Many of the operations of gynaecology are performed for the removal of massive fibroid growths. This leaves the patient with a very considerably decreased abdominal content, and it stands to reason that, unless the walls which enclose the abdomen are submitted to treatment, considerable weakness and therefore lack of support must invariably ensue. The result is visceroptosis. Treatment for this condition can be arranged on lines similar to those suggested as suitable in obstetrical practice. It must be remembered, however, that patients from whom large uterine or ovarian tumours are removed are considerably older than most of the patients who bear children, and also that the condition has usually been progressive for many years rather than for months. Treatment, therefore, cannot be carried forward at a similar rate, and it may prove wise to omit the more vigorous exercises suggested altogether. When a tumour of any great size is removed, the stretching may have been so prolonged, and so great, that it is wise not to rely solely on treatment by exercises, but to add as an auxiliary graduated faradic contraction. Even treatment on the Bergonie chair may be required. Where any attempt has been made to fix the uterus to the abdominal wall, or to repair the perineum, all the exercise treatment must, of course, be postponed.

In the treatment of prolapse it is possible to do a great deal to benefit the patient by the skilful prescription of treatment by exercises. The plan already described as applicable to obstetrical cases is again an adequate outline, since prophylactic treatment corresponds almost identically to that for treatment of patients suffering from prolapse. One addition, however, is extremely useful when the condition has been established, and it is something which the patient can do for herself after retiring to bed at night, and before going to sleep. She assumes the knee-elbow position. The labia are separated so as to allow air to pass into the vagina. As this happens, the uterus drops automatically under the influence of gravity, forwards and upwards, and all strain is thus taken off the stretched and weakened ligaments. The patient rolls over on to her side and does not get up again until the next morning. The only thing that is calculated to disturb the re-position of the pelvic organs during the night is a violent attack of coughing. This, together with the systematic exercises already prescribed, will often suffice to cure the symptoms of prolapse, which, after all, is all that matters. The presence of prolapse of itself is not objectionable: it is only the symptoms which are derived from it that are of importance. It must be remembered that prolapse in women after child-birth is usually only part of a general downward slide of the whole of the contents of the abdomen, and that therefore general treatment is no less essential than the re-position of the uterus at night, and exercises designed to strengthen the perineal muscles and levator ani are of great value.

Whether anything can be done to assist patients who suffer from amenorrhoea or not, is, to my mind, an open question. I cannot help quoting from Kleen, who says: "So often have I observed an increase in the catamenia, and an earlier appearance than usual, in ladies who are, to all intents and purposes well, and who have had massage of the back or general massage for some slight ailments, that I have come to regard this as one of the physiological effects of massage. In amenorrhoea or dis-menorrhcea, where neither local treatment nor operative procedure is indicated, massage would seem to be a good means to employ, especially in atony of the nervous system and when there is not present any abnormal state of the blood or of any of the pelvic organs." Personally, I should be most reluctant to prescribe massage treatment in any shape or form primarily as a cure for any disorder of menstruation. Treatment for debility, for anaemia, and for functional disorders of the central nervous system by massage and exercises is a thing in which I have the greatest faith. If, as general condition improves, the general physiological functions of the body are also benefited, so much the better. It does not seem to me, however, that it is right to attempt in any way to treat a symptom and to ignore the cause.

If there is one symptom above all others of which the gynaecological patient complains, it is pain in the back. Doubtless displacement of the intra-pelvic organs is capable of causing pain, but a very large number of people suffer very severely from their backs who do not present the faintest trace of abnormality; while yet more complain of the symptom when displacement is so slight that it is hard to believe that the symptom is due to this cause. Were it so, few women who have borne children would be free from constant and insistent back-ache. When we consider what has already been said on the subject of sacro-iliac "strain" and of lumbo-sacral "strain," and that women are liable to muscular rheumatism and fibrositis no less than men (even if they escape more freely from the curse of gout), it will become obvious that many women may suffer from back-ache without the symptom being due to intra-pelvic displacement or pressure. When we further consider that during child-birth the sacro-iliac joints are subjected to a relatively large amount of unusual mobility, it is not hard to realise that the ligaments may have yielded to a sufficient extent to allow a certain amount of abnormal rotation between the sacrum and the ilia. Again, unless steps are taken to restore it, the muscles of the abdominal wall are frequently weaker after confinement than they were before, and we have every reason to anticipate that this will alter materially the gait and carriage of the patient. Dr. J. G. Goldthwait, of Boston, Massachusetts, has produced overwhelming evidence to show that faulty carriage is responsible for a very great deal of pain and suffering connected with the back. In all cases of pain in this region, therefore, even if possible gynaecological causes are present, their presence should not be taken as proof positive that the cause has been found until examination has proved that there is no undue weakness in the abdominal walls, that the postural carriage of the trunk is faultless, that there is no undue pain or tenderness in the region of the sacro-iliac joints, and no exaggeration of the normal spinal curves due to one leg being develop-mentally shorter than the other. It is never wise to attribute back-ache solely to any displacement within the pelvis. It should always be remembered also that flat feet are a fertile source of aching pains in the neighbourhood of the back.