INTRA-PELVIC TECHNIC (Manipulative
Surgery of the Pelvic Organs)
PERCY H. WOODHALL, M.D., D.O.
Adhesions (Figs. 10, 11, 13, 14, 19, 28, 29, 30, 31, 46) are scar tissue
and are usually the end results of acute inflammation. This inflammation
is either specific, due to the gonococcus, or septic and due either to
the pyogenic organisms or in a small percent of cases to the colon bacillus.
Adhesions are sometimes apparently due to mechanical irritation of one
serous surface when opposed to another under undue pressure. An example
of this is when a retroverted uterus becomes adherent to the posterior
wall of the pelvis. As further examples may perhaps be placed, those cases
in which the pelvic colon is found adherent to the uterus and adnexa. In
the female constipation is common and the pelvic colon is often distended
with feces and from pressure the opposed serous surfaces may become irritated,
abraded and then adherent. The colon bacillus as well as the
streptococci and staphyloccocci often found in the colon, may also play
a part in these processes.
It also seems possible that adhesions might result from long continued
passive congestion with an outpouring of plastic lymph, followed by its
ultimate organization. Here too, the presence of a low grade of infection
may be the determining factor.
It may be well in this connection to discuss the relationship of deranged
spinal innervation (the osteopathic lesion) resulting from disturbed structural
relations along the spine and intra-pelvic inflammation. Dr. Carl P. McConnell
in Bulletin No. 1, The A. T. Still Research Institute, says, "The lesion
effects upon viscus correspond definitely to the path of spinal innervation.
It would seem that fundamentally, impairment of the vaso-motors plays the
important role, though undoubtedly disturbance of viscero-motor, secretory
and other nerves are necessary factors, aid herein, probably vessel relaxation
would take place as a reparative process. Congestion and inflammation are
basic to the large majority of diseases, and in all our experiments we
find vessel disturbance a constant feature whether in the immediate locality
of the osteopathic lesion or as a remote effect, but still related physiologically
by way of the nerve centers. Consequently, we conclude some involvement
of the vaso-motor mechanism is fundamental to at least a large portion
of visceral lesions. Remember we are considering only the Osteopathic experimental
field as it is presented to us, not attempting to correlate it with other
undoubted etiologic factors."
In the same bulletin the experiment of Dr. Louisa Burns showed that
lesions through the lower dorsal and lumbar regions were regularly followed
by dilatation of the blood vessels of the reproductive organs. Dr. Burns
in Bulletin No. 5 says, "There seemed no doubt that vertebral lesions
affecting the centers in the lower thoracic region are more apt to affect
the ovaries or the testes; that lesions in the upper and mid-lumbar regions
are more apt to affect the uterine and prostatic tissues; that lesions
of the sacrum are more apt to affect the rectal, vesical and vaginal tissues.
... Bony lesions, with their disturbing influence upon circulation, innervation,
secretion and nutrition must be considered important factors, but not the
only factors, in controlling the localization of infections and the power
of the tissues to overcome various infectious agents. Local circulatory
disturbances may be due to the bony lesion exclusively."
Dr. Burns has also shown experimentally in rabbits that lesions affecting
the spinal innervation of the pelvic tissues produce edema, decreased elasticity
and lessened tensile strength of the broad ligaments and a localized acidosis.
Clinical observation and experience give every evidence that similar lesions
cause identical conditions in the pelves of women. These conditions undoubtedly
lessen resistance and favor infection.
Adhesions occur in two tissues of the pelvis - peritoneum and connective
tissue. It is unusual for either of these tissues to be involved alone.
They are so closely related anatomically that pathology arising in one
would inevitably spread to the other.
The gonorrhoeal inflammation causing adhesions travels by way of the
mucous membrane of the uterus to the uterine tubes and from thence to the
peritoneum through the fimbriated end of the tube. The progress of the
infection is determined by the amount and virulence of the invading infection
and the local and systemic resistance offered to it. It may result in a
mild salpingitis with destruction of the ciliae of the tube and a mild
thickening and infiltration of its walls. A slightly more severe type will
extend through the tube walls involving their peritoneal coverings and.
the connective tissue between the layers of the mesosalpinx. Further invasion
and involvement of the peritoneum may be prevented by the sealing of the
fimbriated end of the tube by plastic lymph. There may now occur a serous
exudate into the tube, which is exceedingly likely to become purulent and
unless the uterine end remains open and allows drainage, a pyo-salpinx,
a collection of pus in the tube, results. If this does not occur the tube
walls may become thickened and nodular and infiltrated with pus.
Should the fimbriated end not become sealed the pus leaks out, inflammation
extends and involves the peritoneum on and about the ovary.
Fig. 10. Pelvic Peritonitis.
The uterus is displaced anteriorly and to the left. Adhesions bind it to
the bladder and intestine and to the tubes and ovaries ***. These
plastic inflammations are due to gonorrhoeal salpingitis or to metritis
or perimetritis from puerperal or operative lesions of the genital mucous
membrane. (Schaeffer, Atlas and Epitome of Gynecology.) Left ovary contains
Fig. 11. Pelvic Perintonitis,
Perioophoritis, PerisalpinIgitis and Right-sided Pyosalpinx. View of the
pouch of Douglas. Pseudoligaments fix the uterus and its adnexa to the
sigmoid flexure. The left tube is bent at an angle, the right tube shows
inflammatory redness, and is transformed into a pyosalpinx by the agglutination
of the abdominal ostium. The globular divisions of the tumor are characteristically
shown. (Schaeffer, Atlas and Epitome of Gynecology.)
Plastic lymph is poured out and the fimbriae may become adherent to
the ovary and an ovarian or a tubo-ovarian abscess form. The ovary
may escape, direct involvement only to be surrounded and covered by this
fibrinous exudate which as it organizes and contracts not only interferes
with the rupture of the Graffian follicles but may compress the ovary.
Because of the inflammation of its peritoneal covering the ovary becomes
closely adherent to all other peritoneal surfaces which come in contact
with it. Should the stroma of the ovary become involved a true ovarian
abscess, even to the size of an orange may develop. Escaping this an atrophic
or "cirrhotic" ovary may result. The ovarian function is now damaged, if
not destroyed, and severe symptoms may arise particularly with the onset
of the menstrual congestion. The inflammation may extend further causing
a more or less extensive peritonitis. If this is fibrinous in nature and
sufficiently extensive, the coils of intestines in the pelvis will become
adherent to the pelvic organs. If purulent, in addition, there will be
one or a number of small collections of pus within the pelvis. These collections
lie among the adherent organs or may have even burrowed into the connective
tissue. The picture is now one of general pelvic inflammation
salpingitis, plus ovaritis or per-ovaritis, plus peritonitis, plus cellulitis
- with the involved tissues bathed in and infiltrated by pus and agglutinated
with fibrinous exudate. (Fig. 10, 11).
Should resolution occur and this condition pass into a stage of chronicity,
at which time only would it be amenable o intra-pelvic technic, there would
be found a conglomerate mass in one or both sides of the pelvis composed
of tube, ovary, peritoneum, connective tissue and perhaps coils of intestines
and adhesions. The fibrinous exudate of the acute stage has followed its
natural course of organization and contracture and is now binding these
deformed and distorted tissues together in some abnormal position. If the
connective tissues in the uterine ligaments were affected in the acute
stage, these, too, have contracted (shortened) and have drawn the uterus
into some malposition. In severe cases with extensive involvement the resulting
contracture may have almost obliterated the ligaments and connective tissues
and left the uterus immovably fixed in some displaced or perhaps normal
position. (Figs. 13, 14.)
The disastrous effects of this condition upon the blood vessels which
so freely traverse this connective tissue is easily imagined. As connective
tissue, following its inflammation, is organized into scar tissue with
its inevitable contracture, blood vessels are obliterated and vital functions
are correspondingly disordered. The same is true of the lymph channels.
They, too, disappear and proper nutrition and drainage become impossible.
Even more important is the involvement of the nerve tracts and plexuses.
Interwoven as they are through this connective tissue and in turn permeated
by it, if by any means they escape destruction in the acute attack, they
are subject to continuous pressure and tension and distortion by the unrelenting
grip of the contracting tissues. Can a more prolific source of reflexes
These adhesions vary all the way from gossamer-like films and spider
web threads, easily broken by slight traction, to sheets and cords of organized
tissue which it is impossible to rupture without serious damage to the
organs to which they are attached.
Should a limiting exudate fail to form either because of the virulence
of the infection or the weakness of the natural defenses a diffuse peritonitis
with a fatal outcome may result.
The inflammation causing adhesions due to pus germs generally follows
labor, abortion or the use of instruments within the uterus. In such cases
the inflammation usually passes directly through the uterine wall by the
way of the lymphatics to the connective tissue, located principally at
the sides and in front of the cervix and at the base of each broad ligament.
The involvement may vary from a small localized spot to that of the entire
area of connective tissue. As the inflamed area extends the peritoneum
superposed becomes affected, adding a peritonitis of proportionate extent.
Following the actute state there may be abscess formation that demands
immediate evacuation or resolution may occur. In the latter case
scar tissue, adhesions, develop in the infiltrated areas of the acute stage.
Organization and contracture occur in these areas and displacement or immobilization
of the uterus results as before mentioned. It is doubtless true that these
contractures occurring in the connective tissues are a more prolific cause
of displacements, than those occurring primarily in the peritoneum.
In the treatment of these cases it is important to determine if possible
whether the original acute inflammation was due to infection by the gonococcus
or the streptococcus, these being the most frequent infecting agents. As
a rule a collection of gonorrhoeal pus becomes sterile or innocuous in
a few months while it is doubtful if streptococcus pus ever does. In treatment
the danger of arousing a streptococcus inflammation, while remote if care
is used, is still present. As a general rule, with exceptions, gonorrhoeal
infection travels along the mucous membranes. Some one has said that it
is a "surface rider," and its chronic lesions are mostly along the tube
and its immediate vicinity. The streptococcus usually travels by way the
lymphatics and its chronic lesions are found mostly in the pelvic connective
tissues. In the gonorrhoeal cases there is, at least the clinical
history of gonorrhoeal infection or of trouble developing in the pelvis
without apparent cause, often soon after marriage. In the streptococcus
cases there is the history of labor, abortion or some operation about the
uterus or cervix.
Aside from the purely physical effects of adhesions, Graves has the
following to say: "The conditions which produce genital neuroses are more
apt to be the minor pelvic affections which, without causing severe symptoms,
maintain a nagging discomfort and keep the searchlight of the attention
constantly turned upon them. The most common or most important source of
such neuroses is that which comes from the adhesions of chronic pelvic
inflammation. The discomfort may be caused by peritoneal irritation or
by the immobilization of organs which normally enjoy free motion in the
The symptoms arising from pelvic adhesions may vary according to the
location and severity of the primary attack and the amount of destruction
of tissues and function it has caused, all the way from a slight local
indisposition to chronic invalidism. This is easily appreciated when one
considers the varied pathology which a given case may present. The area
involved may be slight or it may be enormous. The degrees of intensity
may vary as greatly. Then, too, the functional importance of the affected
part will intensify the symptoms. Because of the enormous nerve supply
the reflex or constitutional symptoms are fairly constant.
The victim of adhesions usually has the appearance of invalidism. She
looks tired, worn and prematurely aged. She complains of fatigue and nervousness.
She is depressed, irritable or even hysterical.
Pain or some degree of discomfort is usually present. This may be constant,
definite and localized. It is often complained of in one or both of the
iliac fossae. Again it is an indefinite and general pain throughout the
pelvis. Such pains may be reflected to the back or down the legs. The so-called
"bearing down pain" which is so commonly complained of is frequently due
to adhesions. It is often caused by the pull or the drag of the pelvic
organs upon the adhesions rather than by any prolapse of these organs.
Such pains are often bitterly complained of when no prolapse is discernable.
Again the pain may be intermittent and caused by exertion of some kind.
Standing, walking, jolting, the use of a sewing machine or any overexertion
may cause the pain to appear. Whatever the character of the pain it is
usually increased just before or at the menstrual period. This is because
of the increased pressure upon the nerve terminals from the congestion
attending this function.
Disordered menstrual function is frequent. It may be profuse in the
more recent cases to later become scanty or irregular from the general
atrophic changes caused by the constriction of blood vessels and nerves.
Dysmenorrhoea is common. It may occur as a general deep ache throughout
the pelvis with an increase of the backache, legache and bearing down pains.
A localized ovarian pain is often manifest at this time. The menstrual
flow is often dark and clotted.
Leucorrhoea is present in many cases. In some of the cases of long standing
it may not be a noticeable symptom. Atrophic changes have supervened in
the meantime and the excessive flow has ceased. Occasionally there
may be the emptying of a hydro-salpinx through the uterine end of the tube,
accompanied by a profuse gush of serum or pus from the vagina.
Sterility is almost inevitable. The tubes are often occluded by stricture,
adhesions or the accumulation of serum or pus within them. The ovaries
may be covered by adhesions or have become the seat of a severe ovaritis.
Constipation is common in women ordinarily, but some cases are due to
adhesions constricting the colon, rectum or interfering with peristalsis
in the colon.
Pelvic adhesions are diagnosed by bimanual palpation only after one
has become familiar with the contents of the normal pelvis, their location,
size, consistency, sensibility and normal mobility.
One of the first steps in diagnosis is to test the mobility of the uterus.
In nearly every case this is diminished. It may be but slightly so,
or in severe cases it may seem as fixed as though it had been set in cement.
In these extreme cases further palpation of the pelvic organs is almost,
or quite, impossible. Sometimes by a recto-abdominal examination by getting
the finger in the rectum above the mass of adhesions some additional information
may be obtained. When the uterus is movable, the pain or discomfort that
may be caused by an attempt to move it is of some diagnostic importance.
Suppose on moving the uterus toward the right wall of the pelvis, the patient
in response to an inquiry says that pain is felt on the left and if at
the same time motion is restricted toward the right, one would strongly
suspect, adhesions in the left side of the pelvis. If now with the hand
on the abdomen and the middle finger of the intra-vaginal hand the uterus
is pressed toward the right side of the pelvis the tightened adhesive band
can be felt with the index finger of the intravaginal hand. By approximation
the two hands, keeping the uterus toward the right, the adhesions can be
definitely located and their size, rigidity and tenderness determined.
This applies particularly to adhesions arising in the connective tissues
lateral to the cervix and in the broad ligament. If on the other hand when
the uterus is pressed toward the right and pain is caused on that (the
right) side it is evident that some inflamed or sensitive organ is being
pressed upon. Look now for an inflamed ovary or a growth of some nature.
These symptoms and conditions are of course reversed when the uterus is
pressed toward the left, if there is similar pathology on that side.
It sometimes happens that adhesions and inflammation or a growth occur
on the same side of the pelvis. An inflamed ovary, or tube may exist coincident
with adhesions. In such instances pain is caused both by pressing the uterus
from the affected side and stretching the adhesions and by pressing it
toward the affected side and compressing the inflamed tissues or growth.
If on pressing the uterus upward and forward mobility is restricted
and pain is elicited toward the back or rectum, adhesions along the course
of the sacro-utterine ligaments are to be suspected. Their presence can
he positively determined by palpating them between the fingers of the two
After the mobility of the uterus is tested in all directions and the
cause of decreased mobility determined, the ovaries and tubes are next
palpated. This is done in the manner indicated in the chapter on
Examination. On one or both sides a mass may be felt in which it may be
impossible to differentiate the organs and tissues composing it. This mass
is usually separate from the uterus, but may be closely adherent to it.
Oftentimes the tortuous, nodular or sausage shaped tube may be felt and
traced back to the cornua of the uterus. Again only an enlarged and tender
ovary, perhaps displaced downward and backward even to the bottom of the
recto-uterine excavation, will he found. These conditions may be found
on one or both sides of the pelvis. Sometimes the tubes and ovaries of
both side are found prolapsed and adherent in a single mass in the posterior
part of the pelvis.
Readustment of organs and reconstruction of tissues with restoration
of function is the ideal in treatment.
Some time ago in an article on this subject I used the term "ankylosis
of the uterus." If this idea be extended to include the ovaries and
tubes also, I believe a better conception of the principles involved in
the treatment of these cases will be gained. Motion is of course not the
primary function of these organs, but it is a condition very necessary
to their proper function. That this motion may be free they are covered
by serous (peritoneal) surfaces which glide easily over each other unhindered
by the loose and elastic connective tissue about the cervix and in the
broad ligaments. Under the influence of inflammation, a plastic exudate
is thrown out, serous surfaces become adherent, connective tissue is infiltrated
and finally contracts and limitation of motion results. While this is not
the matter of greatest moment in pathology, it does give the first indication
for treatment, RESTORATION OF MOTION. Without this, adjustment, the ideal
in treatment is impossible. Motion is restored here according to the same
principles that would be used in an ankylosed and flexed knee joint. The
contractured tissues are stretched longitudinally and if necessary are
at the same time manipulated transversely. Suppose uterine mobility is
restricted toward the right and a contractured band is found in the base
of the left broad ligament. To treat this the uterus is pressed toward
the right which stretches the band longitudinally. If the band does not
yield it is at the same time manipulated transversely by the hand not employed
in pressing the uterus to the right. Circumstances will determine the hand
with which to do the active manipulation. Ordinarily it is best done with
the abdominal hand. The finger tips, the flexed knuckles or any part of
this hand may be used that most readily accomplishes the purpose intended
whether it be stretching or manipulating. Should the abdominal tissue he
thick or tense the stretching may be done by the abdominal hand and the
direct manipulation by the intra-vaginal hand as the intervening vaginal
tissues are much thinner and the manipulation is more direct and more effectively
applied. Crowding the hands into the pelvis will often sufficiently stretch
the adhesions so that the transverse manipulation may be made with the
adhesions between the fingers of the two hands. In this way vigorous and
effective treatment may be given. Occasionally only the longitudinal stretching
will be employed, but as a rule both maneuvers will be combined. Should
the restricted mobility be toward the left side the methods are reversed.
If on pressing the uterus upward and downward restricted motion and
a contracted band is found running backward and upward along the course
of the sacro-uterine ligaments, this band is stretched by pressing the
uterus forward and is manipulated just as the bands running laterally in
the broad ligaments. Here particularly will it be possible to manipulate
the stretched bands between the two hands. In those cases in which
the restricted motion is found when the uterus is pressed posteriorly,
the band anterior to the cervix is stretched and manipulated according
to the same principles. When the mobility of the uterus is restricted in
all directions and the organ is fixed, the stretching manipulation must
extend outward from the uterus in all directions. As a rule a point of
least immobility can be found and working from this as a starting point
a great deal can sometimes be accomplished.
The transverse manipulations should not be confined to one point of
the contracted band, but beginning at one end its entire length should
In the case of the agglutinated tube, ovary, intestinal coil, peritoneum,
etc., an attempt should be made to separate and identify the different
structures. This is done by trying to insert the tips of the fingers, usually
of the intra-vaginal hand, between the separate parts of the mass and in
a manner try to pry them apart and at the same time manipulate the mass
with the fingers of the other hand. In the case of an enlarged tube, especially
if containing fluid, all manipulations should be made toward the uterus
so that it may be drained in this direction rather than into the peritoneal
cavity. This precaution is particularly important if there is any reason
to suspect streptococcus infection as the primary cause of the disorder.
No inflexible rule regarding the force, the frequency or the length
of time necessary for a treatment, can be given. Each case presents a different
problem and requires judgment to meet its individual conditions as determined
by a careful and correct diagnosis. Sufficient force should be used
to cause some discomfort, but care should be used, especially in the beginning
of the treatment, never to cause severe or excruciating pain. Certainly
at no time should enough force be used to rupture an abscess wall, the
tube or intestine. The manipulations should be gentle, firm and deliberate.
Some soreness or discomfort will often result and this is a fair index
as to the severity of the treatment. If it is particularly severe the following
treatment should be less vigorous. This, too, is a good indication for
the frequency of treatment. The treatment should be repeated as soon
as the effect of the previous treatment has subsided. This is not
oftener than every other day, possibly only twice a week; while rarely
a week or ten days should elapse before another treatment can and should
be given. Ordinarily cases do best if treated twice or three times a week.
Reactions to treatment should be closely watched. Accomplishment and not
length of time should be the criterion of treatment. It is given for a
definite purpose and should be persisted in until some part of this purpose
has been accomplished. This should ordinarily be done in less than ten
It is advised that the intra-pelvic treatment should precede any other
that is to be given.
Inhibition over the lower lumbar and upper sacral regions in addition
to an ice bag or hot packs to the hypogastric region, or a hot douche
or a hot Sitz bath will aid in relieving the pain, if any occurs,
following a treatment.