The author employs a method which consists in splitting open the cervix by bilateral incisions and excision of a wedge shaped piece of tissue from either side. In case of necessity this excision can be carried through around the whole circumference of the cervical canal. The incision wounds are afterwards closed by sutures. In 47 cases collected in the last seven years the result was in all but one case absolutely perfect, and up to date no relapse has been observed. The last mentioned case became infected in some way or other so that inflammatory and edematous conditions of the concerned parts still prevail thus causing, up to this time, absolute failure, so far as relief of the dysmenorrhea is concerned. In three of the operated cases, pregnancy and easy confinement followed the operation after two, five and six years' matrimonial sterility respectively. The author wants the operation employed only in properly selected cases of mechanical dysmenorrhea when all the other bloodless methods have been tried and failed. The hymen should only be destroyed by the surgeon after the patient has been fully made to understand the importance of this step.

92 STATE STREET.

BY DR. GEORGE RUBIN, CHICAGO.

In the preface to Doctor Stapfer's book entitled "A Treatise on Gynecologic Kinesitherapy," Professor Pinard says: "The act of operating which I admit is so often followed by success, seems to dominate and throw in the back-ground, or is at least considered as accessory, that which constitutes the most essential part of our art, viz.: The exact determination of indications" (Pozzi). He also says: "The act of opening the abdomen to see what is in it will always be considered as an act and confession of incompetence, and our efforts shall be to render this act as rare as possible." He further says: "The act of removing organs which could have been conserved and cured will always be considered as an act of mutilation. I must admit that these operations are often successful, and sometimes of therapeutic value, but this is a success of an inferior order if something less and better can be done." There is no doubt that the entire medical world will agree with this eminent teacher, the illustrious pupil of Tarnier.

I know personally of a score of cases where mutilating operations have been performed without justifiable indications. The operations were mere explorations. They were performed merely because the patient complained of pain in the abdomen or pelvis and the surgeons or gynecologists, being sure of the harmlessness of modern operating, undertook to relieve their patients of their pains. Among these series of tentative operations which came under my observation, two terminated fatally. One case in which the surgeon intended to break up adhesions of the bowels due to a former öophorectomy, where there were no particularly serious symptoms, and the patient died on the third day of a most virulent peritonitis. Another case of a young woman who had been married about a year, had some pelvic pains in which the surgeon (a lady) suspected a diseased ovary operated on her, removing a slightly enlarged ovary and healthy appendix, the latter as a prophylactic treatment. The patient died six hours after the operation-it was thought from internal hemorrhage. Another case in which the surgeon expecting to find something in the pelvis that would justify its removal was completely fooled, and in order to soothe his conscience-which I believe he had, because he left both ovaries intact-he stitched up one of the internal inguinal rings to prevent hernia. This patient, fortunately, made an Chicago Medical Society, Nov. 5, 1902.

uneventful recovery and she really thought that the operation had done her some good.

Another case of a young woman, married, nullipara, who had been subject to hysterical "fits" was operated on by a surgeon who thought he could trace those hysterical manifestations to a slightly enlarged ovary, which he said was the source of her trouble. The ovary was duly removed but with the exception of a couple of microscopical cysts the organ was entirely innocent. The patient still had her "fits" when she left the hospital, about ten days after the operation. I have also witnessed a number of hysterectomies, mostly vaginal, in which the uteri were apparently little, or not at all pathologic. None of those who witnessed the above operations ever dared to question the indications for the operation because of the recognized (?) authority of the operators. I am positive that "something less and better" could have been done in those and many other cases.

We have had a number of patients at the dispensary of the Brainard Policlinic who were advised to submit to operations, but who refused to be operated upon, were treated in our clinic by massage and gymnastics, with the occasional administration of some drug. Nearly all of them improved in spite of their skepticism in the beginning, on account of the simplicity of the method.

INDICATIONS AND CONTRAINDICATIONS OF GYNECOLOGIC MASSAGE AND GYMNASTICS. (BRANDT'S METHOD).

It is indicated-1st. As a means of diagnosis. 2nd. As a means of treatment. In the first, massage alone is necessary, but in the second massage and gymnastics, or gymnastics alone, ought to be employed. For its usefulness as a means of diagnosis Doctor Stapfer says: "Outside of some rare cases" (I take exception to the word rare) "where the diagnosis is made from the beginning and where the occurrence of grave accidents renders urgent intervention necessary, treatment ought never to be advised, and above all an operation, without having first cleared up the situation by massage. It constitutes, in spite of its slowness, the best means in diagnosing certain conditions of the genital organs because it takes the place of chloroform by suppressing abdominal contractions for its involuntary defense; besides it possesses the quality of dissipating edemas, inflammatory infiltrations, and dissolves soft adhesions which agglutinate the organs and render them unrecognizable.”

Massage should not be administered in acute inflammatory con

ditions; in such cases we all know that rest in essential; but in subacute or chronic inflammations it often produces astonishingly good results. Massage is contraindicated in carcinoma, sarcoma, tuberculosis, abscess and cysts of the genital organs. In nonmalignant neoplasms it does no harm but ought not to be employed, although Doctor Bloch, one of Doctor Stapfer's assistants, told me that he made fibromata disappear in a case by massage, but that lacks authenticity since no histologic examination had been made, and it might not have been a neoplasm at all.

In most instances where massage is contraindicated and radical treatment is refused, gymnastics alone will be beneficial as a palliative by diverting the circulation from the affected parts and by tending to improve the general system.

Among the disorders where gynecologic kinesitherapy does the most good, are displacements of the uterus. It stimulates the muscle fibers of the stretched ligaments to contraction and improves the nutrition of the entire suspensary apparatus of the uterus. It works admirably well in flexions-which are usually due to atony of the uterine musculature by improving the circulation and toning up the muscle fibers.

Constipation responds more or less promptly to this method of treatment, and that alone is worth something, since all gynecologic cases, or, as Professor Fenger once said, "All women are constipated."

Mr. Hugo Ad. Oldenborg (Masseur) told me of an interesting case in which he had produced a diarrhea in a man after a single sitting of abdominal massage. The diarrhea stopped after a few hours, to reappear after another sitting of abdominal massage, but ceased altogether when the massage was discontinued.

TECHNIQUE.

The technique in gynecologic kinesitherapy is very simple. No especially devised instruments or apparatus are necessary. All you need is a bench, a stool and two hands. The bench ought to be about five or six feet long, sixteen inches high and about twentyfour inches wide. It is better to have it slightly padded and with a headrest. The stool ought to be of the same height as the bench.

The massage is usually preceded and followed by certain gymnastic movements. The movements to begin with are as follows:

Flexion and Extension of the Arms: The patient sits on the corner of the bench, head upright, spine in full extension and chest thrown forward. The knees are widely separated. The arms are

up and forward and the hands of the patient are held by the operator, palm to palm, his fingers around the patient's wrist and vice versa. The operator stands on the stool, one foot forward and facing the patient; the patient is now directed to flex her forearms on her arms and to carry her elbows outward as much as possible. Flexion and extension ought to be performed with slight resistance, in the former by the operator and in the latter by the patient. These movements are repeated four or five times. The flexion, of course, coincides with expiration and extension with inspiration. These movements and abduction of the thighs, of which we will speak later, are, according to Doctor Stapfer, the most important in gynecologic kinesitherapy, on account of their decongesting effect on the pelvic organs. It should, therefore, be omitted in the first two or three days of menstruation except in menorrhagia, in which cases it is highly beneficial.

Massage: This is executed bimanually, one or two fingers in the vagina (the French masseures use the index finger alone, while the Germans introduce two fingers) the pulp of the finger, or fingers, is lightly pressed against the cervix as near to the isthmus as possible. In displacements or flexion of the uterus it is well for the operator to try and correct the position first and steady the womb. in that position by the left hand. Where there are no adhesions this is easily accomplished, and in the other cases it ought to be brought as near the normal position as possible. The right hand is placed on the abdomen and after obtaining a complete relaxation of the abdominal wall, the massage is commenced and may be performed by circular friction, stroking or vibrations-I prefer the first. Pressure should be avoided. The affected organs should not be massaged directly, but around them. Direct massage is indicated in subinvolution or in flaccidity of the uterine musculature itself; in nearly all other conditions the indirect massage should be given. This treatment should last from two to four minutes only and should be done with an exceedingly delicate touch. The position of the patient should be the same as for an abdominal exploration, with the thighs flexed and separated so as to permit a maximum amount of relaxation of the abdominal wall. The pelvis should be somewhat raised, which is easily accomplished by having the patient place her fists under the seat. The operator is seated on the stool to the left of the patient, leaning forward and resting his left elbow on his left knee, thus giving him more freedom to manipulate the cervix with his fingers.

The last part of this treatment, and not the least, is the abduc