On the third day short, gentle massage may be administered to all four limbs. It should be sedative. No fear of causing any complication need enter our minds, as, unless the course of the puerperium at this point were normal and any dangerous sepsis out of the question, massage treatment would not be prescribed. The patient should be encouraged to make a little more effort during the performance of her deep breathing movements, which may now amount to gentle exercise.

Two days later the patient may be taught to draw up the knees alternately during inspiration, and extend them, pressing them out to their full extent, and fully dorsi-flexing the foot during expiration. Lying fully extended, with the feet crossed, the abdominal muscles can be taught to contract and relax, and slight arm movements up to the level of the shoulders may be added to the breathing exercises.

At the end of the week - provided the change in the lochial discharge is following the usual course - it is time to consider the stretched, and therefore inactive, and probably weakened, muscles in the perineal region. With the knees drawn up resistive exercises are given to the adductors, both excentric and concentric. This is one of Brandt's exercises for the treatment of prolapse. Actually it probably has no effect whatever on any of the internal muscles unless the patient is taught at the same time to contract the levator ani. When this is done, the contraction of the adductors seems to have a definite synergistic action. The contraction of the muscle is encouraged during the adduction of the knees. It relaxes during their abduction. Killogg's "inspiratory lift" exercise may be prescribed at this point. Respiration is checked in forcible expiration, and the abdominal muscles and diaphragm are made to perform the movements of inspiration, although no air is allowed to pass the glottis. The idea is, as it were, to cause a vacuum in the abdomen. Slightly more vigorous movement of the arms is encouraged during the breathing exercises, early alternate leg-lifting may be prescribed, and the lumbar spine may be pressed down upon and raised from the bed. Early attempts may also be made to raise the trunk in the crook lying position. Progress is gradually made till by the middle of the second week a definite table of exercises can be performed. The following would serve as an example: -

(1) Lying, double arm forward and upward raise, with deep breathing.

(2) Crook lying, sacral lifting.

(3) Lying, feet crossed, back bending and stretching.

(4) Deep breathing without arm movements.

(5) Resistive exercises to the adductors of the thigh, with contraction of the levator ani.

(6) Inspiratory lift exercise.

(7) Stretch grasp lying, trunk raising, with assistance.

(8) Lying, neck rest, alternate leg raising.

(9) Repeat 1.

Most of this table might be performed twice a day and the breathing exercises at intervals throughout the day. A steady advance will be made until about the middle of the third week, when the patient might well be able to perform: -

(1) Sitting, deep breathing with double arm rotation.

(2) Crook lying, sacral lifting with double knee abduction and adduction.

(3) Wing three-quarter lying, trunk raising.

(4) Stretch grasp lying, double knee bending and stretching.

(5) Wing sitting, alternate side bending.

(6) Slack stoop standing with support, back extension.

(7) Wing standing, with back support, alternate knee raising.

(8) Breathing exercises.

Before treatment is concluded, a young and athletic patient may have advanced to a comparatively free table, such as: -

(1) Wing standing, heels raise knees bend, with respiration.

(2) Wing standing, alternate knee bending and extending.

(3) Stretch standing, trunk forward and downward bending, with respiration.

(4) Deep breathing.

(5) Wing sitting, trunk rolling.

(6) Foot grasp lying, trunk raising.

(7) Reach grasp lying, double leg raising.

(8) Crook lying, sacral lifting, with double knee abduction and adduction.

(9) Prone falling, double arm bend and stretch.

(10) Deep breathing.

Naturally, not every patient can advance to this stage of athleticism; but any young and reasonably healthy woman, with athletic tendency, can usually be built up in this way on tables which vary from zero to full strenuous exercise. The gradation, of course, must be slow and skilfully regulated. Due allowance must be made for individual idiosyncrasies.

I have departed from my usual practice of not including any account of Swedish remedial exercises in this instance, because I realise the vital importance of skilled treatment in connection with obstetrical work. Were the ordinary midwife able to take charge of the physical treatment of her patient all would be well, but it cannot be. It looks so simple to be "able to give a little massage" or "just to teach the patient a few exercises," and the general public - even medical men as well - do not realise how very far from simple treatment such as I have outlined really is. To be effective, and possibly even safe, a wide experience and a high degree of technical ability are essential.

Somewhere about the third day, the lying-in patient is liable to be troubled with her breasts. If they are painful and congested the breasts may be smeared over with sweet oil, and the lightest possible stroking should be performed from the periphery towards the nipple. As soon as the tenderness is somewhat allayed, light friction may be employed over any particularly sensitive part. If the flow of milk is inadequate, the treatment already mapped out as suitable before delivery can be continued, and Dr. Elizabeth Sloan advocates the passage of a weak faradic current for twenty minutes on alternate days.

A regular massage technique has been described by Major Brandt for intra-pelvic manipulation, as has been stated in the previous chapter. This has not been recognised as a method of treatment that should be adopted in this country. Not only is it open to obvious and great disadvantages, but, in addition, we must remember that the author of the treatment was not a medical man, and that it is impossible to accept his diagnosis in the cases for which he prescribed treatment. On the other hand, it cannot be denied that he laid great stress on the value of exercises for treatment of various conditions in the pelvic region, and that this form of treatment unquestionably affords us a guide by means of which it is possible to benefit many of those patients who, without physical therapy, would continue to suffer.