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1042 conclusions governing the treatment of these cases. It is evident that a determination whether the original cause of the backache is primarily intra-abdominal or origin­ally static is a necessary preliminary to intelligent or effective treatment. In practice, in the comparatively limited field selected by us for discussion here, the cases would seem to fall schematically into three classes:
 * 1) The gynecologic, of intrapelvic origin.
 * 2) The orthopedic, of mechanical or static origin.
 * 3) The borderland cases in which both elements are present, or in which the differentiation between the two is at first impossible.

The recognition of a borderland class is necessary on account of the frequency of it, appearance in clinical work, but the line between this and the other classes is so indefinite that it can be described only by implication under the other headings.

Static backache is frequently a prominent symptom of the intrapelvic neoplasms. It is then due to an altera­tion of attitude caused either by an instinctive effort to lessen pathologic pressure within the pelvis, or by disturbance of balance from the actual weight of the larger growth. In these cases no improvement in the static condition can be expected until after the removal of the neoplasm, and here an immediate operative removal should be promptly followed by proper orthopedic treat­ment if necessary.

On the other hand, many of the ptoses are merely secondary results of static abnormalities. In these cases especially, gynecologists should be careful not to adopt treatment without first making a study of the static causes which so often have produced, or are perpetuating them, since some previously unmanageable retroverted uteri, prolapsed ovaries, etc., can be promptly relieved by minor intrapelvic treatment after the static fault, which caused them have been corrected. Ptoses of the kidneys and other upper abdominal viscera are equally important and should be considered. Under these con­ditions, also, those cases which still demand major meas­ures will more surely become symptomatic as well as anatomic successes, and many anatomic failures will be avoided.

In the inflammatory affections of the pelvic organs the instinctive efforts of the patient to protect the tender structures from the pressures and jars which are always incident to locomotion in the erect posture, lead usually to so persistent a maintenance of a constrained attitude that the prominence or static backache in these cases is easily understood in the light of what has been said in our experimental section.

The relative value of static or intrapelvic treatment as an initial step in the management of these cases depend, largely on the stage of acuteness at the time at which treatment is undertaken. It is generally conceded that during the presence of an acute symptomatology the inflammatory affections of the pelvic organs should have depletive and soothing rather than radical treatment. In the more acute cases the muscles of the back are almost invariably in a state of irritation and spasm, and no part of the initial palliatory treatment is more impor­tant or more promptly grateful to the patient than rest in bed, support to the irritated muscles, hot packs, the local electric light bath, etc., for their relief. On the other hand, even in the chronic cases too early attempts at mechanical correction of the faulty posture are apt to do harm rather than good so long as the pelvic tender­nesses are unrelieved, since if successful they again expose the tender organs to the pressures from which the faulty attitude has partially relieved them.

The complication of ptoses with inflammatory conditions demands evidently the weighing of relative indications in the individual case.

It is manifestly impossible to cover within the length of such a paper as this, even in outline, the whole field of gynecologic practice in its relation to static backache (even without the equally important lesions of general abdominal surgery), but we hope that what has been here said may serve to illustrate the principles involved.

The gynecologist may, of course, readily examine the backs of his patients and may with practice acquire some facility in the differential diagnosis of back-strains into those of primarily intra-abdominal or primarily static origin, but he should never forget that in the static cases the abnormality which is the original cause of the symptom may often be found in a distant part of the skeleton (e. g., the feet), and that its detection may require special knowledge.

Throughout the field of gynecologic practice the estimation of static conditions is of importance whenever backache is a symptom.

The orthopedic surgeon will be wise to refer to the gynecologist for a preliminary examination and opinion by which to guide treatment, those cases in which the history, or the replies to the usual questions, are suggestive of uterine disease. This is especially important when the symptoms suggest the possible presence of inflammatory disease of the intrapelvic organs, since in these cases, as has been said above, alteration of attitude, such as would be indicated by the back-strain alone, may be distinctly harmful.

The accepted orthopedic treatment of back-strain as it exists to-day has been already spoken of in the beginning of the paper. It is a matter of common information that it is on the whole unsatisfactory. The treatment which from our point of view should be in theory the most satisfactory, and which in practice in our hands has proved the most successful, is as follows:

A defect of balance exists which in the end must be cured by remedying that defect of balance, a matter only to be brought about by substituting a correct for an incorrect attitude. Massage and gymnastic exercises to induce this correct attitude would seem to be the obvious method to follow. But practically this alone at the outset is generally unsatisfactory for the following reasons: One is dealing in most instances not with athletes with well-developed muscles, but with men, or more often women of less than average physique as a whole, whose back muscles in particular are overstrained, weak and irritated. These patients are recumbent not over ten out of the twenty-four hours as a rule, and for the rest of the time are generally sitting, standing, or walking. To begin by gymnastics on muscular development under these conditions is to exercise still further for perhaps half an hour daily, muscles already overused, and for the remaining fourteen hours of the twenty-four the irritation induced by the malposition goes on, for a correct position cannot at once be substituted for an incorrect position. It is a frequent experience to find the backache made immediately worse by such treatment, even when given by skilled persons. It is as if the oculist ordered his patients suffering from eye-strain due to astigmatism to use the eye, a little more each day to strengthen them before he corrected the visual error. The best results in back-strain are to be obtained, not by attempting to