[Reprint from the Michigan State Medical Society, x888.j UTERINE MASSAGE.* W. B. SPRAGUE, M. D., Detroit. General massage has proven very valuable in gynecology at the hands of Mitchell, Playfair and others, but I purpose to speak only of massage of the pelvic organs-uterine massage. Brandt, a Swede, educated for the army, turned his atten- tion to Swedish movements and massage about iSzjo.f In he cured a prolapsus recti in a soldier by rubbing up the sigmoid flexure, and, having knowledge that many women suffer from 'prolapsus uteri, he formed a concept of treatment that would, probably, relieve their sufferings. Being a non- medical man, he had no opportunity of testing his theory until 1861, when a farmer's wife submitted herself to the test of his long-cherished plan, and was cured by a few treatments.§ From this time he rapidly achieved a reputation that necessi- tated his giving his whole time to the treatment of uterine displacements, and he became expert in diagnosis, as well as in treatment. It was not long before he extended his practice to the treatment of chronic inflammatory conditions, as well. The physicians of his country did not recognize him, but he succeeded in attracting the attention of Schultze, of Jena, who became a willing disciple. In a recent preface of a colleague's book, Schultze says: "The method of Brandt gives valuable results in stretching and slackening old parametritic exudations, as well as restoring fixation in prolapsus uteri In 1866, Sinclair, of Boston, reported cases of retroflexion and retroversion cured by massage, with the patient in the *Read in General Session. JO. Nissen, M. D., Christiana, in Sundhedsbladet, June, 1887. JAm. Jour, of Med. Sci., Vol. xciv, p. 600. §O. Nissen, M. D., Sundhedsbladet, June, 1887. 2 STATE MEDICAL SOCIETY. genupectoral position.* Norstrom, of Stockholm, treated 138 cases by uterine massage in two and one-half years, 1872- 1874.* In 1880, A. Reeves Jackson, of Chicago, read a paper on the subject before the American Gynecological Association, reporting a series of cases of " interstitial hyperplasia with para- metritic tenderness " successfully treated Bunge, of Berlin, reported favorable results from the treatment in 1882,J and again in 1885.§ Prochowink, Hamburg, reported 102 cases treated thereby, to the German Gynecological Society, in i885«§ Orum and Howitz have found it efficacious in removing the after effects of periuterine cellulitis when other means had failed.* " Profenter studied Brandt's results for a week, found them good and had his scepticism removed," and reports a series of favorable results in his own practice. || Graham, Stoddard and others have reported favorable results in their experience.* My attention was called to uterine massage by Dr. Jack- son's paper, and the rationale seemed to me to promise much aid to gynecological therapeutics. I therefore arranged with him for some instruction in its administration and the selection of suitable cases in the summer of 1883. His claims seemed to me even more modest at that time than when he read his paper, and, having limited opportunity to demonstrate its value, my faith in this form of treatment gradually waned,-to be revived, however, by the experience of the past year. During the year I have taken occasion to apply the treatment in four- teen cases, which I will report as briefly as is consistent with clearness. Case I.-Age, 39. One child about twenty years ago. Has never conceived since. Had a small but rapidly develop- ing sub-peritoneal fibroid, anterior to the cervico-corporal junction. Applied massage, combined with the secondary cur- rent of electricity, twelve times, between July 22 and August 20, 1887. The tumor steadily increased in size, and I resorted to ergot. *Ref. Handbook of Med. Sci. Article, Massage. •[Transactions of the Gynecological Society for 1881. j Graham on Massage. § Am. Jour, of Obstetrics, Vol. xviii, p. 318. || Am. Jour, of Med. Sci., Vol. xciv, p. 600. W. B. SPRAGUE. 3 Case II.-Age 26. Multipara. Cervical laceration, with ectroprium and catarrh. Moderate laceration of perineum. Greatly relaxed vaginal walls. Alternate anteversion and retroversion, with some prolapsus of uterus. Prolapsus recti. Frequent intense neuralgia in uterus, ovaries and rectum. Rapidly increasing nerve debility. After several weeks' treat- ment with hot vaginal douches, endocervical applications of Churchill's tincture of iodine, and glycerine tampons, the improvement being very slow, I resorted to uterine massage October 24th, continuing the previous treatment. I gave nine- teen massages during the following month, and the improvement was rapid. The cervical catarrh was checked, the lacerated flaps of the cervix were pliable, the vaginal walls less relaxed, and the prolapsus recti, incidentally much improved. I repaired the cervix November 27th, and, after the patient's recovery from the operation, dismissed her, with a pes- sary, and injunctions to avoid over-exertion for a few months. She has been three times indiscreet in exercise-dancing nearly all night on the first occasion, only a few weeks after the opera- tion; and on each occasion the womb has become congested and packed down upon the pessary, and the cervical catarrh has again appeared. Gave seven, four and five massages respectively, on these different occasions, with the result of speedily relieving the exacerbation. The prolapsus recti has not appeared since December, the vaginal walls have steadily retracted to a nearly normal, firm condition (except for the lacerated perineum), and the pessary was removed May 28th. There is still too much freedom of motion to the uterus, but it has not been displaced since the pessary was removed. The patient still tires easily, and congestion of uterus occurs at such times, but health and strength are gradually returning. Case 111.-Age 20. Primipara. Examination three months after confinement found laceration of cervix, and sub-involution and retroversion of womb. Cervix enlarged and secreting abundant glairy discharge. Much backache, headache and debility. Used the usual remedies until November, one month, and then decided to combine massage. The improvement was very rapid from this time, and after repeating it thrice 4 STATE MEDICAL SOCIETY. weekly for a month I repaired the cervix, December 7th. In this case, also, I found it necessary to repeat the treatment, for the ill effects of mental shock (a great sorrow), sudden check- ing of the menses by exposure, and over exertion. From three to six massages removed the symptoms on each occa- sion, and the patient has steadily improved in health. Removed the pessary June 12th, and found the womb normal in condition and position, except a slight prolapse. Case IV.-Age 31. Primipara. Has not been pregnant for ten years, although normal intercourse has continued uninter- ruptedly. Bilateral laceration of cervix and large cicatricial deposit, everting the flaps extremely. Profuse catarrhal discharge. Retroversion, engorgement and tenderness of uterus. Both ovaries congested and low. After a few weeks of ordinary treatment I repaired the cervix, February 8th, and dismissed the patient with a Thomas-Smith pessary and injunctions to avoid over-exertion. As is usual, the injunction was not heeded as soon as the patient began to feel her usual health returning. In this case, treading the sewing machine caused congestion and prolapse of uterus and ovaries, the fundus resting heavily on the pessary. Cervix was again enlarged and catarrhal. I resorted to massages at once, gave five treatments during the week following March 28th, and then found the tissues in a healthy condition. Six treatments were again necessary between April 19th and May 4th. A little indiscretion caused the ovaries to prolapse, sometimes to become wedged behind the fundus and pessary. May 28th, I removed the pessary, and gave three more massages the following week. The patient now reports herself " well." Case V.-Age 27. Virgin. Anteflexion and cervical catarrh, with marked disturbance of nutrition and constant throbbing in occipital region. Also pain in head and spine. Tires easily. These symptoms have continued for years, and she fears she will have to abandon her occupation-teaching. Gave central and local applications of galvanism and hot vaginal douches for some months, with considerable relief, but as the school year advanced the uterine congestion and displacement were aggravated. She could not well stop her W. B. SPRAGUE. 5 work to receive radical treatment for the anteflexion, and I have resorted to massage. Three treatments from May 16th to 24th entirely relieved the congestion and cervical catarrh, and improved the flexion. The massage was then suspended until June 9th, when the above conditions returned. Massage again resorted to. Patient is still under treatment. Case VI.-Age 26. Multipara. Extreme laceration of cervix had resulted in a pelvic peritonitis after several years. The whole vaginal roof was as firm as the venter ilii, upon pressure, four days after inflammation began, and only the cer- vix uteri, firmly imbedded, indicated the presence of the uterus. Two weeks later, February 13th, I applied a gentle massage, giving little pain and a resulting sensation of relief. The ante- verted womb could be outlined in the mass of exudate at the close of this treatment, the tissues were so markedly softened. The treatment has been repeated two or three times weekly ever since, except during menstruation, and only a small por- tion of the exudate now remains. In this case I combined hot vaginal douches, etc., with the massage. Treatment is contin- ued with a view to repair the cervix when prudent. Case VII.-Age 32. Several miscarriages, but no mature birth. Last miscarriage was January, 1888. February 21st the uterus was anteverted and engorged, and there was cervical catarrh. I gave ten massages before March 10th, and then found all the parts in a comparatively healthy condition. Case VIII.-Age 30. Virgin; seamstress. Extreme retro- version, with engorgement and prolapsus. Has suffered for more than a year with severe and more frequently recurring headaches (occipito parietal), and it has been very appreciable that her strength and energy were waning. Corrected the retroversion, and supported the uterus with glycerine tampons every alternate day for a week, but it had recurred on each occasion. I now combined massage with the previous treat- ment, and there was only a partial recurrence at the next visit. Gave nine massages between April 14th and May 4th. Improvement was steady, and at the latter date the parts were in a normal condition, except that the womb was too freely movable. Dismissed patient with a Thomas-Smith pessary, for the time, and she has been quite well since. 6 STATE MEDICAL SOCIETY. Case IX.-Age 33. Multipara. Extreme laceration of cervix, retroversion, and endometritis. Uterus measures three and three quarters inches in depth. Profuse leucorrhoea, often somewhat colored with blood. She had missed her period, and feared she was pregnant. I discouraged the thought, because I believed it to be a physical impossibility, owing to the cervical catarrh, etc. Gave ordinary treatment a few weeks, with slow improvement, and then combined massage with it. Gave fourteen massages between April 10th and May 22d. At the latter date the discharge had ceased, the depth of the uterus was scarcely two and one-half inches, and it was in a normal position. Menstruation appeared May 24th, three months after the previous one, and was perfectly normal. Backache, headache, dragging sensations in limbs, had all dis- appeared, and patient was cheerful and well. A repair of the cervix not being practicable at present, I dismissed the patient, June 4th, for a time. Case X.-Age 33. Virgin. Retroversion. Patient is quite embonpoint, and the womb cannot be restored to its position, although it is very little congested and otherwise normal. Have given three massages, with patient in genupectoral posi- tion, and have failed to wholly reduce dislocation, although the congestion is removed for the time, and the patient expresses a sense of relief from the symptoms of retroversion. This case is still under treatment. Case XI.-Age 40. Nullipara. Retroversion, prolapse and engorgement of uterus, which measured four and one-half inches in depth, and the external os admitted forefinger. Endometritis. Replaced the organ and applied a gentle massage May 13th, and have given eighteen massages since. The retroversion recurred several times, but not since May 25th, and the uterus has gradually contracted and discharge diminished. It now measures three and one-quarter inches deep, and the os is much less patent. Treatment is still con- tinued. Case XII.-Age 40. One child twenty-two years ago. Had an acute pelvic inflammation many years since. The right broad ligament is shortened, and there is congestion of W. B. SPRAGUE. 7 womb, with alternate anteversion and retroversion, with some cervical catarrh, aggravated, if not caused, by a daily ride on the street-cars, of ten miles. Tampons of surgeon's wool give some relief. Endocervical applications of iodine cause a faint- ness and fluttering sensations in region of stomach. Have given two massages at considerable intervals, each of which was followed by the symptoms caused by the application of iodine, considerably exaggerated, and a weariness which lasted for twenty-four hours. I have abandoned the treatment in this case. Case XIII.-Age 39. Multipara. Cervical and perineal lacerations of moderate extent. Retroflexion and engorgement of uterus. Patient has been much reduced by intestinal catarrh and rectal ulcers. At intervals for more than a year I have corrected these recurring conditions of the uterus, in large part, by ordinary remedies. During the month of May the conditions persisted in spite of the usual treatment, and even became more and more aggravated. Since June 1st I have given five massages, and the improvement has been marked. Still under treatment. Case XIV-Xge Multipara. Extreme laceration of cervix, with ectropium. Anteversion and prolapse of uterus. Great hyperaasthesia of the parts. Coition has caused dis- tress for some time. Have applied four massages with marked relief to hyperaasthesia and cervical catarrh. Still under treatment preparatory to repair of cervix. Hot water douches are conjoined with the massage. It will be seen that I have considered the treatment applica- ble to a variety of pathological conditions, especially during the past few months. Wherever there exists old parametritic exudations, congestion of uterus or its appendages, or relaxation of the normal supports, I believe it is indicated, provided my acquaintance is such as to establish my patient's fullest confi- dence. This relation seems to me an essential consideration. 1 am satisfied that I erred in applying it in the case of the fibroid, and also in the case where the sympathetic nervous system was so susceptible of slight disturbance. While in those other cases, where I have combined the massage with 8 STATE MEDICAL SOCIETY. the usual line of treatment for the different cases, it is impos- sible to determine just how much credit should be given to the massage, I am certain that improvement has been much more marked after introducing the massage. Where the massage has been used alone, the response was better than my experi- ence has taught me to expect from any other remedy. Williams sets forth that the arterial distribution to the uterus and adnexa is such that no flexion or displacement (except in hernia) can seriously interfere with the circulation,* but experience snows that a large proportion of pelvic disorders are either the effect or the cause of congestion. The above mentioned wise provision of Nature undoubtedly acts as a preventive of serious trouble in a degree, but the vascular supply is so large, and the compressions, torsions and flexions of the vessels are so varied that the prevention is only partial. The most successful treatment of uterine disorders, I think I may safely assert, deals largely with measures for relieving congestion. It is very evident that no agent can accomplish more in this direction than the pressure, friction and changing relation of the organs afforded by massage. The activity of the secreting glands is also increased, and the tissues are rendered pliable and mobile. The abundant mucous secretion greatly facilitates manipulation. Even in cases where the vagina is hot and nearly void of mucus, and all the tissues are resistant, I have found that after a few moments' manipulation the secretions become copious and the engorgement seems to melt away- The change in the size and density of old inter- cellular exudations is especially marked. Patients almost invariably speak of a sense of relief, as of a weight lifted from the region, at the close of a seance. Even in the case where the nerve disturbance was so great, this effect was noticed. We may be entering the domain of the psychical, as has been said, when we broach the subject of reflex nerve disturb- ances due to uterine disorders, but those who have any experience, will not deny, I think, that we find a pretty constant train of head and stomach symptoms complained of by our patients; and I cannot feel it very rash to hope that we may *American Journal of Obstetrics, Vol. XVII, p. 977. W. B. SPRAGUE. 9 ere long have such a knowledge of the relation of the cerebro- spinal and sympathetic nervous systems to each other, and to the general system, as well as to particular organs, as to be able to trace these symptoms more clearly. Do we not have our attention called to uterine disorder more often by these symptoms than in in any other way, at present? Savage says: "Uterine sympathies find a better exposition in these later dis- coveries, the nerve endings more especially, which go to show that the uterine system possesses abundance of nerves of special sense hitherto unsuspected."* It is not unusual to find the tissues exquisitely sensitive at the first examination, and at the first contact in successive treatments. In nearly all such cases I have found that gentle but persistent manipulation overcomes this hyperaesthesia. Neuralgia of the ovaries and other organs, backache and head- ache, usually disappear during a seance, so that the patient often says she " feels perfectly well " at the close, although suf- fering in one or more of these ways at the beginning. More- over, I have often observed a markedly sedative effect on the general nervous system, which lasted a few moments after the close of a seance, and then gave place to a rested feeling; and it seems to me probable that the nerve control of the nutritive function is favorably influenced. It seems to me immaterial whether we delegate these influences to the psychical or phys- ical realm, if only we secure the effect desired. Many treat- ments for nerve affections seem much allied in their modus operandi to those used in treating insanity, for instance. Methods of manipulating are differently described by almost every individual writer. The latest that I have observed seems very rational, but partakes more of the nature of Swedish movements than of massage. Preuschen describes it fully, and a report of his method may be found in the American 'Journal of Medical Sciences for June of the current year. I have not limited myself to any single " method," believing that it is better to modify it for almost every individual and patho- logical condition. In this power of adaptation lies the secret of success in general massage, and especially so of local mas- * Introduction to Savage's Anatomy, etc., of Female Pelvic Organs; 3d Ed. STATE MEDICAL SOCIETY. 10 sage. Hence it will be seen to be necessary that it should be applied only by the physician, himself, and thoroughly incor- porated with his best judgment. Making all due allowance for the unwarranted enthusiasm always inspired by new thera- peutic measures, I cannot doubt that this treatment is destined to take high rank in uterine disease.