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conclusions governing the treatment of these cases. It is evirlent that a determination whether the original cause of the hack ache 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 eases wonld seem to fall schematically into thrce c1a"es: The gyneCQlogic, of intrapelvic origin.

The orthopedic, of mechanical or static origin. The borderland cases 'in which both elements are pr""ent, or in which the differentiation hetween the two is at first impossible. The recognition of a borderland class is necessary on account of the frequency oI it, appearance in clinical work, but thc line between this and the other c1.sses is so indefinite that it can be described only by implication under the other headings.

Static backache is frequently a promineut symptom oI the intrapelvic ncoplasms. It is then due to an altera­tion of attitude caused either by an instinctive effort to lessen pathologic pressure , ... ithin the pelvis, or by dis4 turhance of balance fTom the actual weight of the laTger growth.. In the'e cases no improvcment in the static condition can be expected until after the removal of the nE'oplaRm, and here an immediate opel'atiye removal should be promptly followed by propcr orthopedic tTeat­ment if necessaTY.

On the other hand, many of the pto,es are merely secondary results of static abncnnalitie,. In these cuscs especially, gynecologi,ts should be careful not to adopt treatment without first making a stuely of the static causes which so often haye produced, or are perpetuating them, since some previously nmnanageable retroverted uteri, prolapse-d oVHl'ies, etc., call be promptly relieved by minor intrapelvic treatment after the static fault, which caused them have been correct,,1. Ptoses of the kidneys and other upper abdominal v;"cera are equally important and shonld be considered. Under these con­ditions, also, those cases which still demand major meas­urcs will more surely become symptomatic as well as anatomic snccesses, nnd many anatomic failures will be ""aided. • In the inflammatory "ffcdion. of the peh-ic organ, the instincti'-e efforts of the patient to protect the tenelcr ~trndnl'es from the pres~t1re~ and jars which are alw:lYS incirlent to locomotion in the crect posture, lead usually' to so persistent a maintenance of a constrained attitude that the prominence or :::tatic bac-k~chc in these cases is easily understood in thc light of "'hat has becn said in onr experimental section, Thc relative value of static 01' intrapelvic treatmcnt 8:::: an initial step in the management of these caBCS depend, largely on the sta)!e of acutene,,' at the time at which treatment is undcrtakcn. Jt is )!enerally conceded that during toc preseuce of an acutc symptomatology thc infhtOlmatory affections of the peh-ie organs should have dcplcti"c "nd soothing rathcr than radical treatment. In the more "cute cascs the musclcs of the back arc almost invariably in a ~tate of irritation anLl Sp.1Sffi, and no part of the initial palliatory trcatment is more impor­tant or more promptly grateful to the patient than rcst in bed, support to thc il'l'itated muscles, hot packs, the loca) electric light bath, ctc., for thcir relief. On the othcr hanel, even ill thc chronic cases too earlv attempts at mechanical correction of the faulty posture· are apt to do harm rather than good so long as the pel"ic tender­nr.~::,cs arc unrclicrcu, since if successful they agnin expose the tender organs to the prc,sures from which the faulty attitnde has partially relicved them. The complication of ptoses with inflammatory condi_ tions demands evidently thc weighing of rel.lti\'c indica. tions in the individual case. It is manifestlv impossible to cover within the lenath of snch a paper as this, evcn in outline, the wholc fi~ld 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 bcen here said may serve to illustrate the principles involvcd. The gynecologist may, of conrse, Teadily examine the backs of bis paticnts and may with practice acqnire Some facility in the differential diagnosis of back-strains into thosc of primarily intra-abdominal OT primarily static origin, bnt he should never forget that in the static ca;e, 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 reqnire special knowledge.

Throughout the field of gynecologic practicc thc csti. mation of static conditions is of importance whcn","er backache is a symptom.

The orthopedic surgeon will be wise to rcfer to the gynecologist for a preliminary examination uud opinion by which to gnide treatment, thosc ca,cs in ",hieh the hi~tory, 01' the replies to the usuill questions, are suggc54 tive of utcrine disease. This is especially important when the symptoms snggest the possib.le presencc of inflammatory di~ea3e of the intrapclric organs. , .• incc in these cases, as has been ~aicl aboyC'. altcHltioo of attitmlc, sneh as would hc indicatcd by thc bark·,hain aionc, mav be distinctly harmful.

The accepted orthopedic trcatment of back-strain a.' 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. Thc treatment which from onr point of "iew should. be in theory the most satisfactory, and which in practice in our hands has proved the most successfnl, is as follOws:

A defect of balance cxists which in the cnd must be curcd by remedying that defect of balance, a matter only to be brought about by substituting a corrcet for an inrorrect attitude. :Massage and gYll"mflstic cxcr('i~(,3 to induce this correct attitUllc would seem to be the ob\'ions method to follow. But practically this alonc at the out­~et is gcncrnll.,- unsatisfadory for the following rra~nn5: Onc is dealin~ in most instances not with ath-letcs wit1, wcn-developccl muscles,. but with men, or more ofbn women of les.3 than average physique as a wholc~ \\"ho~c back muscles in particular are overstrained, weak and irritatcd. These patients are recumbcnt not ol'cr tCll oot of thc twenty-foUl' hours "s a rule, and for thc rc,t of the time arc generally sitting, ~tanding~ 01' walking. To begin by gymnastics on mu~cular (l(:\'cloplllcnt lIIHIrl' thcse conditions is to exerti,e still furtber IOI' pcl'i"'Jl' Iwlf an houl' rlail)', muscles alrcady ovcruscd, am) for the remaining fourteen }lOurs of the twenty·folll' the irrita­tion induced by the malposition goes on, fol' a correct po~'ition cannot at once he suhstifnted for nn illcol'rr.rt position. It is a frequent experiencc to find thc backache made immediately wor~c by such treatment, eren when gil'cn by skilled pcrson,. It is as if thc oculist OJ'(lcrcr1 1Ji~ patients suffering from eyc-stmin due to flfo!tiglllati~lJl to usc the eye, a little more each day to strengthen thcrn heforc he correct cd the "isual errol'. The bc,t resolts in back·strain are to be obtained, not by attcmpting to