If massage is of value as a remedial agent after abdominal operations, it is not less so in obstetrical work. Anything more grotesque than the treatment many women receive after childbirth is difficult to imagine. They are told to take all the exercise they reasonably can manage in order to keep in health up to the day of confinement; then they are kept in bed devoid of any exercise for three weeks. In addition to this the abdominal wall has been severely stretched; then the stretched muscles are placed under a most unwonted strain, it may be for hours. Small wonder then, that, when the stretching is relieved and the strain is over, the muscles simply "give out" and remain flabby and torpid. The muscles are naturally "stiff" and sore after their unwonted exertion, and the earliest attempts to contract them will cause some pain or discomfort. This will act as an inhibitory agent and, unless something is done to counteract it, the oatient will leave them in a state of flaccid inhibition from which, not uncommonly, they never recover. As a rule no attempt is made to restore the tone and power of the stretched - and, when relieved, weakened - muscles; and an inert binder is applied to maintain the intra-abdominal tension, which hitherto has always been the duty of the freely-acting muscles of the abdominal wall. The result is that the bowel is deprived of the "internal massage" which it has always received during respiration, and a tendency to constipation is inevitable. Add to this the fact that the expulsive powers are materially reduced, and it becomes evident that it is only reasonable to expect that the patient will have difficulty with defaecation and urination. This means that there will be faulty absorption from the bowel, and the sudden lack of exercise entails a decreased elimination of waste products. Further, the portal circulation is deprived of the chief source of assistance, namely, the contraction of the abdominal muscles. Then, when the patient is allowed up, the anterior abdominal wall is flaccid, so that, failing adequate artificial support, enteroptosis is assured to a greater or less extent.

The author has heard the sweeping statement made that in one part of the world a large percentage of women of the upper classes go completely "smash" after the birth of the first child and "are never the same again afterwards." It is certain that the amount of visceroptosis to be discovered amongst matrons in this country is a blot on the foresight of their medical attendants. There can be no excuse for the frequency with which a pathological change follows a purely physiological process. Nature could not be guilty of so grievous an error; therefore human management must be at fault. The remedy is simple.

The physical treatment in obstetrical practice may be divided into three stages: -

(1) During pregnancy.

(2) During labour.

(3) During the puerperium.

During pregnancy the expectant mother frequently suffers from a multitude of ailments. These vary very greatly in severity, but it must be remembered that it is the minor troubles of this life which are often the hardest to bear. Comparatively few mothers pass through pregnancy to full-time without suffering in some degree from discomfort. In many the discomfort becomes positively acute. It is these minor troubles that physical therapy can help, and the lot of many women could be rendered far more happy were it more frequently employed.

During the early stages of pregnancy, and particularly in primiparae, various nervous manifestations are frequently encountered. Nervous headaches are frequent, and every stage of disturbance may be encountered up to the condition of acute neurasthenia. In pregnancy, as, indeed, almost whenever this condition supervenes, massage stands out pre-eminent as a curative measure. If it is taken in time, the avoidance of insomnia is the one great prophylactic treatment for other forms of nervous breakdown. The treatment has already been described in the chapter dealing with neurasthenia (see Chapter XXI (Massage Treatment In Neurasthenia).).

It would be good to know of any remedy that successfully combats the morning sickness which is so common in the early stages of pregnancy. Stimulation round the region of the spine of the fifth thoracic vertebra is well worthy of a trial in the hope that the pylorus may be induced to relax. In applying percussion to this area, it is well to note that the manipulations should not be carried below the level of the twelfth thoracic vertebra, or undesirable abdominal reflexes may possibly be excited.

Cramp in the legs, particularly in the calf muscles, is another very severe trial to a pregnant mother, and is a not infrequent cause of disturbed sleep. Five minutes' general massage applied to both legs - percussion of all sorts being prohibited - will probably do more than anything else to alleviate this distressing symptom, and, usually, it will be found to relieve it altogether.

At a rather later stage the patient may suffer a considerable amount of pain in the small of the back, and dry-cupping, as advocated for the treatment of lumbago (see Chapter XXVI (The Treatment Of Constitutional Disorders).), will often give relief. Another pressure symptom, at a still later period, is swelling of the legs. This may be merely trivial, and pass almost unnoticed. In other patients a sense of discomfort is produced by quite a moderate amount of oedema, and this will often disincline the patient from taking her normal daily exercise. In a third class of case the swelling may be so great that the walking powers are reduced almost to zero. In massage, and in massage alone, have we any hope of securing relief, except by enforcing absolute rest in bed. There can be no question which is the wiser alternative; but even in the lighter cases, massage, properly performed, conveys a sense of comfort which affords so great relief that patients often instinctively long for it. Provided they receive skilled treatment, their gratitude is very great. The technique advised for dealing with oedema (see Chapter III (General Principles Of Massage Treatment (Continued). 2. The Mechanical Action Of Massage).) should be strictly adhered to. The treatment should, of course, be sedative throughout.