EXAMINATION PER VAGINAM.
For this report I am indebted toDr.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-sacformed 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 tosuit it.’