A system of practical medicine. By American authors. Vol. 4

by Unknown

For digital examination the dorsal position is preferred: the patient should be drawn close to the edge of a bed, or preferably a table, the thighs being flexed, the feet about fifteen inches apart, and the knees widely separated. The examiner should stand facing the patient, never at the side. The index finger of the left⁶ hand, lubricated with vaseline or oil, then slowly advances over the perineum into the vagina, noting the condition of the perineum, the presence or absence of cicatrices or of sub-involution of the vagina or perineum, the capacity of the vagina, the condition, size, and direction of the cervix, its distance from the sacrum and vulva, its mobility or fixation. Now, for the first time, the right hand is pressed well down behind the pubes, and the uterus is engaged between it and the examining finger. (See Figs. 16 and 17.) In this way the examiner may determine more accurately the position, location, and size of the entire organ; may detect the possible presence of complicating tumors, both inflammatory and non-inflammatory; may also note, if possible, the location and condition of the ovaries, which, especially in the posterior displacements, are liable to be prolapsed and excessively sensitive, and to constitute, therefore, a most intractable complication. The index finger sweeps around the cervix in search of tender places which may be the result of former cellulitis or the expression of some neurosis. Above all, the digital examination requires a light, gentle, delicate touch.

⁶ The left-hand method of examination is incomparably superior to the right. The palmar surface of the index finger is more easily directed toward the left side of the pelvis, which is especially subject to disease. Its tactile sense is more acute and more easily educated. The stronger right hand should be free to palpate the surface of the abdomen in conjoined manipulation.

In exploring the uterine cavity to learn its position the fine silver-wire probe of Emmet—not the sound—should be used. The uterus, if freely movable, is liable to be thrown out of its accustomed position by the heavier, unyielding sound. The sound also causes much more pain and exposes the patient to great danger of cellulitis. The frequent lighting and relighting of pelvic inflammation by injudicious slight manipulations of the uterus doubtless led Emmet to the utterance of a prophecy which ought to become classical: "A great advance in the treatment of the diseases of women will be made whenever practitioners become so impressed with the significance of cellulitis as to apprehend its existence in every case. The successful operator in this branch of surgery will always be on the lookout for the existence of cellulitis, and take measures to guard against its occurrence."

When the probe or the sound is used without the speculum, the patient should be on the back and the index finger of the left hand should be used as a guide. The bivalve and cylindrical specula are almost useless in explorations of the interior of the uterus. The exploration is most effectually and gently made with Sims's speculum, the patient being in the left latero-prone position. In some cases the probe cannot be passed by any other method.

Ascent of the Uterus.

This mal-location may result from traction above or from pressure below. The organ may be drawn upward and backward by shortening of the utero-sacral ligaments, which results from inflammation and which usually induces a troublesome form of anteflexion. The enlarged pregnant uterus sometimes becomes attached by adhesive inflammation to a portion of the peritoneum in one of the higher zones of the pelvis or in the abdomen, and the organ may consequently remain fixed in its elevated position after involution. A tumor connected with the uterus or its appendages which has grown too large to be retained in the pelvis may, upon rising into the abdomen, drag the uterus with it. Pressure below may come from excessive distension of the rectum or bladder, or from a large accumulation of menstrual fluid in the vagina, or from a tumor originating in any portion of the pelvis below the level of the uterus. In diagnosis, prognosis, and treatment this displacement is wholly subordinate to the more significant lesions of which it is only the incidental result.

Retro-location of the Uterus.

The uterus may be forced back into a post-normal location by the presence of a tumor in front or by the distended bladder, or it may be drawn back and fixed by peritoneal adhesions. Retro-location is liable to induce vesical irritation by putting the vesico-vaginal wall on the stretch and thereby dragging on the neck of the bladder. This intractable symptom is sometimes relieved by Emmet's buttonhole operation of urethrotomy, for an account of which see section on Anteflexion. This operation would obviously be applicable also for the relief of the same symptom when caused by ascent of the uterus.

Ante-location of the Uterus.

The causes of this displacement are similar to those which produce retro-location; they are—distension of the rectum, post-uterine hæmatocele, post-uterine tumors, and peritoneal adhesions. Ante-location often causes vesical irritation, consequent upon the invasion by the uterus of that space which belongs to the bladder.