March 26, 1910
the toes or heels. Without this precaution the mechanical distortion due to the oblique position of the foot in high-heeled shoes would lead to evident error.
THE EFFECT ON BALANCE OF HIGH-HEELED SHOES AND CORSETS COMBINED
Our observations on the combined effect of high-heeled shoes and corsets opened up a very complicated question that we have not yet been able to solve satisfactorily, although it is a more important question clinically than the others, because the combination of high-heeled shoes and corsets is what one meets clinically. In all of our experiments, moreover, we found that models in corsets, and most markedly in bad corsets, were much more comfortable standing in high-heeled shoes than without them—a fact confirmed by clinical experience. In our work on this point each observation was taken of the model without shoes or corsets, then with corsets of one of the various types, and then with both the corsets and shoes. The three tracings were then overlaid for study. The mechanical complications involved were so many that at present we are not prepared to make a more definite statement than that the use of high-heeled shoes seems to modify, toward the individual's normal, the position induced by corsets and particularly the position induced by bad corsets, already described. Figure 10 shows a record of this combination.
Finally, in this connection, we would protest against the indiscriminate advice so generally given to patients with backache to avoid high-heeled shoes. In many instances coming under our observation, such a change has been followed by most uncomfortable results.
DEDUCTIONS FROM OBSERVATIONS
Our conclusions from the experimental part of our paper are: that the center of gravity can be determined in the living erect individual; that this center of gravity is so located in relation to the supporting structures that the erect position is maintained by the tonicity of the posterior musculature; that forward displacement of the center of gravity leads to increased demand on the posterior musculature to maintain the erect position.
In the position induced by what we have designated as the good corset, the strain on the posterior musculature is lessened by displacing the center of gravity backward, and more especially by the fact that the shoulders are moved back at least as far as are the hips.
Though the bad corset also displaces the center of gravity backward, the relief to the posterior musculature which would be expected from this is neutralized in the position which they induce, by the fact that the pelvis is moved much further backward than the shoulders, thus inducing an inclined position of the back in which the weight of the trunk, considered by itself, is thrown so far forward as to place undue strain on the posterior musculature of the lumbar and pelvic regions.
In the position induced by the wearing of high-heeled shoes, without any other modifying apparatus, the strain on the posterior musculature is relieved by motion of the center of gravity backward, through movement of the body backward as a whole, chiefly from the ankle-joint.
The study of two forms of modifying apparatus applied to the subject at the same time introduces so much complication of conditions that conclusions therefrom must be drawn up with great caution. When high-heeled shoes are observed in conjunction with either form of corset we conclude that the attitude characteristic of either form of corset is modified slightly toward the normal of the individual by the addition of high-heeled shoes, but the analysis of the effect so produced involves so complicated a mechanical study that we are not yet prepared to publish conclusions as to why this effect is produced.
II. CLINICAL SECTION
The clinical section of our paper is best introduced by the presentation of a few personal illustrative cases selected from many similar ones and reported in abstract for economy of space.
ILLUSTRATIVE CASES
CASE I.—Patient, single, 53 years old, was sent to E. R. by a prominent orthopedic surgeon for backache and sense of weight in the abdomen which in spite of evident static faults had been uncorrected by his treatment, and which he was acute enough to believe must be traceable to some pelvic condition. On examination it was evident that her forward posture was due to an unconscious attempt to lessen pressure on a fibroid which nearly filled the true pelvis, and that the orthopedic apparatus had been ineffective in correcting the attitude or in relieving symptoms because it had been applied in the face of the determining cause, the fibroid. The patient made a prompt convalescence from a hysterectomy, but on rising from bed was extremely discouraged to find that the backache, which had led her to seek treatment, was, if anything, worse than before; but when she returned to the orthopedic surgeon who had originally treated her he found that the same apparatus which had before been ineffective now gave prompt relief, and after a few months she was able to drop it gradually. When last heard from, some time afterward, she was entirely well without treatment.
In this case orthopedic treatment was unsuccessful till the primary cause was removed. Hysterectomy alone might ultimately have relieved the backache without orthopedic treatment. Backache was, however, immediately and permanently cured by orthopedic treatment following the operation.
CASE 2.—Patient of E. R., married, aged 35, had undergone three major operations and prolonged local treatment without relief at the hands of three very prominent gynecologists, the chief symptoms being renal pain and sacral backache. The operations were nephrorrhaphy, anatomic success, with therapeutic failure, and two suspensions, both of them anatomic and therapeutic failures. Prolonged trials of pessaries had been made by two of the gynecologists, always ineffective, and always increasing pain and backache. Evident static faults, too complicated for the gynecologist to treat, were present and the patient was referred to the orthopedic surgeon of her choice after she had positively declined to allow replacement of the uterus and the insertion of a pessary on the ground of her previous experience. After considerable orthopedic treatment she was relieved of all her symptoms except sacral backache, which continued distressing. She then allowed E. R. to insert a pessary, which for the first time in her history she wore not only without pain but with immediate relief of the backache, and after wearing it for several months became able to maintain a forward position of the uterus without the pessary. She is still under orthopedic treatment but is relieved of her symptoms. Orthopedic treatment should have preceded an operation.
The names of the other medical men connected with these cases are omitted for obvious reasons.
CASE 3.—Patient, sent to E. R. by Dr. Chandler of Medford in January, 1908, 40 years old, married; no children; dysmenorrhea always; dyspareunia always; indigestion with intestinal gas three years; frequent frontal headache; occasional not very severe neuralgia in left sacrosciatic region, along the distribution of the left sciatic nerve and over the inner surface of the left thigh, always increased by walking and standing, but almost constant before and during catamenia. Pains and aches in all portions of the body. Patient did not seem in very bad condition, but was very self-centered, running from one specialist to another. On examination pelvic organs were normal. Diagnosis, orthopedic disability. Patient was
