Among the diseases of women which lend themselves best to massage * are the parametritic and perimetritic exudations and the inflammatory products, more or less remote from the original disease, which affect the pelvic organs, its connective tissue, or its serous membranes (e.g., oophoritis, perioophoritis, salpingitis, perisalpingitis, pelvic cellulitis, etc.) after the inflammation has subsided. In these days a considerable number of gynaecologists are in a position to compare the results of their treatment of these cases without massage with the results they have gained later with the use of massage. Among these the opinions on this important point are unanimous. The products of inflammation are more quickly and completely removed by massage than by any other treatment, and for the most part the danger of a relapse is also removed; the uterus regains its mobility to a greater or lesser extent by the stretching of shrunken tissues, bands or adhesions, which is often of great importance in removing the symptoms. As regards the consequent alterations in the position of the uterus, to which I shall presently return, one must confess that complete replacement, especially in cases of retroflexion and fixation, is an exception; on the other hand, one may claim that the improvement is usually sufficient to remove the troublesome symptoms and that the alteration in position is usually of little consequence in itself when the organ is no longer fixed.

* In this chapter, as in the rest of the work, I have omitted certain uses of massage which I consider unjustifiable. For instance, I have entirely omitted massage of fibroids, without speaking either of their diminution in volume or of the lessening of the haemorrhage which follows, which some people profess to have observed. Similarly I consider that there can be no reason whatever for giving massage to ovarian cysts of any kind or under any conditions. Finally, I think it is unsuitable in amenorrhoea to attempt directly to produce menstruation in anaemic patients by means of mechanical stimulation. These patients are not anaemic because of the cessation of menstruation, but on the contrary, menstruation and ovulation have ceased on account of the anaemia, and it must be considered as nature's attempt at economic compensation.

The shorter the time which has elapsed since the inflammation was acute the greater the danger of producing fresh inflammation, and this forbids us to advocate early treatment, in spite of the greater ease with which recent exudations are removed by massage than those of longer standing. When one remembers how products of inflammation which have been present for many years may be almost entirely removed, one must not place too much importance on the conditions which may arise through allowing one or two weeks more than are necessary to elapse before beginning massage treatment. The suitable time for this varies in different cases very much, but a minimum time may be given, which ought to separate the last of the symptoms of acute inflammation (marked tenderness to pressure, rise of temperature, etc.) from the first massage treatment; for my part I consider two months is not too long for such a minimum length of time. Besides the long time which has elapsed, the characteristics which distinguish the older and less dangerous exudations and may to some extent serve as a guide to us, are the firmer consistency, and lessened tenderness to pressure. When the treatment begins during the earlier days of exudation, one must, especially at first, go to work with the greatest care, and at the least sign of any irritation producing acute inflam-mation one must stop massage at once.*

* In this connection I would emphasise the necessity of letting a long time elapse between similar acute inflammatory processes and treatment by massage of the consequent power to set up inflammation makes its way through the peritoneum, there is grave danger of peritonitis. There are cases which have come to my knowledge among the unwritten records of gynaecologists which demonstrate this danger.

In perioophoritis and oophoritis (between which we cannot distinguish in practice, and which we therefore class together here) massage is often used with advantage, and is carried out, mutatis mutandis, in the same way as in perimetritis or parametritis. In these cases also the exudations are removed more quickly than by any other means, and with the exudations the pains are removed; one may later possibly stretch the adhesions present and restore the ovaries to their former position. Here, however, as in the case of the uterus, the chief object is not to replace the organ in its absolutely normal position, but to restore its mobility. This may be done either from the vagina or from the rectum; one may try carefully to insert the tip of the finger between the adherent organ and the part to which it is fixed, and equally carefully and by degrees to stretch the adhesions, helping this by means of the other hand placed outside the abdominal wall. The technique in these cases is often difficult. Too strong manipulations are dangerous. Enlarged ovaries, in spite of massage, often remain undiminished, a fact which is of no clinical importance.

In a work of this kind it is as important to point out the dangers of massage of diseased ovaries as to state the indications for massage treatment of those diseases which massage can cure. To begin with, the diagnosis often requires a skill in palpation which can only rarely be found among "general practitioners." And there are still fewer among us capable of recognising changes in the tubes which would make massage in their neighbourhood dangerous.

As regards inflammatory processes and the conditions in the tubes resulting from them,, it is my opinion that in the great majority of cases they should only be treated by massage with the very greatest care even by doctors. I will not deny that various inflammatory changes in these regions can with advantage be treated by massage, or that this has been done in many cases. But I wish to differentiate between those cases in which this can be done without danger and those in which there is more danger than advantage in massage, and which present great difficulties even to an experienced gynaecologist. If a purely serous salpingitic exudation empties itself into the pelvis through the distal orifice of the Fallopian tube no danger usually follows. One of the rather common cyst-like dilatations of the tube may often burst without dangerous symptoms arising. But if a purulent exudation, however slight, with the inflammatory products. To apeak <>of massage for the phlegmon of the thigh, which is called phlegmasia alba dolens, resulting from phlebitis and lymphangitis, is pure foolishness. As long as such a condition continues it forms the strongest contraindication to massage, which may only be thought of many months after recovery, in order to remove the infiltrations which remain.