RECTAL EXAMINATION.
a. The. Simple Rectal Touch.—The examination of the internal female genital organs must be made by the rectum when examination by the vagina is impossible or very difficult, owing to occlusion or narrowing of this canal, either congenital or acquired, in the presence of irreducible tumors, inversion of the uterus, vaginismus of high degree, and further still in case of developmental anomalies of the genitals, especially absence of or congenital vice of the uterus, and again for the purposes of palpating the recto-vaginal septum, the coccyx and the rectum itself. The rectal examination is also of value in case of short vaginae and in case of all tumors which involve the posterior pelvic wall.
The examination of the rectum may be undertaken, even as that of the vagina, by the finger alone, by the combined finger and external hand, by one finger in the rectum and another in the vagina, and Simon recommended and practised the insertion of half or the entire hand. Formerly rectal examination was limited to cases where it was impossible to examine by the vagina, but Hoist proved the great advantage which the rectal has over the vaginal examination under certain further condi tions. It may be performed with the patient in the dorsal, lateral or knee elbow position, the erect and the complete dorsal interfering with the deep insertion of the finger. Unquestionably this method of examination is both physically and psychically more objectionable to the woman than the vaginal, and it is, therefore, advisable not to spend much time in per suading her of the necessity of resorting to it, but to insert the finger immediately after the vaginal touch, with the precaution, of course, first to cleanse it and oil it. The index finger, two fingers, and occasionally the half or whole of the hand is to be used. In case of resort to Simon's method of rectal palpation, anesthesia is necessary, but the examination by one or two fingers is only painful in hyper-sensitive women, and in the presence of large hemorrhoids, fissures, or inflammatory affections.
The finger is introduced and the remaining fingers are held even as in case of the vaginal examination. Elevation of the buttocks is of assist ance, and it goes without saying that, where needed, the rectum should be emptied by an enema.
The finger first passes through the resisting anal opening, and we are thus informed as to the state of the sphincter, the existence of fissure, prolapse, hemorrhoids, polypi, and as to the distensibility and sensitive ness of the muscle. We next enter a wide cavity with yielding walls, the ampulla of the rectum. The anus constitutes the entrance into the lowest and widest part of the rectum. We examine here the state of the mucous membrane, the width of the rectum and its direction. Above the third sphincter (llyrtl) or the plies transversalis recti (Kohlrausch,) through the anterior rectal wall, the finger feels the posterior wall of the vagina, the cervix, a portion of or the entire body of the uterus, fre quently the normal, and almost always the enlarged ovaries, the border of the broad ligaments with the tubes, the retro-uterine ligaments, all the greater part of the inner wall of the pelvis, and very clearly the anterior surface of the sacrum and of the coccyx. This wide portion of the rec tum is unquestionably more distensible and thinner than the vaginal wall, in particular the fornices, and this is the reason why the posterior wall of the uterus and the broad ligaments may be better palpated than by the vagina, and also why tumors in the posterior pelvic space, whether new growths of the uterus or the ovaries or exudations, are more readily investigated.
A frequent source of error with beginners is the cervix, which projects against the rectal wall as a large soft body, and simulates the body of the uterus. The differential diagnosis may be made by seeking for the os, which may usually be recognized through the rectal and vaginal wall, or else by means of the combined rectal and vaginal touch.