We must, therefore, on the one hand, test the sensitiveness of the patients after the methods we have already dwelt upon, and, on the other hand, often only resort to massage when it has become obvious to the patient herself that nothing can be accomplished in any other way (Prochownik). These precautions are leas necessary in those instances where the desired aim may be secured by external massage.
The chief indications for massage are to influence the absorption of exudations and of transudations, the stretching and methodical straining of cicatricial bands and thickened ligaments, the equalization of the cir culation through the pelvic organs. Under these indications are included, therefore, parer and perimetritis, exudations in the pelvis, sub-involution.
In case of displacements and of flexions of the uterus, I have only Been results when they were dependent on one or another of the above mentioned processes. Rosenstein also advises massage in hiematocele; Douglas Graham in amenorrhea and dysmenorrhea.
All acute inflammatory diseases are contra-indications to massage. The effect of massage on the body heat has not as yet been snffici'ntly studied. I have often in case of general massage, in the absence of any recognizable affection, seen the temperature rise .5 to .75 of a degree, and have considered this rise an indication for stopping the massage. For the sake of safety it is best only to institute massage when for some months fever has been absent. Those cases are to be excepted where we aim by massage to cause dense infiltrations to break down, to become abscesses. Such a purpose is of questionable value in the pelvis, but in the mamma I have often thus seen infiltrations, which had existed for years, cured through conversion into abscesses.
Other contra-indications are pregnancy, the suspicion of phthisis, latent gonorrhea (Prochownik). Massage should also not be resorted to at the menstrual period.
In regard to the technique of massage we must distinguish between an external and an internal, an active and a passive. The external con sists essentially in centripetal strokings and kneadings, which are applied by the flat hand, the fingers, the thenal eminences, the knuckles. The skin, for the process must be applied to the bare skin, must be smeared with grease, if necessary shaved. W' here possible, the direction should be such that the massaged part lies on a firm surface. Thus we press
against the posterior pelvic wall, the symphysis, the iliac crests. In case of old exudations we first begin to massage at the borders, and when ab sorption has here taken place, wo proceed to the centre of the mass. The association of warm baths (Ziemssen) and warm vaginal injections (Prochownik, Runge) assist gireatly the efficacy of massage.
Internal and combined massage is resorted to either from the abdo men and the vagina, or from the abdomen and the rectum, or from the vagina and the rectum against the symphysis and the anterior surface of the sacrum. The rules for resorting to these combined methods are similar to those described under the respective subjects. The finger in the vagina or rectum should be oiled, the external hand not. The finger in the vagina is kept quiet in order not to excite the patient, and it steadies the parts which are rubbed and pressed upon by the external hand.
If one hand alone is used in the pelvis, then here as well the borders of the swelling are to be first manipulated, otherwise an abscess may readily be caused to form in the centre.
During the massage the patient should lie on a firm couch in a posi tion convenient to the operator, for the steps of the method are very tire some and require the exercise of strength.
External massage should last from ten to fifteen minutes, the internal much less, at best only a few minutes.
After the end of the procedure the patient should lie quiet for awhile, particularly if she has any pain.
Pelvic massage should be associated with the use of warm baths and injections, of medicated baths and resorbents (iodine, iodoform), and also with systematic exercise of the loins and the lower extremities (Reib mayor), even as in case of general abdominal massage.
Passive massage consists in resort to pressure or traction on bands and adhesions in the pelvis. We have often referred to the fact that contin uous traction will cause softening and stretching of the tissue to which it is applied, even as do Bozeman's dilators or Prochownik's hard rubber cylinders, when left for a number of hours to one half day in the vagina.
With the same end in view I have to advantage used the previously described elastic traction, which obviously will answer the purposes of elastic pressure.