Modern gynecology; a treatise on diseases of women ...

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UNITED STATES OF AMERICA.

Chapter I

Examinations. — Oral — Physical — Positions — Dorsal — Sims' — The Genu-Pectoral — The External Genitalia — The Digital Examination — Bimanual Examining — Examination of Single Women — The Speculum and its Uses — Sims' Speculum — Self -retaining Specula 17

Chapter II

Menstruation. — Normal — Puberty — Menstrual Abnormalities — Dysmenorrhea — Uterine Neuroses and Eruptions — Vicarious Menstruation 48

CHAPTER HI.

Amenorrhea. — Primitive or Acquired — Causes — Pregnancy — Anaemia — From Plethora — Hyper-involution — Castration — Menopause 61

CHAPTER IV. Scanty Menstruation. — Treatment — Douches — Applications

10 CONTENTS.

Chapter V

Menorrhagia and Metrorrhagia. — Uterine Hemorrhage — Causes — Immediate Control by Packing the Vagina — Intra-uterine Applications — Drugs for Hemorrhage — After-treatment for Menorrhagia — Metrorrhagia — Dilatation of Cervix for Examination — With Tents — With Divulsors — Treatment of Metrorrhagia 114

Chapter X

Metritis. — Causes of — Symptoms — Corporeal — Cervical — Laceration of Cervix — Membranous Metritis — Uterine Syndronia — Examination for Metritis — Treatment 197

CHAPTER XL

Uterine Displacements. — Causes — Symptoms — Diagnosis — Tlie Normal Position — Anteversion — Anteflexion — Dysmenorrhea — Sterility — Examination — Directions for L"se of the Sound — Tampons — Methods of Retaining the Restored Position — Retroversion — Retroflexion — Methods of Reducing — Uterine Massage — Repositors — Pessaries — Operations for Retroflexion — Mollites Uteri — Prolapse of the Genital Organs — The Perineum — Rectocele — Cystocele — Treatment 227

Chapter XII

Salpingitis and Peri-salpingitis. — Purulent and Non-purulent — Varieties — Symptoms — Sequela? — Salpinx — Treatment — Peri-salpingitis — Pelvic Peritonitis — Symptoms — Treatment 292

Chapter XIII

Ovaries. — Diseases of — Congestion — Oophoritis — Acute — Chronic — Neoplasms 313

CHAPTER XTV.

Fibroma.— Positions and Symptoms of— Abdominal Fibromata — Treatment by Drugs— By Electricity— Operations for— Curettement— Ligating of the Uterine Arteries— Castration, , , , 327

12 CONTENTS.

Appendix

Instruments and Office Appliances 363

General Index 377

ILLTTSTBATIONS.

Fig. 1. Dorsal-recumbent Position 21

Fig. 2. Sims' Position seen from in Front 22

Fig. 3. Genu-pectoral Position 23

Fig. 4. Separation of Labia Majora and Buttocks for Inspection of

External Genitalia 25

Fig. 5. Position of Hand usually advised for Examinations 27

Fig. 6. Improved Position advised by Davenport 28

Fig. 7. Correct Position of the Hand in making Examinations. ... 28 Fig. 8. Posterior Vaginal Wall pushed into View by Finger in the

Rectum 30

Fig. 9. Examination of the Rectal Mucous Membrane turned out

by Fingers in the Vagina. (Munde.) 31

Fig. 10. Outline View of Bimanual Examination. (Davenport. ) . . 32

Fig. 11. Bimanual Examination. (Pozzi.) 33

Fig. 12. Bivalve Speculum in Position 39

Fig. 13. Sims' Speculum 40

Fig. 14. Manner of Holding Sims' Speculum when Introducing 40

Fig. 15. Sims' Depressor for Anterior Vaginal Wall 41

Fig. 16. Hunter's Depressor 41

Fig. 17. Sims' Method of Holding Sims' Speculum 42

Fig. 18. Munde's Method of Holding Sims' Speculum 42

Fig. 19. Relative Positions of Patient, Physician, and Nurse when

using Sims' Position. (Sims. ) 43

Fig. 20. Cleveland's Speculum 44

Fig. 21. Cleveland's Speculum 44

Fig. 22. Belt and Strap for Holding Cleveland's Speculum 45

14 ILLUSTRATIONS.

Fig. 23. Patient in Sims' Position with Cleveland's Speculum in

Position 47

Fig. 24. Reynolds' Tank and Tubing for Douches 98

Fig. 25. Reynolds' Bed-pan with Siphon Attachment 103

Fig. 26. Reese's Uterine Leech 112

Fig. 27. Straight Sponge Tent, Hollow 136

Fig. 28. Curved Sponge Tent 137

Fig. 29. Laminaria Tent 137

Fig. 30. Tupelo Tents 138

Fig. 31. Skene's Tenaculum Forceps 140

Fig. 32. Ellinger's Rapid Divulsors 142

Fig. 33. Bozeman's Dressing Forceps 143

Fig. 34. Thomas' Wire Curette 144

Fig. 35. Emmet's Urethral Button-hole Scissors 159

Fig. 36. Correct Position of the Pelvic Organs 165

Fig. 37. Imperforate Hymen, Vagina Largely Distended 166

Fig. 38. Vaginal Tube, Glass 171

Fig. 39. Bozeman's Vaginal Dilator 173

Fig. 40. Bozeman's Vaginal Dilator 173

Fig. 41. Hank's Uterine Dilator 187

Fig. 42. Set of Peaslee's Uterine Dilators 187

Fig. 43. Wylie's Uterine Dilator 188

Fig. 44. Sims' Uterine Dilator 188

Fig. 45. Barnes' Dilators, Three Sizes 190

Fig. 46. Outerbridge's Introducer for his Drain 192

Fig. 47. Method of Grasping Drain with Dressing Forceps for Introduction 192

Fig. 48. Outerbridge's Drain in Position 193

Fig. 49. Hypertrophy of the Cervix 204

Fig. 50. Outerbridge Drain used for Drainage 217

Fig. 51. Uterine Applicator 219

Fig. 52. Method of Wrapping the Uterine Applicator 219

Fig. 53. The Applicator Wrapped for Use 219

Fig. 54. Normal Position of the Uterus in the Pelvis 228

Fig. 55. Position of Uterus in Ante version 229

ILLUSTRATIONS. 15

Fig. 56. Thomas' Anteversion Pessary 232

Fig. 57. Thomas' Anteversion Pessary in Position 232

Fig. 58. Thomas' Anteversion Pessary, Other Forms 233

Fig. 59. Anteflexion of the Uterine Body 239

Fig. 60. Simpson's Uterine Sound 243

Fig. 61. Hunter's Uterine Sound 243

Fig. 62. Sound in Normal Uterus 245

Fig. 63. Tenaculum with Angular Point 246

Fig. 64. Tenaculum with Curved Point 246

Fig. 65. First and Second Steps in Passing a Sound 247

Fig. 66. Third Step in Passing a Sound 248

Fig. 67. Uterine Probe, Wyeth's 250

Fig. 68. Graily Hewitt's Pessary 253

Fig. 69. Thomas' Uterine Stem and Pessary 254

Fig. 70. Outerbridge's Wire Drain 256

Fig. 71. Outerbridge's Wire Drain bent to fit Curve in Uterus 256

Fig. 72. Anteflexion of the Body relieved by Outerbridge Drain. . . 257 Fig. 73. Anteflexion of both the Body and the Neck relieved by

Outerbridge Drain 257

Fig. 74. Discission for Extreme Anteflexion 258

Fig. 75. Retroversion, Third Degree 259

Fig. 76. Thomas-Hewitt Retroversion Pessary 261

Fig. 77. Retroversion before Restoration 261

Fig. 78. Retroversion corrected by Genu -pectoral Position 262

Fig. 79. Retroflexion 263

Fig. 80. Jennison's Repositor 269

Fig. 81. Flexible Metal Ring covered with Rubber 271

Fig. 82. Emmet-Smith Pessary 272

Fig. 83. Inflated Ring Pessary 273

Fig. 84. Hoffman's Pessary 273

Fig. 85. Introduction of Pessary, First Step 275

Fig. 86. Introduction of Pessary, Second Step 276

Fig. 87. Introduction of Pessary, Third Step 276

Fig. 88. Perineal Body as a Support of the Parturient Canal 281

Fig. 89. Inversion 283

16 ILLUSTRATIONS.

Fig. 90. Mucous Fibroid at Fundus Simulating Inversion 285

Fig. 91. Fibroid at Cervix Simulating Inversion 285

Fig. 92. White's Method of Reducing an Inverted Uterus 288

Fig. 93. Polyp with Long Narrow Pedicle 327

Fig. 94. Polyp with Broad Base 328

Fig. 95. Multiple Intra-mural Fibromata. (Martin.) 336

Fig. 96. Sharp Curette (Sims') 337

Fig. 97. Dr. Woodman's Case, Cancer of Vulva 343

Fig. 98. Outerbridge's Drain for Sterility 360

Fig. 99. Gynecological Table 364

Fig. 100. Instrument Cabinet 365

Fig. 101. Brewer's Speculum 370

Fig. 102. Graves' Speculum 371

Fig. 103. Dawson's Modification of Sims' Speculum 372

Fig. 104. Munde's Modification of Sims' Speculum 372

Fig. 105. Dressing Forceps 373

MODERN GYNECOLOGY.

Chapter I

The first information in regard to her condition is obtained from the patient herself, and consists of an historical account of her past life and a description of her present symptoms. This information is obtained partly by allowing the patient to tell her own story and partly in answer to questions asked her by the physician.

The Oral Examination. — Many patients tell a clear, straightforward story, and can be trusted to give their own history with but little in the way of questioning, while others will ramble on aimlessly, talking about trivialities which only confuse and lead nowhere. In no department of medicine will the physician's tact be called upon more frequently than in the endeavor to obtain a definite history of some obtuse patient's gynecological past life.

A good beginning in inquiring concerning her history is

to ask her age and civil condition — that is, if she is single,

married, or widowed. It is important to know at what age

she began to menstruate, and the presence or absence of any abnormalities about the flow, its quantity, regularity, and duration, both during the first months and after. The amount of pain should be told, the number of days the flow lasts at each period, and the duration of time between each menstruation.

If she has been married, the number of children must be asked, and it is well to know the date of the birth of the first and last. Information regarding the character of the labors will naturally follow, and if the deliveries were with the aid of instruments or not. If she has had miscarriages, the period of gestation at which they occurred and the cause in each case are important. Inquiry should be made if children have been born at full term since the last abortion. If she has had children since the last abortion, it is important to know how long they have lived and if in good health. If dead, the cause of death will give light on the subject. This information may give an intimation as to the presence of syphilis or tubercular disease in mother or fetus.

It is advisable to try and learn if the patient has suffered from attacks of any kind of pelvic disease, and especially if she has had a pelvic peritonitis. This the physician must learn by her description of the symptoms and not by her simple statement, as women frequently have erroneous notions in this respect.

The condition at the present time requires investigation next, and it will be discovered if she is menstruating or not, or if she is pregnant, and if so, the probable date of conception. She should always be asked if she has leucorrhcea and its amount and character, and if it is more immediately before or after the menstrual flow.

The importance of learning the trne state of the alimentary canal must be remembered. Constipation is the bane of civilized woman, causing many of her ills. All the resulting aches, pains, and indigestions are so common as only to need mention to reveal their importance.

The condition of the bladder is at times of special importance to the gynecologist in making a diagnosis, dysuria and incontinence being frequently the result of pressure from the genital organs.

In the case of young girls and unmarried women the duties of the physician require much delicacy and care. The patient should always be accompanied by her mother or some married woman, and the inquiries can at times be made through her. She will usually come because of some abnormality about her menstruation, and the companion will generally have been informed of the main symptoms beforehand. If such is not the case, the questions must be put in such a way as to allow her to tell her story as briefly as is possible and at the same time furnish full information for the diagnosis. Anything calculated to shock her sensibilities should be carefully avoided.

The Physical Examination. — Many pelvic diseases resemble each other in symptoms to such an extent that a diagnosis can rarely be made without a physical examination. The object of the verbal examination is more to establish the probability of any disease in the pelvis than to learn its character. The symptoms complained of are often invaluable as aids in making the differential diagnosis in conjunction with the physical signs found on examination. It is consequently essential to both physician and patient that the physical examination be as thorough as it can be made. At the same time it is important that the discomfort of the patient should be reduced to a minimum. Consequently every general physician should have in his office the facilities for examining the pelvic organs of the female. The first desideratum for the convenience of both is an examining chair or table. There are many good ones in the market, the more elaborate being expensive. It will be found that the simplest are the most convenient and durable.

The Examining Table. — A table four feet long, two and a half feet high, and twenty-seven inches wide, is all that is absolutely needed. The foot-rest may be the ordinary iron stirrup to rest the heel in, and should be so arranged that it can be readily removed when the table is to be used for other than the dorsal position. Many tables do not have a stirrup at all, the heels simply resting on the table. It is convenient at times to have the table feet adjustable, making it possible to raise the one end higher than the other. This can usually be cheaply arranged.

Most tables are covered with leather, and padded to make them more comfortable ; a small leather-covered pillow also adds to the patient's comfort. Very stout women he more comfortably if a head-rest is provided that is higher than the ordinary pillow.

A sheet or mantle is also needed to cover the patient while on the table, and should be placed so as to save her from exposure of her person as far as possible. It can be held in front of her while she raises her clothing in getting on the table, and after she is there she should be arranged

EXAMINATIONS.

under this covering, and all examinations and treatment should be done with the sheet so arranged about her as to expose none of her person or underclothing that is not absolutely necessary.

Positions on the Table. — The positions on the table of chief importance to the minor gynecologist are three : the dorsal, the Sims, and the genu-pectoral.

The Dorsal Position (Fig. 1) is most used in the United States, and is most convenient for both patient and physician. The patient lies prone, with the hips as near the end of the

Fig. 1. The Dorsal-Recumbent Position. (From photograph, expressly for this work.)

table as possible ; her heels are placed as near the buttocks as is comfortable and held there by a stirrup, the knees being widely separated. She will appreciate the delicacy which prompts the examiner who wraps a sheet around her in such a manner as to completely cover each leg down to, and including, the foot.

A thorough and searching digital examination can only

MODERN GYNECOLOGY.

be made when the hips are well down to the end of the table. The nse of the bivalve speculum is also much more satisfactory when this simple precaution is taken. In making first examinations it often requires some patience to get the patient to understand what is required of her.

The Sims Position (Fig. 2) is less used by the general practitioner because, until recently, it required the service of a nurse or assistant to hold Sims speculum. In this

Fig. 2. The Sims Position. (From photograph, expressly for this work.)

position the patient is placed on her left side with the left arm and shoulder drawn back. The left side of the face and chest is in contact with the table. The right shoulder is bent over forward as near to the table as is possible without turning the hips, the knees are then drawn up toward the chin, the right or upper leg being more bent than the left or under one. The corset and all tight clothing must be removed from about the waist, leaving the abdominal walls entirely free. The result is that in this position the

EXAMINATIONS.

tendency of the pelvic organs is toward the diaphragm. They are consequently more difficult to reach by the examining finger, yet the advantages of this position are many and it is frequently used. It is especially convenient for operations through the vagina where, the patient being under an anaesthetic, two assistants would be required to hold the knees if she were in the dorsal position. The ease with which the uterus can be drawn down by drawing on the cervix with a tenaculum makes it easily accessible for operations.

The Genu-pectoral Position (Fig. 3) is indicated by its name. The patient kneels on the table with her chest on the same level, the face being turned aside ; the hips are thus elevated above the shoulders, consequently the position can be used to cause gravity to assist in replacing flexions and versions

Fig. 3. The Genu-pectoral Position.

of the uterus and some forms of prolapse of the pelvic organs. It is also convenient when it is desired to pack the vagina very tightly with tampons. Entire freedom of the waist and abdominal walls from all restraint is necessary before assuming the knee-chest position. Figure 3 shows the knee-chest position and the tendency of the abdominal viscera toward the diaphragm.

The physician will succeed with his pelvic cases who can make an examination with delicacy and gentleness yet with sufficient thoroughness to obtain all the information required. Mention of some of the necessary details in making examinations will not come amiss here.

The External Examination. — After the patient is correctly placed on the table the examination should be made in the following order : examination of external organs, digital examination, and examination with specula.

Inspection of the External Genitals. — The first step in examining the genital organs of a woman is inspection of the external genitalia. This is usually done with the patient in the dorsal recumbent position, the examiner sitting between her feet. The labia majora can be seen as far as their cutaneous surfaces extend. The labia minora at times are developed largely and extend out between the greater labia. The condition of the mons veneris can be noted, parasites being looked for, and the perineum and anus are in full view. After these external parts have been thoroughly inspected the labia majora can be separated, each being drawn aside by a small piece of cotton held between the thumb and index finger of the hand most convenient to it. This exposes the whole of the external genitalia to view (see Fig. 4). The clitoris with its prepuce is seen above with the labia minora partially inclosing it as they unite just below it and gradually diverging as they pass backward. Between them is the vestibule with the urethral orifice near the middle

EXAMINATIONS.

of its lower margin. Next below the vestibule is the opening to the vagina, more or less closed by the hymen when present, or surrounded by its remnants when it has been ruptured. If the hymen has completely disappeared the caftinclse myrtifornies may be present, in which case

Fig. 4. Separation of Labia and Bnttocks. (From photograph, expressly for

this work.)

they may be seen surrounding the entrance to the vagina just above the point at which the hymen is attached, when present. If the labia majora are widely separated the fossa navicularis can be seen at the posterior edge of the vaginal opening, and. the condition of the perineum can be inspected at the same time.

Inspection of tlie Anal Region. — Pressure with the examiner's thumbs against the buttocks will separate them and enable him to see the condition of the anus (see Fig. 4), revealing the presence or absence of prolapsus, piles, or congested vessels there. Ulcers about the amis will also be seen.

While many words are required to describe all these things, the examination necessary to learn all that is required can be made in a very few seconds. It is important to know if ulceration, parasites, or filth are present on or around the external genitals before making an examination of the vagina, as a matter of self -protection for the examiner, if for no other reason.

When an examination of the pelvic organs is to be made through the vagina, the position and preparation of the patient on the table are first attended to as has been outlined in describing the positions on the table, care being taken to protect her as much as possible from exposure of her person. The examiner should not be abrupt in his approach to the sexual organs and yet should use sufficient despatch to avoid prolonged manipulations or tiresome waits in cramped positions.

The Digital Examination. — Everything being ready for a digital examination, the preparation and position of the hand used in examining is next considered. The first point is which hand to use. The majority of physicians use the right hand for the same reason that they employ this hand to write, etc., because they can use it more readily. Some instructors in gynecology, however, have advised the use of the left hand for a number of reasons, the chief one being that it leaves free the stronger right hand to be used in depressing the abdominal wall in making bimanual examinations. It is better to educate both hands and thus be enabled to use either in case of emergency. A cut on the finger or other cause may make it advisable not to use an injured hand. Another reason for using both hands is that at times more definite information can be obtained by ex : amining either side of the uterus and the lateral fornix with. that finger which will allow the palmar surface of the finger to rest against the uterine wall. The greater acuteness of the sensations from the palmar surface of the finger insures more definite information from its use than can be obtained by depending upon the back of the finger with its nail and less sensitive cuticle.

The Position of the Hand in making examinations is of importance. The position usually advised is not the one calculated to gain the greatest amount of information, nor is it the most comfortable to the patient. Most examiners require to add to the distance they can reach with the finger by depressing the perineum and pushing it upward as far as possible. If this is attempted with the external fingers flexed into the palm, as is usually advised (Fig. 5), the distance gained is not great, and

,-, j. .-,, , . Fig. 5. Position of Hand usually advised.

the patient will complain

of the discomfort caused by the knuckles of the middle and ring fingers. These fingers should not be entirely closed, neither should they be entirely extended, as is shown in this outline (Fig. 6), but they should be held in a partially flexed condition, as shown in Figure 7. To be exact, the chord of

MODERN GYNECOLOGY.

the curve of the external fingers should make an angle of

about forty-five degrees with the line of the index finger.

In this position the hand is introduced under the covering, the index finger having been anointed with vaseline or

some other lubricant.

The index finger should be flexed into the palm of the hand until the perineum is reached, to prevent soiling the underclothing of the patient in all examinations where she is not thoroughly protected by a sheet.

When the perineum is

touched by the knuckle the index finger is extended, its point

pressed against the perineum and allowed to pass forward

until it slips between the

labia majora into the

vagina. As soon as the

finger enters the vagina,

pressure should be made

by its side against the

perineal body, depressing

it in the direction of the

tip of the coccyx as the

finger passes up toward

the cervix. When the web between the index and middle

fingers reaches the perineum, that part is carried still further

Fig. 6. Position of Hand advised by Davenport.

Fig. 7. Correct Position of Hand.

upward by it, enabling the examining finger to reach far up at the side of the uterus, behind it or in front between it and the bladder. The middle finger will lie in the crease between the buttocks, which is depressed with the perineum, so that the external fingers are not in the same plane with the index finger. The angle of divergence between the index and the other fingers varies, of course, as the finger within the vagina passes to one side or the other of the cervix.

The Use of Ttvo Fingers per Vaginnm. — Some examiners advise the introduction of two fingers into the vagina. This is a custom not to be recommended in routine practice. Like the bimanual method of examining, it has its uses, but is not required except when indicated by special conditions.

It is painful to many women to have two fingers thrust into the vagina, and even multipara with large, roomy pelves complain of discomfort. The impression gained as to size, shape, and consistency is not more definite with two fingers than with one, as two impressions will at times confuse the examiner and leave an uncertainty in his mind until one finger is removed and the index finger gives its conclusive report.

When there is doubt as to whether a mass is movable with the uterus or not, it may give information to introduce the middle finger behind the cervix and hold it in contact with the tumor or fundus in Douglas' pouch while the index finger makes pressure on the anterior side of the cervix. The same maneuver is also used to start the retroflexed fundus upward as the first movement toward its reposition. In usual routine cases the 'index finger will give all the information obtainable with least inconvenience to the patient.

MODERN GYNECOLOGY.

Examination per Rectum. — Where additional information is needed it may be advisable to explore the rectum. This is done with the index finger prepared as for vaginal examination and held in about the same position. The tip of the finger is introduced through the anal ring very slowly and gently in order to give the sphincters time to relax. If the patient will "bear down" slightly the entrance is more easily effected.

The finger in the rectum can be passed higher in the pelvis than in the vaginal, and more definite information re-

Eversion of Posterior Vaginal Wall, with Finger in the Rectum. (From photograph, expressly for this work.)

garding the condition and position of the posterior of the uterus can be obtained. The position and size of the ovaries and tubes can be better learned per rectum, also the condition of the utero-sacral and the broad ligaments.

Occasionally it is of advantage to introduce the middle finger into the rectum and the index finger in the vagina at the same time. This is not often necessary, but is at times required.

Inspection of Posterior Wall of the Vagina. — When it is required to inspect the posterior vaginal wall a finger is introduced into the rectum until its tip passes the sphincters. It is then pressed forward, everting the lower part of the posterior vaginal wall, exposing it to view. The labia are separated to give a clearer view by pressing the one to the examiner's right with the right thumb (the right index finger

Fig. 9. Digital Eversion of the Rectum. (Munde.)

being in the rectum), the other labia being held aside by the index finger of the left hand. In this manner the posterior vaginal wall can be inspected a considerable distance upward unless the perineum is very resistant. A photograph of this position is shown in Figure 8.

Inspection of Mucous Membrane of the Rectum. — By a reversal of the above-described process the interior of the rectum can also be examined, two fingers depressing the posterior vaginal wall and everting the rectum (Fig. 9). In either of these maneuvers care must be taken when the septurn is thin between the rectum and vagina or the ends of the fingers may break through, making a recto-vaginal fistula.

Bimanual Examinations. — A bimanual examination is occasionally required to give more information of the pelvic contents than can be obtained by examination through the vagina and rectum. The method of making such examination is simple. The index finger of one hand is introduced

Fig. 10. Relative Position of Hands in Bimanual Examinations. (Davenport. )

into the vagina as in making a digital examination, and the other hand is placed on the abdomen just above the symphysis pubes. This hand rests with its palmar surface against the abdominal wall, the fingers being partially flexed. Pressure is made gently but firmly against the abdominal muscles, depressing them just above the pelvic brim until the fingers sink into the pelvis. The depression

EXAMINATIONS.

can be made deeper and more quickly if the greatest force is used while the patient makes a deep expiration, slightly relaxing the pressure during inspiration. Figure 10 shows in outline the relative positions of hands and pelvic organs

Fig. 11. Bimamual Ex am ination (Pozzi).

when making a bimanual examination. Figure 11 is a photograph of position of hands in making a bimanual examination.

The Object of the hand on the abdomen is to depress the pelvic organs and bring them down in the reach of the finger within the vagina. The size and consistency of the uterus, the ovaries, or a pelvic tumor can be made out by getting it between the hands in this bimanual method. When it is desirable to g^et a finger into the uterine cavity counter-pressure on the fundus with the hand on the abdomen will be of assistance. The uterus is forced down over the finger in the vagina and pressure upward on its ligaments and other attachments is avoided. The hand on the abdomen can frequently render valuable assistance in reposition of uterine displacements or in restoring an inversion.

Some examiners use the bimanual method as a part of each pelvic examination. This is unnecessary, as a perfect knowledge of the true position and condition of the important organs in the pelvis can be obtained without it, except in a few special cases. The hand on the abdomen is not pleasant to the patient, the pressure exerted often causing pain. If the abdominal walls are thick or rigid much pressure must be used to get the hand depressed enough to be of any assistance. If the patient is nervous it may be impossible for her to relax the abdominal muscles sufficiently to allow any depression above the symphysis. In addition to the above objections to a bimanual examination as a matter of routine is the fact that the pressure of the hand above pushes the organs toward the pelvic outlet and changes their position in the pelvis and in relation to each other, thus giving the examiner a false impression in regard to them.