Clinical Professor of Otology, Laryngology and Rhinology, Indiana University School of Medicine. Second edition revised. Octavo of 598 pages, with 305 original illustrations, many in colors. Philadelphia and London: W. B. Saunders Company, 1911. Cloth, $5.50; Half Morocco, $7.00 net.

Among the changes in this volume, the following are cited in the author's preface:

1. The chapter on the examination of the function of the ear has been entirely

rewritten, and includes the description and formula of a uniform system of tests. 2. A more extended statement regarding operative injury to the facial nerve. 3. A description of the "Conservative" Radical Mastoid Operation, commonly called the Heath Operation. 4. Several paragraphs relating to the symptoms, pathology and surgical treatment of Labyrinth Suppuration.

Anatomy of the Temporal Bone; Physiology and Bacteriology of the Ear; The Causation of Ear Diseases; Diseases of the External Ear; Examination Methods: Middle Ear Diseases: The Mastoid and Operations Upon It; Chronic Diseases of the Ear and Mastoid, and Intra Cranial Complications are the chief chapter headings.

Special comment should be made on the excellent illustrations which are shown throughout the book. Some of them are colored, especially those showing special dissections in operations.

The method and style of the author's writing is commendable.

Modern Diagnosis and Treatment of Diseases of Children.

By Herman B. Sheffield, M. D., Instructor in Diseases of Children at the N. Y. Post-Graduate Medical School and Hospital; Visiting Physician (Diseases of Children) Yorkville Dispensary and Hospital for Women and Children, etc. 150 original halftone photoengravings. Philadelphia: F. A. Davis Co., publishers. 1911. Price, $4.50 net.

This volume is a clinical treatise on the Medical and Surgical Diseases of Infancy and Childhood, both for the student and general practitioner.

A special feature of the book is the carefully selected illustrations from photographs of actual diseased conditions from cases occurring in the author's practice. It seems, however, that the prefatory announcement that all of the illustrations save those properly credited to other were original would have done cally crediting himself with them. away with the necessity for parentheti

The chapter on Nutrition is a very practical one. It is to be regretted that no mention is made in the section on milk of the work of the Medical Milk Commission in the production of Certified Milk for infant feeding. A cut showing colostrum could well have been given with the other illustrations of the microscopic appearance of milk.

Mention should be specially made of the opening chapter on Examination of the Patient, the information here being splendidly condensed and simplified.

The section on Hypertrophy of the Tonsils is dismissed in one page, and no mention is made of the more radical and complete operation of tonsillectomy, which we consider a great oversight.

Appendicitis is considered a surgical disease; "every case of appendicitis. should sooner or later be operated upon."

The resume of the treatment of gastroenterocolitis is very complete and up-todate.

One is struck by the one lone negro photograph, with characteristic rachitic. deformity of the tibal head, epiphyses and flat feet, illustrating the section on syphilis.

The book is an excellent practical one, and will fill a need of the profession.

What two letters aptly describe the condition of the man who is taken in by sharpers? E. Z.

VOLUME 18

Original Contributions

SACRO-ILIAC STRAIN-WITH REPORT OF A CASE OF SCIATICA

BY JNO, J. MOREN, M. D.,

LOUISVILLE, KY.

Back-ache and pain, referred to and from the pelvic girdle, is of sufficient frequency and importance for us to consider any plausible etiological factor that might help to give these individuals relief.

I ask your attention to-night to a subject which has received quite a good deal of well-deserved attention. I refer to strain and luxation of the sacro-iliac joint. To Goldthwaite, of Boston, is due the credit of first calling attention to such conditions as factors in producing pain in the back, and a good percentage of the cases of persistent sciatica.

It is well recognized that tuberculosis, arthritis, and malignant disease may attack the pelvic articulation, but practically little has been said about strain. The pelvic girdle in men is very important. and a moment's reflection will show that stability depends upon the sacro-iliac articulation. It is held by muscles and ligaments, as are other joints, and it is likewise subject to strain. Should this articulation become weakened or affected, posture and motion will suffer.

The first question that might be asked:

*Read before the Medico-Chirurgical Society.

NUMBER 3

Is the sacro-iliac a true joint and capable of motion? There is some difference of opinion among anatomists as to whether this joint is a true joint and, therefore, capable of motion. Gray says it is partly lined with synovial membrane, and subject to limited motion. Morris says there is no appreciable yielding at the articulation. Goldthwaite claims the pelvic articulations to be true joints, and, in health, motion is a definite part of their normal function. He regards the sacro-iliac as the most important, as the symphisis cannot move without motion at the synchondrosis. The motion of the symphisis is an up-and-down play and can be separated; that of the sacro-iliac is a backward and forward movement of the sacrum along the line of the transverse axis about the middle of the sacrum.

The obstetrician has long recognized the relaxation and motion of these articulations, and the Walcher position recently advocated is a position to gain the full advantage of the forward and backward

movement of the sacrum.

In the study of these conditions, Goldthwaite recognizes three conditions: (1) simple strain; (2) loose joint, with possibly strained ligaments, without displacement; (3) displacement.

Under the etiological factors, he recognizes three groups: (1) that dependent. upon relaxation during pregnancy; (2) menstruation; (3) those due to trauma and general weakness, or lack of tone.

Swett gives the causes under two heads: (1) constitutional: (2) local, or traumatic.

"Under constitutional causes may be mentioned: (1) pregnancy, wherein protuberance of the abdomen and the dragging forward of the lumbar spine causes a strain upon the sacro-iliac ligaments; the congestion of all the surrounding pelvic tissues present at this period, also tends to relax the ligaments.

"(2) During parturition the ligaments are always stretched, and the condition may become chronic.

"(3) Menstruation. Here, as in pregnancy, though to a less degree, the physiological congestion tends to increase relaxation.

"(4) General lack of tone. Here it is not always easy to decide which is cause and which is effect. In this class of cases the weak foot is almost a constant accompaniment of the sacro-iliac relaxation, and such cases occur in weak, anemic, overworked, neurasthenic type of women.

"Local or traumatic: acute and chronic. "Acute causes: (1) Direct blows to the sacral region; (2) any sudden exertion which brings a strain upon the joint, and is then spoken of as a 'crick;' (3) straining the back in lifting; (4) prolonged recumbency under ether, where the lumbar curve is obliterated, straining the ligaments by the dragging downward of the lumbar spine.

"The chronic causative factors are: (1) Faulty balance, caused by straight front corsets, with tight garters and highheeled shoes-these incorrect positions in weight bearing are bound to cause a prolonged strain; (2) pendulous abdomen, from various causes, which involves a dragging forward of the lumbar spine and tilting backward of the sacrum; (3) any form of prolonged occupation requir

ing much lifting, stooping and standing in a strained attitude."

The physiological relaxation during pregnancy and menstruation needs no discussion. Any general atonic condition, resulting from actual physical weakness, can be readily appreciated as a factor, especially when undue strain is brought to bear upon any joint. It is the third class, composed of local and traumatic causes which furnish the most interesting study. The most prominent difference between this class and those due to pregnancy, etc., is that, usually, only one side is affected. The onset is sudden, following a "stitch" in the back from heavy lifting, etc. The case which I report later followed stepping into a buggy which was much higher than the one which the patient was accustomed to. I saw a lady, between sixty and seventy years of age, who lifted a heavy mattress, and immediately her back hurt, and later she suffered symptoms resembling sciatica on the left side.

A farmer hurt his back while lifting at a log-rolling. He now has back-ache over both sacral joints, and is unable to do any work without a belt, about three inches wide, buckled tightly around the pelvis.

A carpenter was raising a plank to the second floor, by means of a rope. He held his position by bending his back and lifting the plank by arm motion, while his hips and legs were held rigid to support his position. He suffered a stitch in the sacral region, and afterwards had stiffening. lack of motion, took short steps, and could not lift one foot over a car rail. Back-ache was a prominent symptom.

These cases are, in my opinion, affections of the sacro-iliac articulation, and are often overlooked and treated for other conditions. Blows, accidents, and

missteps, as in the dark, etc., can affect the joint. Strains from lifting are common. Doubtless many of you have observed men who do heavy work wear their belts around the pelvis. By this means they support the pelvic articulation.

A point that the surgeon should note is the back-ache following anesthesia. The relaxation and straight table permits. the lumbar curve to disappear, and, if the position be continued for some time, marked strain may result. The relief obtained from a small pillow is explained. by restoring the curve and thereby removing the strain.

The result of these strains may be only a sudden "crick in the back," which disappears on resuming the erect position, and no further ill effects are noted. In some cases the back-ache continues. Should the force be great, a dislocation may result, the most common being a backward displacement of the upper portion of the sacrum, which does away with the normal lumbar curve and produces a "flat back." The ligaments may tear, producing a weak and painful condition. Arthritis may complicate either condition.

SYMPTOMS.

Many of these cases never suffer more than a slight back-ache, noted at certain times and under certain circumstances that demand extra strain upon the pelvic girdle, as going up-stairs, etc. Others suffer from slight stiffness and inconvenience, though able to attend to their business.

Only recently a young married woman consulted me for back-ache. The pain is on the left side, and came on about two weeks after a fall on a skating rink, two years ago. The pain would bother her only at times, and was noted most often

early in the morning. It was worse after lying down. She had an attack of tonsillitis which confined her to bed, and she suffered more from the back-ache than from the tonsillitis. The pain is felt most. over the recti muscle, with a tender spot over the left sacro-iliac joint. When she first starts to walk there is a slight limp, and the left leg feels heavy to lift or move. She cannot raise the left leg with the ease that she can the right. The right hip is more prominent than the left. She apparently has free movement forward and to the right and left sides. For the past few months she has suffered quite a good deal, awaking early with pain which is not relieved until she lies upon her fist under the small of her back. During the day she has but little pain. unless her duties are particularly tiresome. She is distinctly chlorotic; the blood shows only 75 per cent. hemoglobin.

The most prominent symptom is that of pain, usually located over the joint. However, it may be confined to the lumbar and sacral regions, with distinct tenderness over the joint. The patient locates this tenderness. If there be a dislocation or luxation, the sacral plexus, which passes in front of the articulation, may become irritated to the point of producing sciatica, or muscular spasms or contractions.

Howard Kelly, in a recent article on abdominal pain, says: "There is one source of pain, and an important one, which it behooves the surgeon always to be looking for, and that is that one due to loose sacro-iliac joint, first discovered, investigated, and heralded by Joel E. Goldthwaite, of Boston. This pain is apt to be associated with more or less severe back-ache, generally on one side, over the sacro-iliac joint. It sometimes extends through to the front of the joint,

One feature characteristic of these conditions is the frequency of back-ache (sacral) after lying down, and is often noted in invalids confined to bed. In some cases the strain may fall upon the second lumbar vertebra instead of the sacro-iliac joint, and the pain will be located at that point.

There is always more or less disturbance in the posture of the individual. While standing the trunk is inclined away from the affected side, resembling a man walking and carrying a heavy weight. In arising from a chair, the spine is more or less rigid, and he uses his arms in assuming an erect posture. He cannot take long steps, and, if both joints are involved, the gait is more or less waddling, depending upon the knee action. Limitation of motion varies with the severity; however, more or less is noted in each case, being more pronounced standing than sitting. When the ham-strings are relaxed, as in sitting, forward flexion is much better. In disease of the vertebra, this would not occur. Lateral movement is affected, and, in unilateral affections, the motion is limited on the affected side. In marked unilat eral affections there may be some swelling, causing the affected side to appear larger. Often there is slight spinal curvature from position. The time-honored test for sciatica, by means of flexing the extended leg upon the abdomen, causes pain, as the ham-string muscles are attached to the ileum.

Goldthwaite claims that abnormal mobility can be detected by grasping the crest of the ileum in the fingers and placing the thumbs upon the sacrum, when the sacrum can be induced to move. Another method which he uses is to place the hand firmly over the sacrum, grasp

and asking the patient, while standing, to flex the thigh upon the abdomen.

Kelly says that a loose joint can be demonstrated by shortening of the affected leg, by rotating and flexing it strongly, or by pulling it outwards.

Sometimes by rectal examination distinct tenderness can be noted over the joint; in fact, I have seen patients relieved by pressure upon the coccyx.

In distinguishing between arthritis, inflammatory conditions of the joint, and simple loosening of the joint, holding the pelvis firmly by a belt, or other support. will relieve the distress, while in inflammatory conditions it would be increased.

In recognizing these conditions, we must take into consideration the previous history of the individual, either of having received an injury, lifting heavy weights, etc., or of having been confined to bed, which would throw strain upon the pelvic articulations, or back-ache following operations, with the pain localized over the sacro-iliac joint, worse while lying down; possibly pain radiating down the sciatic nerve, or cramps or spasms about the muscles supplied by the lumbar and sacral plexes, temporarily relieved by pressure or support to the pelvic girdle, would be sufficient reason to suspect strain or luxation of these parts, or dislocation of the sacro-iliac joint.

The following case came under my personal observation, and led me to the study of this condition as a possible cause of sciatica.

The first case which I report began to suffer with severe sciatica. Ordinary measures were of no avail. In obtaining the history of this patient. I learned that the pain had started originally with a pain in the sacrum, shortly after buying a new buggy which required a much much higher step