Corpus Uteri.

When the uterus is normal in size, shape and position the finger in the vagina may be pushed high up in the fornices without encountering any check except the elastic counter-pressure of the vaginal walls and surrounding connective tissue. The hard body of the uterus, when the bladder is empty, may be felt for a short distance along the anterior vaginal walls, gradually receding forwards and upwards beyond reach. Any considerable quantity of fluid in the bladder should lift the uterine body entirely out of reach of the finger in the vagina (see Fig. 3), and give a sensation of semi-elastic or characterless resistance.

Palpation of the Displaced Uterus.

If the fundus be displaced towards the symphysis the uterus may be felt as a smooth pear-shaped body, three inches long, lying flat over, or down upon the anterior wall of the vagina with the os, at the smaller end, pointing backwards.* If the fundus be displaced backwards the same pear-shaped body may be felt over the posterior fornix vagina, lying with its larger end against or near the sacrum, and the smaller end turned forward, so that the os looks toward the perineum or the pubis. An elevation or concavity of the anterior fornix is caused by a backward displacement of the fundus, and is in proportion to the displacements.

The resistance of the connective tissue at the bases of the broad ligaments prevents palpation of the body of the normally placed uterus through the lateral fornices. When, however, the fundus is displaced laterally, the os is turned to the opposite side, and thus secondarily displaced, and the finger can feel the lateral uterine wall on the side of the displacement to be continuous, almost in a straight line, with the side wall of the cervix. Pressing high up in the anterior fornix, on either side of the median line, it loses the corpus uteri on one side, but can trace it for some distance toward the lateral pelvic wall on the other. The lateral fornix having a definite relation to the side of the cervix, must be shallower and wider than its opposite. on the side towards which the fundus (or from which the cervix) is displaced.

When only the cervix is displaced laterally, the os is felt turned toward the side of displacement so as to be entirely to one side of the rectum and coccyx, and the body to extend toward the median line, sustaining about the same relation to the direction of the pelvic axis as in displacement of the fundus to the opposite side, but it will reach

* B. S. Schultze calls attention to the fact that the uterus is larger during life than after death owing to the amount of blood its vessels contain. During the ante-menstrual congestion it is still larger.

only a little beyond its normal median position. The fornix is also higher and narrower on the side of the cervical displacement-unless altered by a growth or appreciable deposit-but the disparity of the lateral fornices is greater in width but less in height than that accompanying primary fundal displacement.

In extreme lateral displacement of either end of the uterus, the other end while turned in the opposite direction is drawn to, or over, the median line, so as to be mainly in the same side of the pelvis.

In co-existent primary displacements of the fundus to one side and the cervix to the opposite, both are nearly equidistant from their median positions, but the direction of the long axis of the body of the uterus will be felt to be more transverse than the amount of primary displacement of the cervix or fundus alone would produce. The long axis of the body points toward the iliac fossa rather than merely to one side of the pelvic axis. The fornix on the side of the cervical displacement will be very much higher and narrower than its opposite.

Lateral displacement of the whole uterus may be recognized by the nearness of the cervix to one lateral pelvic wall, or by its position entirely to one side of the rectum and coccyx, accompanied by a nearly normal direction of the uterine axis or lateral walls, as determined by passing the finger-tip up into and in front of the lateral fornices. The fornix on the side of the displacement will be very much narrower, but of almost the same height as its opposite.

While examining for lateral displacements, when the fundus lies back of the pelvic axis, we of course palpate its posterior surface and lateral edges through the posterior and lateral fornices (see Fig. 47). The spaces between the sides of the fundus and the pelvic walls are narrow and easily measured by the finger pressed well back on either side; while the direction of the long axis of the uterus, and the amount of displacement of the os, are easily recognized by passing the finger straight back under the pubic arch along the anterior vaginal wall to, and under, the cervix. The coccyx under the finger may be used as a guide to the median line.

Palpation of the Pregnant Uterus.

The pregnant uterus assumes, even during the first three or four months, qualities that otherwise belong to pathological states. The cervix feels soft and oedematous about the external os, is down nearer the coccyx, and a little farther away from the inferior pubic ligament. The body is felt to recede less rapidly upward from the anterior vaginal wall, is softened and more bulging above the cervix, and is more easily grasped bimanually. The partly filled bladder is depressed in the centre or on one side by the heavy fundus so as to form a broad, flattened fluctuating tumor.

Examination of the Uterus during General Anesthesia.

Examined in connection with the administration of an anesthetic or during an unusually relaxed and insensitive state of the tissues, the uterus can be grasped bimanually and turned in all directions. By pushing the cervix back with the finger in the vagina, the uterine body may be brought down upon the anterior vaginal wall by the hand over the abdomen, so that the thickness, and the conformation of its anterior and lateral walls, will be readily determined. Fig. 45 shows the relation of the fingers to the uterus.

Bimanual Palpation of the Uterus from the Posterior Vaginal Wall (4).

By drawing the cervix forward with one or two fingers in the vagina -first pressing upward in the anterior fornix, and then drawing forward under and behind the free end of the cervix-and pushing the fundus back with the hand above the pubes, the cervix and lower portion of the corpus can be grasped between the fingers outside and those in the posterior fornix as represented in Fig. 46.

When it becomes necessary to palpate the whole posterior wall, the

vaginal fingers, after the fundus has been pushed as far back as possible by the external hand, may press the lower, or free end of the

FIG. 46.

Bimanual Palpation of the Uterus, through the Anterior Vaginal Fornix (3).

cervix, up toward the pelvic brim and thus turn the fundus into the hollow of the sacrum, or the recto-uterine pouch, as represented in Fig. 47.

The posterior wall of the whole body will then be accessible. In replacing the uterus the cervix is pulled down by the finger upon it, or drawn down by pressing the posterior fornix vagina toward the coccyx, and then the fundus uteri pushed up toward the sacral promontory. The natural supports, if normal, will do the rest.

In pushing the fundus backward into the hollow of the sacrum we must press just over the pubes, so as to get under the fundus; in bringing the fundus forward over the anterior vaginal wall we press deep into the abdomen just under the umbilicus and then downward. over the fundus.

The uterus, as thus felt, should be smooth, hard and slightly flattened upon the anterior and posterior surfaces, without ridges or pro

jections except at the upper angles or horns, where the Fallopian tubes and the ovarian and round ligaments pass off laterally.

Uterus artificially turned back against the hollow of the Sacrum, for palpation of the
Posterior Wall (3).

Digital Exploration of the Pelvic Roof through the Vagina.

By pressing with one hand firmly down over the abdominal walls to one side of the artificially anteverted uterus, and with the other upward against the anterior vaginal wall on the same side, we may make both hands meet with only the abdominal and vaginal walls, and broad ligament with its contents, between them, and palpate against the external hand or make the approximated fingers (external and internal) glide together successively over small contiguous areas of the pelvic roof, until the whole is explored. The skin and mucous membrane move with the fingers and each tissue as it slips between. them may be recognized by its shape and position, or be traced throughout its course in the pelvis. In bimanual examination of the right side of the pelvis we should use the right hand for the vagina, for the left side the left hand. As a rule when the fundus uteri is low in the pelvis the abdominal walls should be depressed as much as possible; when the fundus is high the vaginal walls should be pushed well up. In this way the parts are more easily reached, and are not much disturbed in their relations.

A rough finger in the vagina may press upon the tissues of the pelvic roof a thousand times without recognizing them, while the touch