Treatment

Readjustment 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 be thick or tense the stretching may be done by the abdominal hand and the di rect 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 often 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 be covered.

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, espicially 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 minutes.

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.