Shortly before I gave my definite opinion that these cases were in every respect unsuitable for treatment by massage except by a gynaecologist, a German colleague sent me for treatment a young woman in whom might be clearly felt through the abdominal wall an enormous salpingitic and perisalpingitic exudation, which for many months did not show the slightest tendency to reabsorb, the result of gonorrhoeal infection from her husband. I began treatment exclusively through the abdominal wall with small careful manipulations, such as I have described in this book as "abdominal kneading," and after only two weeks reabsorption began. After most of this obstinate exudation had been absorbed, I dispersed the greater part of what remained by bimanual treatment, ending the treatment with a feeling of relief from a great responsibility.

Salpingitic processes will certainly in the future be dealt with more by surgical methods than by massage, although a specialist accustomed to this routine may often remove by means of massage very troublesome thickenings, swellings, and the resultant pain and tenderness in and round the tubes.

Koblanok does not massage directly upon pyosalpingitic exudations, but upon the uterus, which may be said to work as a suction pump by means of the changes of form and thus suck out the exudation "per vias naturales." Personally I know nothing of the value of this treatment.

Massage is of no use whatever for displacements caused by tumours in or around the uterus. For congenital conditions of a similar kind, as for those which arise as a result of laxity in the adnexa, the value of massage in any case is very much more limited than in cases of exudation. At present it cannot be definitely estimated. We may leave it an open question whether the inflammatory residua are, as many are inclined to believe (Ziegenspeck, Freund, and others), almost exclusively the cause of forward deviations owing to retraction of the sacro-uterine ligament, or of backward deviations owing to retraction of the connective tissue between the cervix and the bladder, or of lateral deviations owing to retraction of parts within the broad ligaments. What is certain is that the presence of such residua very often causes alteration in position and fixation of the uterus, and that it is in these cases that one may expect the best results from manual treatment.

Much more important than the correction of displacement is the restoration of the normal mobility of the uterus. To attain this end it is obvious that the products of inflammation must be removed by means of frictions, and that the shortened and shrunken parts must be lengthened by lifting, pushing, stretching in various ways, and replacement. The manipulations, which are in themselves not necessarily massage manipulations, are carried out in the usual gynaecological manner, usually bimanually, by working on the uterus in two ways, through the vagina and through the rectum or the abdominal wall.* The patient, according to the nature of the case and the difficulty in treating, ought either to take up the usual position on the back, or to remain standing, or to take up the knee-elbow position on the plinth. If the uterus is fixed one tries little by little to loosen it by means of moving it with gentle force in the opposite direction. I would specially draw attention, however, to the fact that the "liftings," so well described by Brandt further on and used for prolapse, may with advantage be used for other misplacements, especially for deviations backwards, to stretch the contracted parts. All manipulations which aim at stretching the parts shrunken as a result of inflammation belong particularly to the later part of the treatment, after frictions have done their work; to stretch parts which are still largely infiltrated or contain a considerable amount of exudation cannot produce satisfactory results. Further, it is necessary to emphasise that all stretchings must be made softly and gently, and that one must content oneself with gradually rectifying the position without using undue force. It seems to me to be sufficient to refer to the above manipulations, which do not belong to massage, without further complicating matters, in order to give the reader an idea of the endless variety of manipulation according to the nature of each case. They are not in themselves specially difficult cases when the details are once understood, but this for any one not a specialist is often difficult enough, +

With displacements, however, when it is not possible to obtain complete replacement, the question arises of treatment by means of pessaries or other supports along with or after massage. I would here remind my readers of the modern opinion that the displacement is in itself unimportant, and that the use of the pessary has largely decreased.

* Brandt, who was most dexterous, could however often replace a movable uterus which had slipped backwards with one hand, by means of inserting the forefinger in the vagina and carrying the fundus upwards and forwards, and then quickly pushing the cervix backwards and upwards, though others were obliged to use both hands. He did this with the patient in standing position. In other cases of retroflexion, very difficult to replace, he, like other gynaecologists, was obliged to work upon the uterus in all three ways by inserting the thumb of the left hand into the vagina and carrying the cervix backwards, with the forefinger of the same hand in the rectum drawing the fundus forwards, the manipulation being assisted by the right hand on the abdominal wall. From witnessing Brandt's work one obtained the impression that he developed also this part of the treatment much more than most gynaecologists, as a result of constant use of the manipulations and also of using them in different ways.

+ Gynaecological massage is perhaps that which requires the greatest skill, but even in this the technique of massage is so easy compared with the diagnosis that an otherwise well-trained gynaecologist can easily learn it in one day.

The products of inflammation are, along with massage, treated by the usual absorbent means, tampons supplied with various medicaments, mud baths, compresses, hot irrigations, which latter I constantly use with some kind of iodine tincture.