valuable landmark. From this point the outlines of the greater and
lesser sacro-ischiatic foramina can be traced by the fingers; and any
new growth, encroaching on the pelvic cavity through these apertures,
could be easily detected.
‘If the hand be now pushed farther up the gut, the promontory of
the sacrum is reached; the pulsation of the iliac vessels becomes
manifest, and the course of the external iliac can be traced along the
brim of the pelvis to the crural arch, the loose attachments of the
rectum permitting very free movement in this direction. The internal
iliac artery can also be followed to the upper part of the great
sacro-ischiatic foramen.
‘By semi-rotatory movement, and alternately flexing and extending the
fingers, the hand can gradually be insinuated into the commencement of
the sigmoid flexure. In the sigmoid flexure the fingers can explore the
whole of the lower part of the abdomen, the loose attachment of this
portion of the gut permitting the hand to travel freely over the iliac
and hypogastric regions.
‘The parts that can here be felt are the bifurcation of the aorta, the
division of the common iliac arteries, the iliac fossa, and the crest
of the ilium.
‘In the female, the uterus in the middle line, and the ovaries on
either side, can be readily distinguished.
‘In the introduction of the hand into the rectum, in a patient under
chloroform, the dilatation of the sphincter ani should be very gradual:
first two fingers, then four, and finally the thumb should be passed.
It is necessary to use considerable force, and unless care be taken,
not only the integumentary edge of the anus, but the sphincter itself,
may be lacerated. The introduction is facilitated by the application of
the other hand upon the abdomen.
‘When the dilatation has been gradual and the hand not too large, no
incontinence of fæces and no very considerable amount of pain has
resulted.
‘We have been informed on reliable authority that permanent
incontinence of fæces has occasionally followed these examinations.’
Lastly, we think it right to insist upon the important fact that, in
some subjects, even a small hand cannot be passed up the rectum beyond
the reflection of the peritoneum over the second part of the gut. In
such instances the peritoneum offers a resistance like a tight garter,
and prevents the farther advance of the hand without great risk of
laceration of the parts.[12]
_EXAMINATION PER VAGINAM._
For this report I am indebted to Dr. Godson, of St. Bartholomew’s
Hospital:--
‘The finger introduced into the vagina comes upon the carunculæ
myrtiformes, which are vascular membranous processes independent of the
hymen, variable in number, size, and form. It also feels the transverse
ridges known as “rugæ.”
‘Along the anterior wall of the vagina the finger readily detects the
track of the urethra, which feels like a prominent cord and forms an
excellent guide to the orifice of the meatus urinarius in passing a
catheter. The orifice is indicated by a slight semicircular prominence,
situated about one-third of an inch above the orifice of the vagina.
Behind the urethra the finger comes upon the posterior wall of the
bladder. But the bladder is not perceptible, as such, to the touch
unless distended. With a catheter previously introduced it is much more
readily explored.
‘The septum between the vagina and the rectum is so thin that, should
the rectum contain fæcal matter, its presence becomes at once apparent
to the finger.
‘The cervix uteri is felt protruding from the roof of the vagina in
a direction downwards and backwards--that is, in a line from the
umbilicus to the coccyx. The os uteri is felt, small and round, in the
centre of the cervix. The posterior lip feels a little lower than the
anterior. The cul-de-sac formed by the vagina in front and behind the
cervix should be perfectly elastic to the touch, and not communicate
the sensation of a resisting body. Any resistance here bespeaks an
abnormal condition.
‘The bony landmarks within reach of a finger, or perhaps two, in a
woman who has not borne a child, are the symphysis pubis, the rami
of the pubes and ischia. The coccyx and part of the hollow of the
sacrum may also be felt, but not without exerting much pressure on the
posterior wall of the vagina, which gives considerable pain. If the
promontory of the sacrum can be felt, it is a sign that the conjugate
diameter of the pelvis is abnormal.
‘The finger in the rectum can detect almost everything which has been
mentioned in connection with the vagina. The shape and direction of
the cervix uteri are almost as perceptible, and the posterior wall of
the uterus can be examined. The peritoneal fold termed recto-vaginal
(Douglas’s space) can also be well explored, and anything abnormal
detected in this direction--a point of great importance in the
diagnosis of diseases and displacements of the uterus.
‘The ovary in its normal state and position cannot be detected by
the touch even with the hand firmly pressed on the hypogastrium. If
a movable body be felt through the vaginal roof on one side of the
cervix, if this body be exquisitely tender and recede at once from the
finger, it is an ovary in a state of prolapse.
‘The fundus of a healthy unimpregnated uterus never rises above the
level of the brim of the pelvis, and cannot therefore be felt by
pressing the hand on the hypogastrium.
‘The direction of the uterus is subject to changes which cannot be
looked upon as abnormal. The fundus may be thrown backwards by a
distended bladder, or forwards by a distended rectum. The axis of its
cavity is not a straight but a curved line; and uterine sounds should
be shaped to suit it.’
NOTES.
[1] Some pertinent remarks on this subject have been made by Mr. C.
Heath in a pamphlet ‘On Anatomy in relation to Physic.’
[2] In several adult normal skeletons measured in the Hunterian
Museum, the average diameters of the upper opening of the chest
were--antero-posterior, about 2¼ inches; transverse, about
4½ inches. In the skeleton of O’Brien, the Irish giant, the
antero-posterior diameter measures 4 inches, the transverse 6¼.
[3] Special experiments upon this subject were made many years ago by
the late Professor Quekett in the work-rooms of the College of Surgeons.
[4] See a beautiful illustration of this in Sir C. Bell’s ‘Anatomy of
Expression,’ p. 160.
[5] See some good observations on the position of the enlarged spleen,
by Sir W. Jenner, ‘Brit. Med. Journ.,’ Jan. 16, 1869.
[6] ‘Lectures on Rest and Pain,’ by John Hilton, F.R.S. London, 1863.
p. 280.
[7] Nélaton, ‘Pathologie chirurgicale,’ t. iv. p. 441. 1848.
[8] Bigelow, ‘Mechanism of Dislocation and Fracture of the Hip.’
Philadelphia, 1869.
[9] See Pruge on ‘Ossa Acromialia’ (‘Zeitschrift für rationelle
Medizin’), 3. Reihe, Bd. vii. 1859.
[10] See on this subject a monograph, ‘Canalis Supra-Condyloideus
Humeri.’ By W. Grüber. Petersburg, 1856.
[11] ‘Ueber Grund und Bedeutung der verschiedenen Formen der Hand.’
Stuttgart, 1846.
[12] For further information on this subject, see a paper by Mr.
Walsham, in St. Bartholomew’s Hospital Reports, vol. xii.
_Spottiswoode & Co., Printers, New-street Square, London._
Transcriber’s Notes
A few obvious errors in punctuation have been fixed.
The reference in section 153 to tabatière anatomique in section 140 has
been corrected to 144.