treatment that a satisfactory result will be obtained by means of mechano-therapy.

The gymnast occupies, properly, the same relation to the physician as the chemist. The doctor does not lose his patient when he sends him with a prescription to the chemist. It is the untrained, ignorant, pretentious and arrogant "gymnast" that tries to impose upon the public that with massage treatment he can, in a few hours, cure any sort of ailment mankind may be suffering from. This is the "quack" proper, and he is the cause of the discredit in which mechano-therapy and its representatives are held by so many physicians.

Of the therapeutic value of gymnastics and massage, when judiciously used, there is no doubt, but it is for the physician or surgeon to say when it should be applied. He will be guided by the condition of the patient, and the effect he desires to produce, in directing the employment of different modes of mechanical treatment. The gymnasts should always confine themselves to their gymnastic treatment, and leave to the physicians the diagnosis and the prescriptions. If it were so the prejudice now prevailing on the part of the latter would be removed, and mechanotherapy would gain for itself and its practitioners the confidence of the medical men and the position as a prominent part of medicine to which it is properly entitled.

The gymnastic and massage treatment acts essentially by increasing circulation and improving nutrition. It has been shown by Lander Brunton that more blood actually flows through the tissues during and after rubbing. The number of red corpuscles and, to some extent, their hæmoglobin value is also increased. At the same time the movement of the lymph stream is also accelerated. In order to assist the flow of blood and lymph, stroking is applied centripetally, that is, upward along the limbs and the lower part of the body, downward from the head.

The effects of the increased physiological activity set up are numerous. Functional ability and strength are restored to exhausted muscles by the removal of waste products and the induction of a fresh blood supply. Congestion is relieved; the renewal of the epithelium of the alimentary canal becomes more active and the smooth muscle fibers are stimulated, collections of serous fluid are dispersed,

secretion and excretion are increased, and the appetite is strikingly improved as are local and general nutrition. These effects indicate the conditions in which medical gymnastics or massage may be usefully applied. Such are most heart diseases, muscular wasting, chronic and subacute affection of the joints, sprains and contusions, dislocations, fractures, and in fact almost always after surgical operations, when the functional power has to be restored. In muscular rheumatism, sciatica, and other neuralgias, contractions, insomnia, and some forms of headache, in local congestions, inflammatory and other affections of the eye, mechano-therapeutic treatment is beneficial.

All nervous affections, such as tabes dorsalis, muscle atrophy, diseases of the spinal cord, various forms of paralysis, professional neuros es, tonic cramp, hysteria, neurasthenia, scoliosis, are cured with partial use of gymnastics and massage, either medical or orthopedic. Massage is also used in the treatment of anemia, chlorosis, general weakness, melancholia, and other forms of insanity, morphinism, obesity, chronic constipation, chronic catarrh, and certain other stomatic disorders, particularly those that are among the most common concomitants of civilized life. The abdominal massage employed in disorders of the heart and of the digestive organs has a most beneficial influence when properly applied, but its value is more than problematic when coming from the hands of ignorant practitioners. Gynecological massage, as introduced by Thure Brandt, is now well known throughout Europe, and in some places in North America, and his manner of treating certain diseases of women is gaining more confidence every day, and is well accredited among all physicians of experience.

If it be true, as we have pointed out before, that massage should be given only by persons who have both practical knowledge and the necessary theoretical insight, it is of still greater importance that gynecological massage should be employed only by operators, who can give some guarantee both of their competency and of their cleanliness.

We cannot here further extend the list of diseases in the treatment of which massage has to be utilized, but we may just mention a few of the affections to which massage is not

applicable. Among these are fevers, acute inflammations of the joints, inflamed veins, fragile arteries, diseases of the skin, and, generally speaking, those conditions in which it is not desirable to increase the circulation, or in which the patient cannot endure handling. Other contra-indications to massage are pregnancy, severe local or constitutional affections, and certain conditions of the kidneys and urinary passages. Often certain manipulation may be employed when another form of massage would be entirely out of place, and might have a very injurious or dangerous effect. The successful use of massage depends upon several conditions, the principal of which are: manual dexterity on the part of the manipulator, the selection of appropriate forms of massage for any particular disorder, a proper proportion of resistance on the part of the patient to the passive exercise effected by the masseur, a certain time of rest after every movement and treatment, a judicious combination of psychical and medicinal treatment as well as of dietary prescriptions with massage and medical gymnastics, and, finally, the treatment must last for a sufficiently long time if beneficial effect of any duration is to result.

If it would be possible to give a general rule in this last respect, we should say that one month is the shortest period a patient should take general massage treatment. But the time varies of course greatly with the cases for which it is used. In chronic diseases massage must be applied two or three months if an effective result is to be obtained, and, in the case of heart disease, for instance, the treatment has to be repeated every year and sometimes oftener.

It is a common thing to see a patient leaving off his massage treatment as soon as he feels somewhat relieved, and very often he finds out afterwards that he was not cured, and then his confidence in mechano-therapy is forever lost. It is, however, for the physician and the gymnast to decide when the treatment is to be finished, and not for the patient.

So, for the duration of a sitting, this varies according to the disease, from five or ten minutes to an hour. For general massage at least a half hour is required. In certain acute cases, two or three sittings are necessary every day, and never less than one a day.

Massage, or medicinal gymnastics, should never be taken in the bath, or immediately after, as is often practiced. If thermal as well as mechano-therapeutical treatments are prescribed by the physician, separate time should be devoted to each, although this may sometimes be inconvenient.

We have already drawn attention to the necessity of employing competent and duly qualified gymnasts who have received proper training. In order to show what is generally considered to be the necessary education of a medical gymnast, we will give a short account of the requirements for admission and the courses at the Royal Gymnastic Institute at Stockholm, which is everywhere recognized as the best institution of its kind.

The entrance requirements are: Candidates must be of good moral character, and must have matriculated from one of the public colleges. Only persons from good families are admitted, this because the graduates will have to move in the best social circles.

The course for men lasts three years and for women two years. The curriculum comprises a complete course in the anatomy of the human body, physiology, theory and practice of medicine and pedagogical gymastics. For medical students and physicians there is a one year's course of medical and pedagogical gymnastics.

At the University of Uppsala, in Sweden, every medical student has to pass an examination in massage and gymnastics. In order to be qualified by the Royal Medical Department in Sweden as a medical gymnast, it is now obligatory to have graduated from the Central Institute.

Through this interference of the authorities, mechanotherapy now stands much better in Sweden than formerly, but in most other countries the degree of education possessed by its practitioners is varying, from the usual Swedish standard to below zero.

In conclusion, we would call the attention of our colleagues in the United States to the necessity of doing everything in their power to keep up and raise the standard of the profession, not by eliminating co-operation with the medical practitioners or by intruding into their domain, but on the contrary, by placing themselves in the hands of the physicians following their advice. By so

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doing not only will mechano-therapy get a better reputation than it now enjoys, but its practitioners will gain, both materially and socially. At the same time it is to be hoped that the physicians will exercise some employing their agents for the practicing of medical gymnastics and massage.

Stanford University P. O., August 15, 1903.

care in

TRIPARTITION IN THE STUDY OF THE
FEMALE PELVIS.

(Abstract of a paper presented to the Mississippi Valley Medical Association, at their Annual Meeting, Put-in-Bay, Ohio, September 12, 13 and 14, 1902.)

By A. ERNEST GALLANT, M. D.

Professor of Gynecology, New York School of Clinical Medicine; Attending Gynecologist Metropolitan Hospital and Dispensary, and McDonough Memorial Hospital, etc.

The orderly presentation of a subject based upon a uniform plan as an aid to memory (receptive, retentive and recollective) has always been recognized as of value to teacher, practitioner and student. With this purpose in mind, it has been our custom to arrange the components of the female pelvis (anatomical, functional and pathological) in natural groups of three-tripartition.

Anatomically the pelvis may be looked upon as a cavity bounded (1) circumferentially by a bony wall, roofed in by (2) peritoneum and closed below by the (3) pelvic floor. This bony basin or bird's nest is formed by the union of the two ossa innominata and the sacrum united at (1) the iliac synchondrosis and (2) pubic arch by corresponding ligaments and (3) the greater and lesser sacroiliac ligaments. The superior boundary of this basin is designated (1) its brim or inlet, the inferior (2) the outlet, and the interior lying between inlet and outlet its (3) cavity.

The pelvis is roofed over with peritoneum which enfolds the superior portions of the pelvic organs, and separates them from the peritoneal (1) cavity, the (2) intestines and (3) omentum. As the peritoneum dips down it forms double layers, denominated ligaments, viz: (1) utero-sacral, (2) broad and (3) utero-vesical. The depressions lying between these ligaments and the respective organs are known as (1) the anterior or vesical pouch, (2) lateral and (3) posterior pouch or cul de sac of Douglas.