelvic pressure.
The gynecologic cases described above belong in the latter class and, though it is evident that the field of intra-abdominal or other visceral lesions which may cause such attitudes is wider than that covered by any merely gynecologic cases, yet they are presented as the most frequent representatives of a large class for the purposes of this paper.
It is further evident from the anatomy that in the case of the comparatively unprotected sacro-iliac joints even the painful spasms of the dorsal musculature may, and probably do, fail to prevent painful tension on the connective tissue (ligaments and fasciæ) placed there to regulate extremes of motion. Without denying the occasional existence of abnormally movable sacro-iliac articulations (mostly puerperal) we believe that undue tension on connective tissue from overstrain is sufficient to explain the symptomatology of most cases of apparent functional derangement of the sacro-iliac joints without invoking the possible existence of an abnormal mobility to explain it further.[1]
DIFFERENTIATION OF CASES AND TREATMENT
Our observations would be of little value to ourselves or to others were we not prepared to formulate certain
- ↑ It has been a matter of common observation that pain in the back, of the character described, may be induced by lateral inequalities of the skeleton producing lateral strain, e. g., a short leg: and during this series of observations we have been confronted by numerous instances of it. We feel sure that such lateral inequalities predispose to the unilateral (one-sided) localization of pain induced primarily by bilateral strain, but we have thought it necessary in this series of observations to limit ourselves to the one point of antero-posterior strain and have therefore recorded no observations on this issue.
