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told that she ahould cnll~ult nn orthopedic surgeon but that ~r nlany specialists should be under the control of a neurol­ogist whom she should $ee frequel1t1)· and persi:!ltently j referred to Dr. J. J. Putnam with con~nt of Dr. Chandler with written opinion to this effect; referred by Dr. Putnam to R. 'V. L. Examination by R. 'V. J.... showed that the patient stood with slight left lateral curve and in 1\ general "stumped" attitude. The lumbar region wa.ii flat, the dOTu1 region rounded and the pees were inclined to be held slightl)" flexed. She complained that she felt as if her back were lIot hollow enough j anel to 1ft relief she assumed a position with more lumbar curve in "bich the knees straightened. She showed marked tenderness over the left sacroiliac joint and felt Rome pain in the left leg. A radiognph showed that the sncroiliac joint:! were norniaL She was provided with properly fitled therapeutic corseh giving marked 8upport in the lumbar region and 'which were tight around the pelvis, and was started on exercises. She was Dot markedly improved by this treatment at the end of a month. Orthopedic trentment lun-ing failed to afford relief, Dr. Put­nam put the patient under general rcst-cure methods in a hos­pital. His observation there convincing him that the left-sided pain was genuine and persistent, and its catamenial exncerhn­tion pronounced, he requested another examination from E. R. Examination without anesthesin was again negative, but under anesthesia the presence of a slightly enlarged, hard, non·tender Jeft Fallopian tube was demonstrated, and a few days Jater the abdomen was opened. The Jeft tube proved to be strai~ht and patent, but with much thickened and indurated walls; the cor­responding ovary slightly enlarged, sclerotic, and containing a very Jarge number of sroaJl tense cysts scattered through it like a charge of birdshot. The left ovary and tube were removed, and abdomen closed. KormaJ convl\lp5cence. Patient declared that all abnormal sensations in left side had dj~ap· peared. On getting lip there \\'&$, however, some Jeft·sided sacroiliac backache, relieved by a therapeutic corset. Patient returned to Dr. Putnam's care. 'Vhen last heard from, one year after operation, she considered herself well.

In thi~ case the essential factor was at first missed and th~ ease considered orthopedic. After longer observation the detec· tion and cure of the abdominal lesion resulted in spontaneous relief of the apparently static symptoms.

CASE 4.-Patient of R. 'V. L., a health)" and well-developed young woman, a professionaJ teacher of gymnastics, at the end of a very hard )'ear developed severe sacraJ backache for which advice was Bought. She was-at the time wearing a small girdle. She was treated by corsets and one of Cook's back .pIiots. The pain disappeared immediateJy and an observation was made showing that the center of gravity had been mov.ed back 1lh inches. This change was so great that a second observation was taken a week later for purposes of verifh~l\tioll 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 conioiequent relief to the posterior musculature without further trel\tment.

CASt: 5.-Plltient of R. 'V. L., a married woman, 34 ~-enrs old, of ratl1('1" JCfoi!i than average p1ty~ique, had been fairly well until her confinement a year an.1 a half previous. Shortly after getting about she began to hllve pain in the back and in olle leg, and st,wding wa,:,J A.C'Compl\uied by great discomf?rt. She had lost ftt>5h nnd was ver;y nervous and apprehen81vP'. Examinl\tion indicated that the backache was apparently static. She had heen treated h)' o"teopathy without succ('s~. and 11lter the diatrnosis of a relaxed sacroiliac joint hRcl be~n made. For this nCplaster-oi-Pl\ris j'lcket had been app1i(>d nll(l Worn without any relief of the pain. "-hen she was seen "lw wore a steel lJack-brace and a neutral corset. An attempt wa!' made to throw the center of gmvit)' backward by means of a properly made corset rcinforcetl by 1\ light tempercll steel bM'k bracc to throw her b"h\nce bnck; thi,. gave immediate ('om fort, alld gentle exerci.se8 were bt!gllll. ]n three wCt'ks !ollie wa~ pradically free from p.tin, had I!ailll'li ill flesh nlll1 \n\S improving as to her nen/olls infoltabilil.y. In this ('ase of evident back-stndn tll(' w,e of the onlinary npplialll,:l's to !<plint the lnlck did tlot give relit:!, which W,lfol obtnincl1 lJy ch:\Ilgiu¥ the body lJalance by corsets.

It becomes evident from the most caHI1,1 consideration that in this class of cases there exist two elements, the gynecologic and the orthopedic, and an analysis of the probable primary cam;e of the p,in, therefore, becomes nece~sarJ. That forward displacement of the center of gravity induces increased effort of the posterior musculaturc (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 les::; a matter of common informa­tion, but Illa)' be supported by quotation of certain well­known analogous instances. If the arm is held out hori­zontally, after two or three minutes the muscular effort is translated into an ache. The spROm and irritability of the ciliary lIluscle 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. 'l'hat. back-strain sufficiently long continued, induced by an unduly forward position of the center of gIRdty may be translated into backachc seems evidcnt. The unduly forward position of the center of gravity which induces backache we believe to be usna])v caused bv one of three factors: '-

1. Peculiarities in the form and proportions of the skeleton (not neees •• rily outside of normal limits) resulting in a type of figure with a center of gravity markedly far forward.
2. General muscular relaXAtion leading to a "slumped," relaxed attitude.
3. Tenderness of intra-abdominal or intrapeiric organs inducing the patient to aS~llllle a Stoopillg or other s!rained position to relieve intra·abdominal or mtrape1ric pressure.

The gynecologic cases de8cribed above belong in the latter class and, though it is eddent that the field of intra-abdominal or other vis<:el·"l 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 cl",s 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 fascire) placed th<re to regulate extremes of motion. '\'jthout denying the occa­sional existence pf 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 ucrangement of the E:lcro-iliac joints without invoking the po,.ib1e existence of an abnormal Jllr)r,ility to explain it further.^[1]

Our obserrations would be of little value to ourselves or to others were 'we not preparef1 to formulate cr::-t,lin

1. ↑ 9