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7Feb/110

LEARNING ABOUT LAME BACK

The framework and moving parts of the human body are designed on mechanical principles, although far more elaborately so than any man-made structures such as an automobile engine or a cantilever bridge. They also are affected by the physiology as well as the pathology, which means that they have to work whether the tissues are healthy or diseased. The wonder is that they do not more often go to pieces altogether but just function poorly and, rather than creaking and rattling badly, merely send word to the brain of their worn parts and need of adjustment.
Also in considering low back pain one must remember that the place where discomfort is felt on many occasions is not the chief seat of the trouble. Indigestion may show itself as headache; a disturbance of the middle ear may result in vomiting. A breaking down of the arch of the foot or a badly set fracture of the leg frequently produces backache.
If the broken bone of the leg is set at a wrong angle, then the thigh bone does not rest properly on it. Also the muscles of the leg which are attached to the thigh bone do not pull in the direction that they should. So the mechanics are wrong clear up to the back. The back muscles and ligaments have to handle the whole weight of the body from the waist up. With the little leverage that they have and the rather insecure balance of the body upon the pelvis, which is the great girdle of bone to which the thighs are attached, they have a big job even when everything is normal. Put things out of plumb and their task is really tough.
But one does not have to have fallen arches, broken bones and such catastrophic happenings to develop backache. Nature rarely if ever makes a perfect piece of work in building us. It is common knowledge now that the two sides of one's face are not perfect twins. No more so are our lower extremities (legs to you) or, in technical anatomical terms, the combination of thighs and legs. (I seem to remember from my medical student days that the newly arrived Yiddish-speaking immigrants called the entire limb from the hip to the ground the "fuss" or foot.)
Careful measurements would probably show that your two legs are unequal in length. Most people compensate for this discrepancy with little trouble. An orthopedic friend of mine has told me of numerous patients of his who never got comfortable backs until he took measures to compensate for the unequal length of their "legs."
In fact the lower back is one of the most vulnerable parts of the body. Fortunately the overwhelming proportion of afflictions to it tests our philosophy and equanimity but does not endanger us. When, as and if you get lumbago, it might be worth while to have a good look over, and if it proves to be just "misery," try to be one of the groups, who grins and bears it. Lots of your friends are doing the same unbeknownst to you. And don't take kidney pills. Aspirin is cheaper and better. The kidneys are nestled in the small of your back, but, when they get diseased, they may cause you almost every kind of trouble except a backache.
The one chief cause for backache is man's decision to stand upright on two limbs. It may be difficult to determine with accuracy whether four-legged animals suffer much from this affliction, but I have seen no reason to suppose that they do. Few of us spend much more than a third of our time lying down, and when we are standing or even sitting, there is almost continuous strain on the muscles of our lower back.
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HEALTHY BONES

7Feb/110

MUSCLES: LAME BACK

An observing friend of mine divided men into two classes: those who fuss about their lame backs and those who ignore them. For all men have them unless they die young. The lame back has always been a prolific source of income, much of it received with clear consciences, for its obscurity and, presumably, many different causes have naturally led to many treatments. All the cults have had their own ways of treating it and often successfully, for nearly all of us have had our periods of remission, and the psychic factor is important.
Early in this century earnest and industrious gynecologists provided well for their families by doing "suspensions" on women with aching backs and tipped-back uteri. There are still lots of tipped uteri and lame female backs, but we are now pretty sceptical of the cause and effect. Right now I am thinking of one charming young woman, with a retroverted uterus and five or six children, whose dynamic life is still untroubled by low back pain.
Meanwhile, in the male sex, the sacroliac joints were usually held responsible for lame backs. One did not have to be well informed medically to tell one's friends glibly that one had a "sacroiliac." Probably most of you know that the lowest vertebra rests on a heavy wedge-shaped bone called the sacrum.
This, with its narrow portion down, fits, like the keystone of an arch, between the right and left ilia. On the surfaces between the bones there is cartilage as in a joint. There is little if any space in these joints and as little motion. However, they were blamed for much grief and finally a distinguished orthopedic surgeon developed an operation to fuse the joints. It is outmoded now.
A score or so of years ago it was shown that the disks of cartilage which lie between the vertebrae and act as shock absorbers could when ruptured cause severe back pain. They bulge out into the spinal canal and, as space is limited, they press on nerves. This may happen in the neck but it is far more common in the lower back where the five large lumbar vertebrae are supporting a lot of weight and are subject to severe strains.  Since this has been understood, great numbers of ruptured disks have been recognized and operated upon. The methods of diagnosis have been made more accurate and the operation made much less elaborate. At the same time it has been shown that many cases, possibly most of them, do not require operation.
This episode demonstrates what we believe is the necessarily slow painstaking development of good medicine. About the turn of the century, Theodor Kocher, a great European surgeon, reported a case where the vertebrae had squeezed together and ruptured a disk which had bulged into the canal. But the man had fallen a hundred feet and died within a few hours. No surgical significance was attached to this. But the case was recorded. Years later, Dr. Walter E. Dandy, of Johns Hopkins, found cartilage sticking into the spinal canals of patients who had sciatica. In 1932 Dr. Jason Mixter, of Boston, operated on a patient with sciatica who had had an accident followed by pain in his lower back. Dr. Mixter and Dr. Joseph S. Barr recognized that the material which was projecting into the spinal canal was cartilage and they concluded that the patient had a ruptured disk. By the next year they were able to make the diagnosis, operate, and confirm it. And at the same time a doctor in France had arrived at the same conclusions.
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HEALTHY BONES

7Feb/110

MUSCLES: FOOT STRAIN

In considering the whole framework of the body and the apparatus for giving it motion, I imagine many moderns feel that the foot plays a minor part. But an authoritative article which I have just read says that the highly mechanized army of today depends increasingly on the state of the feet. It also says that the large number of serious foot troubles in the young men entering the service is shocking.
We had best look with a critical eye, however, on what takes place in the armed forces. In World War I, a certain young man was rejected by the armed forces because of flat feet; the year after the war ended he won the Boston Athletic Association Marathon, running twenty-six miles, three hundred and eighty five yards, over hard pavements. This merely points up the fact that too much indiscriminate attention has been paid to the height of the arch under the center of the foot.
The foot is the very basis of human anatomy. Even in this mechanized age most people have to be on their feet a good deal. The feet support us, balance us, and start most of our motions. They should have intelligent care from the moment of birth. A famous orthopedic surgeon said that the care of club foot should begin while awaiting the delivery of the placenta. Actually, very few children are born with bad feet; rather, the great majority starts with good feet and then so-called civilized people proceed to ruin them. I doubt if many American Indians before their association with the whites developed flat feet or if the African savages do.
The foot was originally intended to go bare so that it could take its normal position and get normal exercise. Feet have made trouble principally because shoes interfere with these two conditions. No other part of the body has been habitually encased in a rigid framework, preventing free motion, and, what is more, absolutely forcing it into the wrong positions. For centuries the pointed-toe shoe was considered, if not the acme of beauty, at least of fashion. When Elizabeth Hawes said that fashion is spinach, she slighted the attributes of a very potent drug. Rarely does one see an adult foot that corresponds to what a textbook on the anatomy of the foot considers normal: a turning of the big toe to the outer side is, almost universal. When this is carried to an extreme, a bunion is likely to develop and may be disabling.  Wear proper shoes during the growing age, exercise the feet, and be careful about much wearing of poorly shaped shoes at any time.
These observations should not be construed as a plea for dressy young women to attend their social functions in "common sense" shoes - straight inner sides, square toes, low heels. It is not to be expected that dressy women will go to dressy parties without dressy shoes. If they will wear sensible shoes most of the time, they may indulge in a little foolishness at intervals. A little nonsense now and then is relished by the wisest men. And women.
In this mechanical age it should be unnecessary to point out that when any machinery is "out of line" there is resulting trouble. A misshapen foot puts extra strain on the ligaments and muscles that support it. Add to this that the free movement of the muscles is interfered with, and the trouble is compounded. It is not the lowness of the arch, the "flat foot," that is the cause of the difficulty. Negroes are notoriously flat footed and yet, as we all know, they are often the finest of athletes. But once the ligaments have stretched, a chronic distressful condition occurs that is difficult to restore to normal. A better term than flat feet is "foot strain," as it is the resulting strain upon the muscles attempting to compensate which causes the symptoms. This strain may be felt all the way from the foot to the back. One hint: if you are carrying extra weight, you are not giving your feet a fair chance.
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HEALTHY BONES

7Feb/110

MUSCLES: TYPES, STRUCTURES AND MORE

Most of the muscles are spindle shaped, tapering at the ends. The tough tissue, which has been described as binding the strands together, forms at the ends into heavy tendons. Although, as you know, the muscle is soft and each strand would stand little pulling, when the minute contraction of each cell is multiplied by millions the resulting power is something.
The tendon ends are practically welded into the bones. The end attached to the bone which it does not move is called the origin. The other end where the bone moves a great deal is the insertion. The example best known to all of you is the calf of the leg with the origin on the bones at the knee and the long tendo Achilles, or heel tendon, running down some six inches to its insertion on the os calsis. You people must be lenient with us if we occasionally use our own favorite terms. Never have I heard a professional reference to a broken heel bone; it was always a fractured os calsis.
The tendo Achilles pulls the heel up, thereby causing the ankle to bend and the toe to go down. Feel it just above the heel, so that you may realize how heavy and powerful it is and how it gradually merges into the muscles at the bulge of the calf. How convenient for the grip of the mother of Achilles as she picked him up to dip him in the Styx.
E pluribus unum, which is engraved on our United States currency, is surely the motto of our muscles. I have told just above how the myriad cells of a muscle each adds its mite to form the might of a tendon. At least two muscles in the calf pull on the Achilles tendon; and the triceps on the back of the arm starts as three, merging into one. In fact, no one muscle ever works alone; always some others are either pulling with it or steadying it. Watch an athlete striving to win a hundred-yard dash. Every muscle in his body is cooperating, even to the muscles of expression in his face and even the muscles connected with the alimentary canal may take part.
As an illustration of the combined power of the soft muscle cells, I can tell you that they have been known to tear the great Achilles tendon in half. A fractured patella, or kneecap, is not uncommon and rarely does it result from a blow but from a spasmodic pull by the muscles on the front of the thigh. One of the last cases I handled was that of a delicate little woman of sixty-eight who missed her step from the curb to the street, and whose muscles gave such a jerk that she broke her kneecap.
These spindle-shaped muscles of the limbs are so designed that their bulk may be up out of the way, only slender tendons going to the hands and feet where trimness and unobstructed motion are desired. At the thighs, buttocks, and back, strength and disposition of weight close to the center of gravity are important and the muscles become more massive and ponderous at these parts. Also they are fused together so that it is difficult to say where one leaves off and another begins. But the nerve supply will tell the anatomist because as Dr. Herbert E. Walter so well expresses it: "A nerve once assigned to do duty with a muscle follows it through all its vicissitudes, just as a faithful dog, trotting behind its master, always serves to identify him, regardless of the different costumes or disguises which the master assumes."
A striking example of this fusion is the diaphragm, the great, flat, dome-shaped muscle which separates the abdomen from the chest cavity, and with which we do our best breathing, "belly breathing." The diaphragm originates in the neck; the phrenic nerve which controls it comes off from the spine not far from the skull and runs through the chest cavity. Some years ago it was customary to rest a tuberculous lung by temporarily paralyzing the diaphragm on that side. This was done by making a little incision in the neck just above the collarbone, picking up the nerve and crushing it. Later the injured nerve fibers would grow again and the diaphragm would become active.
Muscles under normal conditions always have some tonus. This means that they are never completely flabby but are kept on a slight amount of tension. Therefore they are always guarding and exerting some control over that part of the body they govern and are on the qui vive to move it if necessary. This tonus is bad, however, if exaggerated. A continuous tightening of the muscles is very exhausting. Athletes in the best of trim can make their muscles hard as iron, they also have more than average ability to relax them. Muscles at their highest efficiency also have to be handled with the greatest care. My poor arm now can throw a ball as well on the first try as on the tenth or twentieth; none of them good. A big league pitcher starts with a very short throw and takes fifteen minutes to warm up.
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HEALTHY BONES

7Feb/110

LEARNING MORE ABOUT OUR BONES

In the first stages of a baby's development there is no bone. In its place is cartilage, or gristle. The bone begins to form in the cartilage at growth centers according to a definite scheme. Long bones, as for instance the thigh bone and the shinbone (femur and tibia), consist at this stage of the shaft which is called the diaphysis and a growing center at each end called an epiphysis. These epiphyses grow so much on schedule that the age of a child may be pretty accurately determined by X-ray.
Yet bone does not grow simply by adding on. It is continuously being reconstructed. Cells called osteoclasts tear down bone and osteoblasts rebuild it with new. As one grows old and uses the bones less, the osteoclasts are apt to get the upper hand. This is best shown in the old man's chin after the loss of his teeth when much of the bone of the jaw is absorbed, causing an upward curve.
There are channels for blood and much soft tissue in the hard bone which is mostly calcium, as is an oyster shell. If you burn a bone, its shape remains but it becomes brittle like an egg shell. If you immerse it in acid, the calcium and other minerals disappear and it is now much like a puppy's rubber bone.
The finished product is an excellent piece of architecture and engineering. One practically never sees an absolutely straight bone.  It is curved to fit its function.   It is enlarged where a bearing surface is needed, or rounded to fit into another bone at a joint. It has ridges, knobs, and rough places for the attachment of ligaments and tendons. It is dense where strength is needed and spongy where weight must be saved. To the knowing eye an old bone is a wonderful object.
One skilled in osteology can tell a female skeleton from a male. The female is usually smaller and the bones are lighter. The bony thorax, or chest, is narrower. The shoulders are narrow and the hips broad. This latter feature is so because the one chief function of the sex is to bear the future members of the race, and the broad pelvis makes room for the child. Before the days of frequent Caesarian section we said that the angle of the pelvic bones in front was widened in the female as all humanity had to pass under the arch. Incidentally, the broad hips result in the thigh bones being well apart at the top and coming together below. Hence all women are knock-kneed. It was said of a drama critic that he knocked everything in the show except the chorus girls' knees and God had anticipated him there.
He, who would take care of broken bones, should have knowledge of anatomy, physiology, and likewise mechanical engineering, not to mention old-fashioned plumbing. Nature heals here much as a plumber of the last century "wiped a joint" in a lead pipe.   With the two ends of bone together, "callus" or new bone is spread around the juncture as molten lead was allowed to cool around the pipe. If the ends touch each other firmly and evenly, the less callus is necessary and the quicker the union occurs. When the extra callus is later absorbed, a perfect union may result and no trace of the injury remains.
But physiology takes precedence over plumbing here. If the ends are displaced to the side so that they barely meet, nature is still able to hold them together with callus and later smooth off the corners. Right here the surgeon must not forget mechanical engineering. The bones are so designed that the muscles and tendons pull in just the right lines of force. If the ends meet squarely but are much angulated at the site of fracture, then the muscles have to pull in the wrong direction and do not work well, thus disabling the victim.
Possibly the most striking example occurs with a Colles fracture, which is a break in the radius, one of the two bones of the forearm, just above the wrist joint. If the lower fragment is left tipping backwards only ten degrees, the result may be a poor wrist thereafter.
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HEALTHY BONES

7Feb/110

BONES AND MUSCLES

Dried bones are usually studied first by the beginner in anatomy for they are relatively pleasant things to handle and easily preserved. A classmate of mine at the Harvard Medical School, now a distinguished scientist devoting his life to the wetness in the body, owned a skeleton which, to the horror of his chambermaid, dangled over his pillow. No other parts of the dead body could be lived with so familiarly.
It might well be thought that mankind, at the very beginning of historic times, would have learned the anatomy of human bones, for the battlefields about "the cradle of civilization" were sprinkled with them and charnel houses furnished an inexhaustible supply. Really to study them, however, requires a knowledge of musculature, and human dissections were generally forbidden.   Besides, for over a thousand years after Christ, the words of Galen on medical and associated matters were accepted practically without question, and Galen, like all men, was fallible. Then, with the revival of other learnings in the Renaissance, came a number of brilliant anatomists, and outstanding was Andreas Vesalius, born in Brussels in 1514. He lived to be fifty, but his anatomical work was pretty well finished in his early thirties. Henry Gray, whose book to English-speaking people is practically synonymous with anatomy, died in his early thirties. Do we really need that extension of life which we are now getting?
Vesalius moved about a good deal but his most famous work was done at the Medical School of Padua which was then several centuries old and is still going strong. The illustrations are such excellent works of art that they have been attributed at times to Michelangelo and Titian. The skeletons as Vesalius shows them remind us that no matter how lifeless bone may appear it is living growing tissue in the body. Add to this that throughout life it is busily engaged in making other tissue. The blood cells are formed in the marrow of bones. When certain blood diseases are suspected, we cut a little disk out of the easily accessible breastbone and under the microscope examine the marrow to see how the cells are forming.
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HEALTHY BONES

7Feb/110

ARE YOU AT RISK FOR OSTEOPOROSIS?

Probably -if your mother had it, if you began menopause early (at age 42 or so), or if you are small-boned and sedentary. Hormone supplements should help you.
Dr. Daniel Mishell, head of obstetrics and gynecology at the University of Southern California, says that nearly all postmenopausal women need supplemental estrogen for protection against osteoporosis. He cites 300,000 hip fractures yearly in these women at a health care cost of $6 billion, adding that 10 percent of the patients die within 6 months.
What about cancer and heart attacks? When it was found that patients receiving ERT developed cancer of the endometrium, the lining of the uterus, doctors added the hormone progesterone to reduce that risk. Progestin, the prescribed form of progesterone, seemed to reduce that cancer risk. Some scientists speculated that, when combined with estrogen, progestin also could reduce the threat of cancers of the breast and ovaries, which are estrogen-dependent. There is no proof that progestin actually can prevent cancer.
Estrogen is said to help the heart by raising the body's levels of "good" HDL cholesterol and preventing the "bad" LDL cholesterol from clogging arteries. But evidence indicates that, in some doses, progestin can increase cholesterol -a point to consider if cholesterol is a problem for you or threatens to become one.
You and your doctor must weigh the pluses and minuses for you.
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HEALTHY BONES