INTRA-PELVIC TECHNIC (Manipulative
Surgery of the Pelvic Organs)
PERCY H. WOODHALL, M.D., D.O.
Chronic endometritis usually follows the acute form. The acute symptoms
subside, but leave in their wake a very definite pathology and distressing
symptoms of the chronic disorder. There are many cases in which a history
of an acute attack cannot be obtained. If such was ever present it was
insignificant and unnoticed. The causes of such cases apparently developing
without acute incidence are:
(1). Deranged Spinal Innervation. By disturbing vaso-motor nerve supply
a congestion of the uterus is produced. This of itself will in time lead
to a chronic inflammation or more properly a proliferation of connective
(2). Constitutional Debility from disease, overwork, poor food, repeated
childbearing or prolonged lactation, if not actively causative are important
(3). Impeded Respiration. Pelvic circulation is to a large extent dependent
upon full and free respiratory activity. Whatever interferes with this
tends to cause pelvic congestion. It may be insufficient exercise, improper
corseting, bands about the waist, postural defects, diseases of heart and
(4). Pelvic Inflammation or Tumor. These when they do not directly involve
the uterus do tend to cause chronic congestion of this organ.
(5). Injuries to Cervix or Uterus. Chronic infective processes may follow
laceration of the cervix or lesser injuries in premature or normal births,
difficult or complicated labors, instrumental examination, attempts at
abortion or the improper use of pessaries.
(6). Disregard of the Laws of Sexual Hygiene. Excessive venery, masturbation
or the use of various methods for the prevention of conception.
(7). Subinvolution. This is a rather frequent cause and of itself arises
from improper care of the patient during the puerperium.
PATHOLOGY. Chronic endometritis, if of long standing, has extended beyond
the endometrium and has involved the muscular structure of the uterus and
has become a chronic metritis as well. As such it may involve the entire
uterus or the pathology may preponderate in either the cervix or the body.
If localized in either of these it is more frequently in the cervix, as
it is more subject to trauma during childbirth, and is subject to irritation
whenever there is a prolapsed condition of the uterus. Next in frequency
the entire uterus is affected, the body alone, least frequently.
The mucous membrane is congested, dark red in color, soft, and owing to its
swollen condition it may protrude from the external os and form a red and inflammed
area around it. This was formerly thought to be ulceration of the cervix,
but is now called an "erosion" or a "granular os" (real ulceration of the cervix
is due to an irritation, as from a pessary, friction of the clothing when prolapsed,
an unusually irritating discharge, chancroid, chancre, tuberculosis or malignancy).
The glands of the cervix are hypertrophied and in a condition of hypersecretion.
The ducts of the glands often become occluded and small cysts filled with glairy,
viscid; cervical secretions are formed. These crysts may vary in size from a
pinhead to a pea and often project beyond the external os.
When the body is affected the mucous membrane is thickened, soft and
contains many enlarged blood vessels. It may also be raised in ridges or
is rough and nodular, from the cystic and hypertrophied glands, or there
may be patches of granulations studded over it. All this causes a leucorrhoeal
discharge as well as a tendency to profuse or irregular bleeding. As a
later change there may be infiltration of cells into the mucous membrane.
The organization of these cells into connective tissue and the subsequent
contraction of this tissue may largely destroy the gland tissue of the
endometrium. As a result of the extension of the congestion to the uterine
walls there is cellular infiltration within them with the formation of
connective tissue. This occurs between the muscle bundles and causes the
uterine walls to thicken and the uterus to become enlarged. This condition
may he confined to the cervix or may affect the entire organ. As a secondary
change the proliferated connective tissue may contract and a condition
of sclerosis or atrophy of the uterus occur.
SYMPTOMS. These are very insidious in their onset. The disease
develops slowly and is usually well established before a physician is consulted.
They are local, due to the direct effect of the inflammation, and constitutional,
or reflex, due to irritation of the abundant supply of pelvic sympathetic
Leucorrhoea is often the first and most troublesome symptom and the
one from which the patient seeks relief. This may have lasted for months
or years and be the only symptom. If this is from a cervical inflammation
the fluid resembles the raw white of an egg; is thick, glairy and tenacious.
If it is from an inflammation of the body it is thin, serous, milky in
appearance or in the most troublesome cases, purulent. The discharge is
sometimes brownish or reddish from a mixture with blood. It is sometimes
very irritating to the external parts with which it comes in contact and
may cause almost intolerable itching and burning.
Menstrual disorders are a common and important symptom. No particular
disorder is constant. Depending upon the pathology present the flow may
be scanty, profuse, irregular, suppressed, or as is often the case, prolonged
Pain or discomfort is common. There may be a sense of heaviness, weight,
bearing down or cramplike pains in the uterus. Pain in the back, loins,
legs and hypogastrium is frequent. The patient is easily tired and her
endurance for physical exertion of any kind is lessened. The irritation
may extend to the bladder and cause frequent urination and sometimes severe
dysuria. These symptoms are worse just before and during the menstrual
Sterility is a frequent accompaniment. Not only does the inflamed mucous
membrane offer a poor nidus for the lodgement of the ovum, but the leucorrhoea
has a tendency to destroy or dislodge the spermatozoa.
The reflex symptoms are some of the most distressing produced by the
disease. This is not surprising when the extensive sympathetic connection
is remembered. The appetite is lost or capricious and digestive disturbances,
even to nausea and vomiting, may be present. Constipation, headache,
disorders of vision, pains in the eyes, irritability of temper, restlessness,
sleeplessness, melancholia, hysterical manifestation, mental and physical
fatigue, and breathlessness on exertion may all be found. All of these
symptoms are not found in every case, but a number of them will be present.
In some cases the mammary glands may become tender, the areolae may become
more pigmented and extensive. These symptoms in connection with the increase
in the size of the uterus and the nausea and vomiting may lead to a mistaken
diagnosis of pregnancy.
DIAGNOSIS. On bimanual examination the cervix is found to be enlarged
and tender, the os somewhat patulous, as a rule, and the soft, protruding
mucous membrane, studded with the enlarged and cystic glands can be felt.
The body, if involved, is enlarged, unless a sclerotic change has occurred,
and is often very tender, when pressed between the fingers of the two hands.
If a speculum is introduced the os will be found filled with a thick tenacious
plug of mucus or pouring from it will be the serous or purulent discharge.
Differentiation must be made from fibroid tumors, tuberculosis of the
uterus and cancer. The first is usually easy as the tumor will be discovered
on careful bimanual examination. Chronic endometritis may exist with a
fibroid. Cancer is rare before thirty-five. Its tissue is friable, and
bleeds easily. It is accompanied by an abundant thin, watery and peculiarly
offensive discharge. The early diagnosis of cancer is a matter of such
great importance that if there is any question, a piece of the tissue should
be subjected to a microscopical examination by a competent microscopist.
Tuberculosis of the uterus is usually associated with a similar condition
of the tubes and pelvic peritoneum. Tubercular bacilli may he found in
the discharge or scrapings removed by a curette.
PROGNOSIS. Relief can almost invariably be given, and a cure effected
in time, though the symptoms often return. If there is an extensive laceration
of the cervix an operation for its repair is necessary.
TREATMENT. First of all is removal of causes. After this is done intra-pelvic
technic to restore pelvic circulation, lymphatic drainage and tone to the
affected structures is necessary. All displacements should be corrected
and all adhesions relaxed. Thorough mobility of the uterus should be secured.
It should be bimanuaily moved in all directions, gently but thoroughly.
The uterus itself, both cervix and body should he manipulated between the
external and intra-vaginal hands by alternate pressure and relaxation gently
applied by circular motions executed by the external hand while the internal
fingers steady the organ and apply counter pressure. A sweeping movement
from the sides of the uterus outward toward the walls of the pelvis executed
by the fingers of both hands simultaneously, the broad ligaments with their
contained blood vessels and lymphatics being between them, aids greatly
in relieving the congestion and inflammation.
The effects of these treatments should he carefully noted. If no irritation
is excited the treatments may be given three times a week. If irritation
is excited it should be allayed by spinal inhibition, hot applications
to the hypogastrium and hot douches, and rest in the recumbent posture,
before the treatment is repeated.
The cystic glands in some cases will require opening. This should be
done through a speculum with a bistoury or some other sharp instrument.
The operation should be done under antiseptic precautions and followed
by the application of tincture of iodine or a copious douche of hot water.
Fig. 45. Left-sided Pyosalpinx.
Fig. 46. Double pyohydrosalpinx, Chronic
Adhesive Perimetritis and Oophoritis. Both tubes are almost filled with pus,
the fimbriated ends, walled off both from the isthmus and from the peritoneal
cavity, are transformed into cysts. (Schaeffer, Atlas and Epitome of Gynecology.)
Chronic salpingitis is nearly always the result of the acute form.
PATHOLOGY. The tubal epithelium is diseased the walls are infiltrated
and thickened by inflammatory exudate which may have become organized into
connective tissue. The inflammation may have closed one or both ends of
the tubes, the fimbriated end, usually first. Any serous exudate which
had accumulated within the lumen of the tube may have become absorbed,
or similar pus collections become sterile, unless due to streptococcus
infection. Should these changes not have occurred a hydro-salpinx, pyo-salpinx
or ovarian abscess may remain. Again the conditions within the tube may
have subsided leaving as sequelae peritoneal adhesions which may bind tubes
and ovaries into a distorted and displaced or immobile mass. (Figs. 45,
SYMPTOMS. These are often vague and indefinite. There is usually tenderness
or pain in one or both of the iliac fossae; or perhaps generally over the
lower abdomen, with a sense of weight and heaviness in the pelvis.
Backache is not uncommon. These symptoms are all aggravated by exertion
of any kind, or by standing, and usually by the onset of menstruation.
Leucorrhoea is often present. Sometimes there may be an occasional gush
of muco-purulent fluid, perhaps due to the discharge of an accumulation
of fluid in the tube. Menstrual disturbances are common. Sterility is to
be expected. There is usually some deterioration of the general health
with loss of flesh and strength and often neurotic symptoms. Acute exacerbations
of the symptoms may occur from time to time from various causes.
DIAGNOSIS. This is determined finally by a bimanual examination. In
mild cases the tubes may be found in a thickened or nodular condition as
slightly tender cards passing out from one or both cornua of the uterus.
Again a sausage shaped sensitive mass will be detected, more or less mobile,
and easily recognized as an enlarged tube. If the tube is filled with fluid
a mass may he found beside the uterus by which it may be adherent to the
pelvic wall. The mass may be pear shaped, the small end toward the uterus,
the large end formed by the dilated tube adhering to the ovary. Often the
tube has gravitated to the recto-uterine excavation where it may be fixed
by adhesions. When it contains fluid, fluctuation can usually be elicited.
The ovary can sometimes be felt free of adhesions, tenderness or swelling,
but it is usually more or less affected, and in tender, swollen, involved
in adhesions and matted to the tubes.
A recto-abdominal examination is of aid in making a diagnosis.
TREATMENT. This has been discussed in the Chapter on Adhesions.
This disease occurs more frequently associated with chronic inflammation
of the pelvic peritoneum and connective tissues than as an affection of
the ovaries alone. Both organs may be involved, but when the disease is
unilateral the left ovary is more frequently affected. This is because
of its proneness to congestion, the left ovarian vein not only being without
valves, but it opens into the renal vein at right angles, and because of
its location it is subject to pressure from fecal accumulation in the lower
The disease is most common in married women and during the age of sexual
CAUSES. (1) Deranged spinal innervation.
(2). Pelvic inflammation, especially gonorrhoeal or puerperal. Endometritis,
salpingitis, cellulitis or peritonitis may cause ovaritis by extension,
the two former by extension through the tubes, the latter by continuity
(3). Uterine Displacements by causing congestion. Retroversion especially
as it not only greatly distorts the course of the blood vessels, but also
displaces the ovaries.
(4). Prolapse of the ovary by producing congestion and irritation.
(5). Repeated attacks of acute ovaritis.
(6). Continued congestion. This may be from intemperate coitus, masturbation,
unsatisfied sexual desire or severe exertion, heavy lifting, alcoholism,
heart, lung or kidney disease.
PATHOLOGY. The disease may occur primarily as a disease of the ovary
or a disease of the peritoneal covering of the ovary, or what is in fact,
a peri-ovaritis. In the early stages of the disease the ovaries are congested
and may be enlarged to two or three times their natural size. This enlargement
may be permanent or the contraction of new inflammatory tissue within the
organs themselves, together with the contraction of adhesions surrounding
them, may cause them to atrophy and become smaller than normal. When enlarged
the ovary is often prolapsed into the recto-uterine excavation or by the
side of the rectum. It may be fixed here or in its normal position by adhesions.
Cystic degeneration is not uncommon. (Fig. 10.) The cysts may be small
and multiple, or one large cyst may form and by pressure, cause atrophy
of the ovarian tissue, a true ovarian cyst being formed. The cysts originate
from the corpora lutea or from Graffian follicles, which are prevented
from rupture because they are deeply seated or covered with inflammatory
exudate, or because of insufficient menstrual congestion to, cause their
normal rupture. Waxy degeneration of the ovary sometimes occurs.
SYMPTOMS. These are frequently vague and may be masked by the accompanying
conditions. Pain is rather constant. It is usually located in the
groin, most frequently on the left, and radiates to the sacrum, the rectum,
the bladder or down the thigh to the knee. It is increased by jolting or
jarring, often by defecation or micturition and by coition, if the ovary
is prolapsed. Standing or walking for even a short while is painful and
difficult. The pain is always more severe preceding menstruation, sometimes
several days before, and is relieved if the flow is profuse, but continues
when the flow is scanty.
Sympathetic pains are often felt in the breasts.
Leucorrhoea is sometimes present as a result of the general pelvic congestion.
Menstruation may be irregular or profuse, in the early stages, but later
if the ovarian tissue is destroyed amenorrhoea will result.
Reflex nervous symptoms are sometimes pronounced. Irritability, mental
depression, hysteria, or even epilepsy may result.
DIAGNOSIS. This is made from the history of some previous pelvic inflammation
or the operation of some of the less frequent causes; together with the
tenderness and spherical enlargement of the ovary, (which increases before
menstruation), the premenstrual pain, and the presence of adhesions about
TREATMENT. In addition to the treatment as outlined under Adhesions,
to free the ovary, it should be manipulated directly. This is done
by making circular movements limited, if not to the painful area,
at least to the ovary itself. These motions can be made by either
the external or internal hand. The hand not employed in these manipulations
is used to make counter pressure and to immobilize the ovary while
the motions are made. When prolapsed the ovary can sometimes be
more easily reached by recto-abdominal manipulation.
Efforts should be made with each treatment to replace the ovary.