The Practice and Applied Therapeutics of Osteopathy Charles Hazzard, D. O. 1905      CHAPTER IX   EXAMINATION AND TREATMENT OF LESIONS OF THE PELVIS  
 
    The importance of pelvic lesion can scarcely be overestimated on account of its relations to the spine above, to its contained viscera, and to the lower portions of the body.  This chapter does not deal with diseases of the pelvic organs, but with bony and ligamentous lesions of the pelvis which are so significant, from the osteopathic standpoint, as causes of disease in the pelvic viscera, in the limbs, or in the body above.
 
 
A.  LESIONS AFFECTING THE PELVIS AS A WHOLE:

    I.  EXAMINATION:  The examiner must not neglect to examine the spine in relation to pelvic lesion as malpositions of this structure are almost sure to destroy spinal equilibrium and thus to effect spinal relations, sometimes to a serious extent.  The most common of such results is swerving or curvature of the spine in response to the efforts of nature to adapt the spine to a crooked pelvis.
    The pelvis as a whole may be tipped forward or backward; may be turned to either side; or may be tilted, throwing one crest up and the other downward.  These malpositions may be combined in various ways.  The general symptoms of such trouble are pelvic diseases, female disorders, backache, neck lesion, sciatica, lameness or paralysis of the lower limbs, etc.  In case of lesion of the whole pelvis, the point of movement upon the spine is usually the lumbo-sacral articulation, but the fifth lumbar vertebra may be carried with the pelvis, or the yielding point may include the whole lumbar region.
    INSPECTION AND PALPATION aid each other in the examination.
    (1) Both superior posterior lilac spines are found equally too prominent in case of backward luxation of the pelvis, or
    (2) They are alike found to have receded anteriorly in forward luxation, or
    (3) One is prominent and the other has receded anteriorly in twisting of the pelvis sidewise, or
    (4) One stands higher than the other in case of tilting of the pelvis laterally.  In the latter case, comparison shows inequality in the length of the limbs, and tenderness is often found in the tissues upon the iliac crest of the low side owing to greater tension upon them.  At the same time the waist line is deepened upon the high side and filled out upon the low side.
    Examination and comparison of the posterior superior spines is best made upon the bared back, with the patient sitting sidewise upon the table.  The practitioner sits upon a low stool directly behind the patient, placing a hand upon each spine, examining and comparing them carefully.  Care must be taken that careless posture of the patient does not cause an apparent inequality, or, on the other hand, that an assumed position does not mask the lesion.
    With the patient sitting or lying on the side, careful palpation is made of the superficial and deep soft tissues in the sacroiliac and posterior sacral regions.  These are commonly sensitive to pressure, but are always tensed, congested and strained over the sacroiliac articulation and the posterior sacral foramina.  These ligamentous lesions alone cause much ill by obstructing nerve-action.  The hand is also passed along the crests of the ilia, making deep pressure in the tissues, to discover tenderness in them.
    Tilting of the pelvis may be ascertained by having the patient hold the tape between his teeth in the mid-line of the body, from which point measurement is made to the inner malleolus of the tibia on each side.  Tilting of the pelvis cannot be ascertained by measurements unless a fixed point above the pelvis is used as the starting point.
    II.  TREATMENT:  In the treatment of all the lesions above described, a preliminary step may usually be made with advantage by thorough relaxation of the soft tissues in the sacroiliac regions as already described.  (Chap. II, divs. III, XIII, XIV, XIX.)
    All the lesions described may be treated with the patient sitting upon the stool, his pelvis fixed by an assistant, who stands in front or behind and grasps the iliac crests, one with each hand.
    (1) For backward tipping, the assistant stands in front and draws the pelvis forward, while the practitioner stands behind, grasps the patient beneath the axillae, and raises and draws the trunk backward.  His work is aided by pressure of his knee against the sacrum.  During this treatment, slight rotation of the body from one side to the other during the lifting process helps the reduction of the lesion.
    (2) For tilting upward on one side or for turning to either side, this same treatment may be applied with variations to suit the condition.
    (3) For tipping forward, the assistant stands behind and draws the pelvis backward, while the practitioner manipulates the trunk from in front, in a similar manner as before, gradually working and drawing it forward.
    (4) For tipping forward, the patient may lie upon his side, the practitioner stands behind the pelvis, making a fixed point with one palm against the lower portions of the innominates and sacrum.  He now draws with the other hand, upon the uppermost iliac crest and anterior superior spine.  The patient lies upon the other side and the motion is repeated.
    (5) For tipping backward, the patient lies upon his side, the practitioner stands behind and presses the flat of his knee against the upper portion of the sacrum.  He now grasps the uppermost limb with one hand, the uppermost shoulder with the other, and draws the body backward, while forcing the pelvis carefully forward.
    (6) For tilting upward of the pelvis, one may adapt to the reduction of this lesion the treatment described in Chapter VII, A, Downward Displacements of Lower Ribs, for the stretching of the quadrati lumborum muscles.
    (7) For turning of the pelvis to one side, one may adapt to the reduction of this lesion the treatment as described in Chap. II, div.  XVIII, third treatment.
 
 
B.  LESIONS AFFECTING PARTS OF THE PELVIS

    We deal here chiefly with lesions of the innominate bones.  They are more frequent than lesions of the pelvis as a whole, and are relatively more important.
    The general indications of innominate lesion, which would lead one to examine for such displacement, are backache, sciatica, pain or lameness in the limbs, limping or unequal gait, pelvic disease, female disorders, etc.
    The lesions of the innominate commonly met with are:
    I.  The innominate displaced forward or backward.
    II.  The innominate displaced upward or downward.
    III.  Combinations of the above, which are the rule.  It is rare that the simple lesion I or II is found.  Frequently the displacement is downward and backward at the some time, lengthening the leg.  This lesion is, on the whole, the most common but the opposite luxation, forward and upward, is frequent.  Generally if the lesion is backward, it is at the same time downward; if it is forward, it is at the same time upward.  In the latter case, the leg is shortened.  Yet it cannot be stated as the invariable rule that the backward lesion is combined with the downward one, and that the upward and forward positions always combine.  The luxation may be back and up, or vice-versa.  Yet, whatever the combined lesion be, a lengthened limb indicates a downward displacement of the innominate, while a shortened limb shows the reverse.
    There are numerous points upon the lateral articular surface of the sacrum, any one of which may act as the fixed point about which the innominate bone may rotate.  This fixed point may be termed the axis of rotation, and its location determines how the innominate rotates, and whether the leg be lengthened or shortened as a result of the lesion.  Thus, if the axis of rotation be located upon the upper and anterior part of the auricular surface of the sacrum, the innominate may rotate forward, while at the same time the posterior superior spine is thrown upward and the leg is lengthened.
    The reason why the downward lesion usually complicates the backward one is found in the beveled edge of the sacrum where it articulates with the ilium.  This bevel is wedge-shaped with its broad end up.  Moreover, its posterior margin is longer, and rises higher than its anterior edge. Thus the beveled auricular surface of the sacrum, which one is broader in front and tilts forward so that the posterior margin of its base stands higher, directs the ilium either downward and backward, or upward and forward, according to the direction of the forces causing the lesion
    IV.  Each innominate may suffer from lesion at the same time, which may be alike upon both sides, or different.
    EXAMINATION: PALPATION, aided by INSPECTION, is used in the examination.
    I.  The length of the limbs is compared, and is one of the first and most reliable methods of examining for lesion of the innominate.  The patient is laid upon his back; care is taken that he shall lie perfectly straight; the limbs are flexed and rotated to relax muscles and ligaments, and to prevent any unnatural tension in these structures from causing merely apparent difference in length.  The limbs are now drawn down and compared at the heels.  It is best to have the patient keep the shoes on, but care must be taken to notice that the heels of the shoes, do not differ in thickness and that they are pushed back snugly against the patients heel.
    This examination is for confirmation only, and while it is a clear indication that one innominate is luxated, further examination is necessary to determine whether one leg is too long, or the other too short, or both.
    II.  Tenderness in the sacroiliac ligaments upon deep pressure, and tenderness in the tissues along the crest of the ilium indicate that the lesion is upon the side upon which such tenderness occurs.  The sacro-iliac ligaments are found tensed upon the side of lesion.
    While this tenderness and tension will usually indicate unilateral lesion, it is not an invariable sign, as the strain thrown upon the opposite side often causes like effects.
    Tenderness at the pubic symphysis is often present in these cases.
    III.  The position of the posterior superior iliac spines is the best indication of lesion, receding anteriorly, prominent posteriorly, up, or down, down and back, forward and up, etc., indicating the corresponding malposition in the bone.  Comparison of the spine of the luxated bone with that of the normal bone is made.  This examination must be made upon the bared back with the patient sitting.  The practitioner sits directly behind the patient, palpation of both spines alike is made at the same time, one hand upon each.  This facilitates comparison.
    IV.  The waist-line is frequently changed in each case.  Usually that upon the side of lesion is deeper through the patient's favoring that side; bending toward it.  For the same reason the  muscles about the hip, pelvis and lower spine upon the opposite side may be hypertrophied.
    V.  The spine adjacent to the pelvis must be examined for curvature, swerving, to one side, hypertrophy or tension of tissues, etc., secondary to pelvic lesion.
    VI.  Measurements may be made from the mid-line of the teeth to the inner malleolus of each tibia.
    TREATMENT: Preliminary relaxation of all surrounding tissues is first done by methods already described.
    I.  BACKWARD LUXATIONS and their combinations:
    a.  Patient lies upon his back; the practitioner stands at the side and places the clenched hand as a fixed point beneath the posterior superior spine of the luxated bone; the knee is flexed against the thorax and is rotated outward strongly enough to raise the weight of the patient and throw it upon the clenched hand.  In this way the weight of the body is made to force the bone forward.
    b.  The patient lies upon his side; the practitioner stands in front of the pelvis, slips one hand between the thighs and grasps the tuberosity of the ischium, the other hand is upon the posterior crest.  He now draws forward upon the latter point while he pushes backward upon the tuberosity.    By pulling forward on the tuberosity and pushing backward on the crest, the anterior displacement of the bone may be set.
    Commonly one alternately pushes and pulls to thoroughly loosen the bone, ending by the appropriate motion to set it.
    c.  Patient lies upon his sound side; the practitioner stands behind the pelvis, making pressure with his hand upon the upper back part of the innominate, while at the same time he draws the uppermost thigh backward.  This forces the bone forward.
    II.  FORWARD LUXATIONS and their combinations.
    a.  The patient lies on his side, lesion uppermost; the practitioner stands behind the sacrum and places his hand or the flat surface of his knee against the lower part of the sacrum, while he draws backward upon the anterior spine and crest of the luxated innominate.
     b.  See "b" above.
    III.  UPWARD LESION.
    The patient sits upon a stool and an assistant stands in front and fixes the pelvis by firm pressure downward upon the crests of the ilia.  The practitioner stands behind, grasps the patients trunk beneath the axilla, and lifts, turns and springs the whole trunk away from the side of lesion.
    This same motion may be applied to forcing the body down toward the side of lesion in downward luxations.
    b.  for reducing the upward lesion one may adopt the treatment described in Chapter VII, A, for the stretching of the quadratus lumborum muscle.
    For downward luxation, see "a" above.
    The SACRUM AND COCCYX have already been discussed.  (Chap. I, divs. V, VI, VII; Chap.  II divs.  XIX, XX).  Anterior or posterior, upward or downward luxation of the sacrum may be overcome by combinations of the treatments described for the sacrum and for the innominate.
Spinal treatment must be given in conjunction with pelvic treatment as the case may require.
 
 
C.  GENERAL POINTS CONCERNING THE PELVIS

    The pudic nerve and artery may be located where they cross the spine of the ischium, and be reached by deep pressure.  The patient lies upon his side, the practitioner stands in front and bends the uppermost thigh backward to loosen the muscles and tissues. Pressure is made down
upon the spine at a point between the middle and lower third of a line drawn from the posterior superior spine of the ilium to the outer side of the tuber ischii.
    The gluteal arteries may be impinged in the same way by deep pressure at a point between the upper and middle thirds of a line drawn from the between the upper and middle thirds of a line drawn from the posterior superior spine of the ilium to the outer side of the great trochanter when the thigh has been rotated forward.
    Deep manipulation may be made over the course of the iliac blood-vessels, beginning at a point about two inches below the umbilicus and  thence diagonally outward to the point where
the femoral vessel leaves the pelvis beneath Poupart's ligament.  The internal iliac artery runs diagonally downward into the pelvis from about the midpoint of the line of the first  manipulation.
    The spermatic or ovarian vessels may be manipulated by deep pressure along a line beginning at the level of the umbilicus, one inch external thereto, and running down to enter the pelvis at a point one and one-half inches internal to the anterior superior spine of the ilium.
    In case of these vessels one aids the venous flow by centripetal progress along the lines defined.  As an aid in relieving or restoring blood-flow in various pelvic diseases the treatments are of value.
The hypogastric plexus is reached by deep pressure at a point about two inches below the umbilicus.  The plexus lies between the common iliac arteries, just below the bifurcation of the aorta.
The pelvic plexuses are reached a little lower and outward from the mid-line, where they lie deep in the pelvis each side of the rectum.
 
 
D.  OSTEOPATHIC WORK PER RECTUM

    The index finger is generally used in rectal work as its use is less interfered with by the knuckles.  Proper precautions for cleanliness and to guard against infection must be employed.  The patient lies upon the right side or stands bent over a table.  The examining finger, lubricated with vaseline or soap-suds is inserted, palm down, into the rectum.  It notes malposition of sacrum or coccyx; weakness, folding or prolapsing of the rectal walls, whether the grasp of the external sphincter is normal; enlargement of the prostate gland in the male; protrusion of the cervix or fundus of the uterus against the rectum in the female; the presence of tumor or other growth; hemorrhoids, protruding or internal.
    The prostate gland lies below the anterior wall of the rectum and is felt in that position about one one-half inches from the anus.  Either lateral lobe, or the central lobe may be enlarged.  In the latter case, stricture of the urethra is threatened, as the gland surrounds its first part.
    TREATMENT: In prolapsed and weakened walls the finger should smooth out the walls and press them upward as far as possible.  This aids reposition, tones nerves and blood-force, and helps to establish normal tone in the muscular walls.
    A weakened sphincter is much stimulated by the simple insertion of the finger.  It may be dilated by introducing two or three fingers held in wedge-shape, spreading them apart upon withdrawal.
For an enlarged prostate gland, the finger makes pressure upon it and is swept laterally over it to aid in freeing the blood-flow from it.  Care must be taken not to irritate it.  Its surrounding tissues should be well relaxed.
    In hemorrhoids, all the surrounding tissues gently manipulated for relaxation and to remove interference with free circulation, after which pressure is made directly upon the intended vessels to empty them of blood, and to gently force them back into place if external. (See "Hemorrhoids.")
Rectal treatments should not usually be given oftener than once a week or ten days.  Great care should always be exercised to cause as little irritation as may be.  As a rule these treatments are but secondary to the removal of pelvic or spinal lesion.
 
 
E.  OSTEOPATHIC WORK PER VAGINAM

    The examination is made with the index finger for the same reasons as in the case of rectal treatment.  The same precautions as to cleanliness, etc., should be observed.
    As a rule local treatment is secondary to that done upon spinal or pelvic lesion, which is usually the real cause of those conditions which require local treatment.
    It is proposed here to review this subject only in a general way, giving the main points in connection with the examination and treatment of this region as a part of the body, leaving
detailed consideration to the portions of the course dealing with the specific diseases of these organs.
    I.  LOCAL EXAMINATION:  The patient on her back or on her side, preferably in the Sim’s position.  In the latter case the practitioner stands behind.  The index finger anointed with vaseline is introduced, passing from the region of the fourchette forward.  The guiding hand is placed upon the abdomen (bimanual palpation) and by deep pressure may aid in locating the organ and in diagnosing its position.  External pressure over the region of the broad ligaments will sometimes reveal tenderness in them in cases of prolapsus uteri.  In case the tenderness is unilateral it is usually in the ligament suffering from the most tension because of the organ having fallen toward the opposite side.
The examining finger should first note the condition of the vaginal walls, which may be weak and flabby, or prolapsed and contorted by the malposition of the uterus.  The presence of enlargement or tumor of surroundings organs is to be noticed.  At the upper extremity of the vaginal canal is felt the cervix protruding into the canal.
    The external os uteri opens transversely at the lower end of the cervix.  In women who have borne children the external os inclines to be circular, but by careful examination the transverse axis may be distinguished.  This is made more certain by the shape of the cervix, which is somewhat flattened antero-posteriorly.  By these two points, the transverseness of the os and the position of the cervix, the diagnosis of the position of the uterus is greatly aided.  If the transverse os (or the longer transverse diameter of the cervix) has assumed an oblique direction in the pelvis, it indicates a corresponding turn in the position of the organ.  This turning to one side is usually combined with the prolapsus or version of the organ in one direction or another.
    If the cervix points forward and upward, the fundus has gone down and back, and may be against the rectum.  In such case the fundus is often felt through the posterior vaginal wall.  Or the uterus may leave turned in falling backward, so that the fundus lies down toward either sacroiliac region.  If the cervix points backward and upward, it indicates that the fundus has descended anteriorly upon the bladder.  It may often be felt through the anterior vaginal wall.  There are all degrees of prolapsus and malposition.  Some may be so slight that the cervix and fundus have deviated but little from normal position.  By noting the direction of the os, the direction of the cervix, and (if possible) the position of the fundus, no difficulty is usually experienced in discovering the form of malposition from which the patient is suffering.
    The different forms of flexion are more difficult, but may be made out by the relative position of the cervix and fundus. For example, if the cervix remains near normal position while the fundus is found backward, retroflexion is diagnosed.
    In these cases, retroflexion, anteflexion, etc., the uterus is bent over on itself.  The examining finger detects the bend in the organ by finding itself in the space between fundus and cervix.
    Adhesions are noted by the fixity of the uterus in malposition; its resistance to pressure directed toward its normal position, or to positions assumed by the patient to aid in replacing it.
    II.  LOCAL TREATMENT: The patient may lie upon the back, upon the side, or kneel upon the table with the trunk inclined forward and the chest touching the table.
    In the first or second position, the patient may, while the operating finger still supports the organ, slip off the table and stand upon the floor, bending forward to remove the weight of the viscera above, while the finger presses the organ toward its position.  In any case, the idea of the treatment is to so manipulate the cervix, by pressure or traction, as to cause the cervix, thus the fundus, to assume its natural position.
    The knee-chest position is the best for the treatment of such cases.  It allows the force of gravitation to act to draw the intestines from the pelvis, which permits easy reposition of the organ.  At the same time the vagina may be dilated, and atmospheric pressure aids materially in forcing the uterus high up to its position.  Moreover, when the patient has changed her position first onto the side, then onto the feet, the intestines fall back around the organ and help support it.
    The treatment described in Chap. VIII, div. III, may be applied to the external treatment of pelvic disorders.
    The round ligaments of the uterus may be located and may be stimulated by pressure upon the upper margin of the pubic arch, about a half an inch externally from the symphysis.
    Inspection of the female perineum sometimes reveals a downward bulging of it in place of the natural slight arch of the healthy perineum.  Such a condition indicates prolapsus of the pelvic viscera.
    In child-birth, strain upon the perineum may be relieved by grasping both tubers ischii from below with one hand, while the other hand presses the tissues over the pubic crest in front down toward the perineum.  The first hand, meanwhile is tending to spring the tuberosities toward each other.