CHAPTER V THE PHYSICAL EXAMINATION (Continued) (Part 1)

CHAPTER V THE PHYSICAL EXAMINATION (Continued) III. The examination (continued) — 3. Palpation (continued) : Anatomy of the pelvic contents, p. 43. Barriers to infection, p. 43. Mobility of the uterus, p. 44. The uterine ligaments, p. 44. Mechanics of the pelvic and abdominal contents, p. 44. The pelvic circulation, p. 46. The normal position of the uterus, p. 49. Structures to be distinguished by palpation, p. 49. Inferences to be drawn from palpation, p. 50. (c) The rectal touch, p. 50. (d) The recto-abdominal touch, p. 53. (e) Gynecological positions other than the dorsal position, p. 53: The Sims position, p. 54; The knee- chest position, p. 56; The lithotomy position, p. 57; The raised pelvis position, p. 58; The standing position, p. 59. 4. Odor as a diagnostic sign, p. 60. 5. The collection of the discharges and tissues for microscopic examina- tion, p. 61 : Bartholin's glands, p. 61. Skene's glands, p. 61. The cervical canal, p. 62. The preservation of tissue, p. 63. III. THE EXAMINATION (Continued) 3. Palpation {Continued) Before describing further the pathological conditions which may be diagnosed by the bimanual touch, it will be well to review some points in the anatomy, physiology, and mechanics of the pelvic organs. No attempt will be made to give a complete description such as may be found in text-books of anatomy. Think of the pelvis as a box, closed below by a flexible diaphragm, the pelvic floor, and open above into the abdominal cavity. Direct communication between the pelvic cavity and the outside world is established through the lumen of the Fallopian tubes, the uterine cavity, and the vagina. The barriers to the entrance of infective bacteria to the peritoneum are (1) the narrowings of the canals at the isthmus of the tube, the internal os of the uterus, and the hymen, and (2) the downward current of the secretions, partially maintained by the cilia of the lining epithelial cells, partly by peristalsis of the tube, and also by coughing and straining. 43 44 PHYSICAL EXAMINATION The uterus occupying the center of the pelvic cavity is suspended with its long axis coinciding with the long axis of the pelvis and at right angles to the long axis of the vagina. An important point to remember is that it is suspended and oscillates every time its owner coughs, sneezes, laughs, or moves about. It is held in place by certain ligaments to which it is attached, by its connection with the vagina, by the pelvic floor supporting the vagina, and by the pressure of the abdominal contents. The ligaments are folds of peritoneum containing connective tissue, vessels, and nerves, and, in the case of the round and utero- Fig. 6. — Vertical Median Section of Body. (Kelly.) sacral ligaments, a few muscle fibers. The broad ligaments are on both sides with long attachments to the sides of the uterus, thick at their lower portions, reaching from the cervix nearly to the fundus and attached at their other ends to the sides of the pelvis. At the back are the utero-sacral ligaments, attached to the posterior surface of the uterus at the region of the internal os and extending to the back wall of the pelvis at the level of the second or third piece of the sacrum. The utero- vesical connective tissue is in front and also the round ligaments, which begin as large fleshy cords PALPATION 45 just in front of each horn of the uterus and extend to the internal abdominal rings, becoming smaller and smaller as they approach their insertion in the fat of the pubes. It is to be noted that when a woman is in the erect position (see Fig. 6) the insertions and origins of the round ligaments lie practically in the same horizontal plane, therefore these ligaments act rather as steadying guys than as supports to the uterus. In the case of the broad ligaments they are thick and strong in their lower portions and really support the cervix. So also the utero- sacral ligaments support the lower uterine segment and through it the upper vagina. The attachments of the vagina to the cervix serve to steady this portion of the organ and keep it in its proper relation to the pelvic floor. The supporting action of the pelvic floor will be found de- scribed in more detail in the section on pro- lapse, Chapter XIV, page 220. The abdominal cavity may be likened to an upright cylindrical vessel filled with water and closed at both ends by an elastic mem- brane. The weight of the water causes the bottom membrane to bulge outward and the pressure of the atmosphere the top membrane to sink inward. In the case of a living woman, standing erect, the diaphragm represents the top mem- brane, the pelvic floor the bottom membrane, i « c i ii i i ii FlG- 7-~ A Vertical the walls of the abdomen the vessel, and the Cylinder closed at either liver, stomach, spleen, kidneys, pancreas, in- End by an Elastic Dia- testines, and uterine organs the fluid. The Phragm and Filied with posterior wall of the abdomen is practically immovable like the walls of the tube, but the anterior wall is elastic and capable of varying within wide limits, not only the capacity of the abdominal cavity, but the pressure exerted on its contents. The contents of the abdominal cavity are solid, fluid, and gaseous, and the different structures are stowed so closely together that there is no waste space between them. The pressure which can be exerted on a solid organ in the abdominal cavity such as the liver, has no effect other than to compress it slightly or cause it to move within the limits permitted by its suspending ligaments. 46 PHYSICAL EXAMINATION According to a law of physics, pressure on the fluid contents of a closed vessel is transmitted with equal intensity in all directions. Pressure on the gaseous contents has no other effect than slightly to lessen their volume. The abdominal organs are supported by their ligaments and mesenteries, by each other, by the abdominal walls, — the upper ones by the ribs, — by the anterior projecting lumbar spine, and by the shelf of the false pelvis covered by the psoas muscles. (See Fig. 86, page 221.) Therefore, when the woman is in the erect posture the weight of the abdominal contents, minus what is assumed by the mesenteries and the abdominal walls, rests on the anterior face of the lumbar spine and the slanting brim of the false pelvis, on the lower anterior abdominal wall, and also on the posterior surface of the uterus and the broad ligaments and through them on the pelvic floor. Increased pressure due to con- traction of the abdominal walls, straining; or downward excursion of the diaphragm, coughing and sneezing; is transmitted to the fluid contents in all directions. The posterior walls of the abdomen are rigid, the anterior walls are rigid when contracted, the bony wall of the pelvis is rigid, the pelvic floor is elastic, therefore it bulges downward, like the membrane on the bottom of the vessel in the figure. If instead of being in the erect posture the woman is in the knee-chest position, the conditions are reversed. Now the weight of the abdominal contents comes on the diaphragm and the upper front walls of the abdomen, the pelvic floor is depressed inward like the upper membrane covering the vessel ; when the vagina, rec- tum, or bladder is opened, air rushes in to replace the negative pressure, thus maintaining the equilibrium of the atmosphere, fifteen pounds' pressure to the square inch exerted in all directions. In this connection the pelvic circulation is to be considered. Emmet pointed out long ago (Trans. Amer. Gyn. Soc, 1887, Vol. XII., p. 65) that the veins of the pelvis are without valves, and to overcome the effect of gravity their course is extremely tortuous. "Moreover, this provision is necessary that undue traction be not made upon the vessels with the change of position, and with the increasing bulk of the uterus depending upon gestation." He noted the fact that if we draw down a healthy uterus to a certain point near the floor of the pelvis and hold it there, the cervix and vaginal mucosa become congested very soon, as evidenced by the 47 48 PHYSICAL EXAMINATION dark color of the tissues, denoting venous congestion due to straight- ening out of the tortuous arteries and veins. If the traction is continued until a portion of the uterus projects from the vagina, the tissues become blanched. This is thought to be due to a stretching out and a lessening of the caliber of the arteries so that the blood supply is cut off. The connective tissue Fig. 9.— The Contents of the Pelvis from Above. (Kelly.) of the pelvis is as the trellis to the grape-vine, the pelvic fascia serving as a firm support for the whole. On each side of the uterus are the ovaries floating, as it were, on the posterior surface of the broad ligaments, and the Fallopian tubes extending from both sides of the fundus uteri to the outer extremities of the ovaries. The ovaries and the fimbriated ends of the tubes are steadied at their outer ends by the infundibulo- pelvic ligaments, otherwise their movements are regulated by the PALPATION 49 movements of the uterus, broad ligaments, and the abdominal contents. The bladder, when filled, pushes the uterus and the ovaries and the tubes backward, tending to cause retroversion. The rectum, occupying the left posterior portion of the pelvis, when distended tends to raise the uterus and also makes for retroversion, because limiting the backward excursion of the cervix. It is plain, then, that the normal position of the uterus varies somewhat according as the woman is standing or is lying down, it being somewhat more anteverted in the former and less ante- verted in the latter, because of the effect of gravity and the vary- ing pressure of the abdominal contents on the fundus. Also its position as well as its mobility varies according to the state of fullness of the bladder and the rectum. In practicing bimanual palpation the following structures are to be felt: the symphysis pubis; the promontory of the sacrum; the uterus; the ovaries; the Fallopian tubes, when diseased so that they are thickened or enlarged ; the appendix vermiformis, very excep- tionally and only when thickened or enlarged by disease; the rectum and bladder, only, as a rule, when their walls are thickened. In rare cases having lax and thin abdominal parietes a thick- ened ureter may be palpated at the point where it crosses the pelvic brim just outside the internal iliac artery and the sacro- iliac joint. A thickened ureter may be felt always for two inches or so after it leaves the bladder. In favorable cases the normal ureters may be palpated per vaginam, but this is a fine point and not an accomplishment of many physicians. On making downward pressure on the abdomen the promontory of the sacrum is felt just below the level of the umbilicus. Midway between the promontory and the symphysis pubis, or a trifle nearer the symphysis, the fundus uteri, if normally placed, is to be made out. In the erect posture the external os uteri is on a level with the upper margin of the symphysis pubis; in the recumbent at- titude the os is slightly higher. Steadying the cervix with the vaginal finger the examiner moves the uterus up and down and from side to side, thus gaining an idea of the mobility, whether normal or limited by past or present inflammatory action in the surrounding tissues, or by a tumor or a full bladder. 4 50 PHYSICAL EXAMINATION The uterus may be displaced as a whole downward in the axis of the pelvis (prolapse), or backward (retroposition) , or excep- tionally upward. Alterations in the axis constitute retroversion (often made to include retroposition) and anteversion. Lateral versions are of little importance. Besides the situation, axis, and mobility of the uterus, one notes its form (abnormalities, flexions, and tumors), its size (atrophic or hypertrophic), and its density (soft in pregnancy and septic conditions and hard in chronic inflammation and in many tumors) » Fig. 9a. — Normal Female Pelvis. Pressure on the uterine body eliciting tenderness denotes en- dometritis; and tenderness of the cervix, endocervicitis. Tumors anywhere in the pelvis are to be placed accurately, and their size, form, consistency, and sensitiveness to pressure de- termined, also their relation to the pelvic organs. This relation is established often by moving the tumor and noting if the uterus moves, or vice versa. In acute pelvic inflammation the abdominal walls are apt to be rigid because of the peritonismus which is generally present. Under these conditions little can be learned except by the vaginal touch. Exceptionally it is best to combine instruments with the bi- manual touch as described in Chapter VII. (c) The Rectal Touch. — This method of examination is resorted to in order to gain a slightly higher reach in the pelvis and also in PALPATION 51 cases where it is inadvisable to make the vaginal touch, as in young girls, a virgin with a rigid hymen, the case of a narrow, shallow vagina, or a congenital or acquired atresia of this organ. In making a rectal examination it is desirable to use a large amount of lubricant because of the tightness of the anus. The digital examination of the rectum causes much more discomfort to most women than the digital examination of the vagina. There- fore, every reasonable device should be employed to lessen the discomfort, and also, unless the finger is well lubricated, the anus will grasp it so tightly as to interfere with its tactile sense. It is well to use a thin rubber cot for the rectum, removing it as soon as this part of the examination is over. Before making the examina- tion the anal region is smeared freely with muco-lubricans and the left forefinger is thoroughly anointed as well. Sometimes in patients who are annoyed by an accumulation of gas in the rectum it is well to let this gas out before making the examination, by passing a catheter through the anus before in- troducing the finger. As a rule, however, the presence of gas in the rectum facilitates the examination. The vaginal touch, if it has preceded the rectal touch, will give an inkling as to the condition of the rectum. The presence of fecal matter calls for an enema. In passing the finger through the anus, note the tonicity and strength of the sphincter ani. In the case of hemorrhoids or fissure, where there has been long-standing irritation with consequent increased muscular action, the sphincter will be found in many cases to be hypertrophied. The sphincter may be weak and insufficient because of injury received during childbirth or by over- stretching at the hands of a surgeon, or in cases of rectal prolapse or atrophic catarrh. A fissure by presenting a localized point of sensitiveness, hem- orrhoids by giving a feeling of lumps in the rectal wall, and also polypi by their feeling of pedunculation, may be detected by touch. The situation of the opening of a fistula in ano into the bowel can not be determined without the aid of a probe. Through the thin anterior rectal wall the examining finger makes out the cervix, the bases of the broad ligaments, and the utero-sacral liga- ments. By raising the uterus, these ligaments are put on the stretch and an idea may be obtained as to their relative length 52 PHYSICAL EXAMINATION and thickness. The posterior wall of the uterus is very accessible through the rectum. The ovaries and tubes if prolapsed may be palpated advanta- geously by the rectal touch. Through the posterior wall of the rectum the coccygeal and sacral vertebrae may be felt, and fractures and dislocations of the coccyx determined. Pain caused by pressure on the coccyx may mean coccygodynia. (See Chapter X., page 159.) Infiltrations or new growths in the recto- vaginal septum are to be mapped out, as to size, situation, consistency, and sensitive- Fig. 10. — Half a Female Pelvis, Showing Accessibility of Contents to Palpation. ness, by combined vaginal and rectal touch, the finger of one hand being in the vagina, and the forefinger of the other hand in the rectum. The presence of new growths and strictures in the rectum is diagnosed by the rectal touch. Too great care can not be exercised in washing the hands before changing from a rectal to a vaginal examination and vice versa, because of the danger of transferring infective matter from one organ to the other. In the case of acute infective inflammation of the vulva and vagina, it is wiser not to examine the rectum at all. Often the rectal examination may be deferred as well to a later date. PALPATION 53 By the rectum it is possible to palpate the branches of the sacral plexus of nerves where they course along the sides of the pelvis, and also to palpate a psoas abscess or disease of the sacro-iliac articulation. (d) The bimanual recto-abdominal touch is the same as the bimanual vagino-abdominal touch as regards the structures which are reached, except that greater opportunity is generally afforded Fig. 11. — The Sims Position. for exploration of the cul-de-sac of Douglas and its contents, than by the bimanual vagino-abdominal touch. Digital exploration of the bladder is an unjustifiable procedure, as all the information obtained by touch may be gained by a speculum examination and by vaginal and rectal touch. The danger of incontinence of urine is too great to justify introducing the finger through the urethra, no matter how small the finger may be. (e) Gynecological Positions other than the Dorsal Position. — Besides the dorsal position which has been