ments.

mistaken for and treated as a retroversion. We allude to the uterus anteflexed and drawn back by pelvic cellulitis of the utero-sacral ligaAs the patients are usually sterile and have therefore somewhat unyielding abdominal walls which cause a difficult bimanual, and as a lump is felt in the posterior fornix, the diagnosis of retroversion is often made. The rectal examination, however, clears up the case, as the finger feels the knee of the flexion and the fundus going forward from it.

The upper hand is used during the rectal examination just as in the bimanual, i.e., the examination is abdomino-recto-vaginal or abdominorectal. The simple rectal (with the finger in the rectum unaided by the other hand) does not give much information as to the condition of the

uterus.

Where, from rigidity of the abdominal walls, it is difficult to press down or fix the uterus with the external hand, this may be done with the volsella in the vagina. The use of the volsella enables us to draw the uterus better within reach of the finger in the rectum. This examination per rectum aided by the volsella will be considered in the next chapter.

Of all manual examinations of the pelvis, the abdomino-rectal or abdomino-vagino-rectal is the most thorough. In retroversions, prolapsed ovaries, and pathological anteflexion, it should never be omitted. A patient may object to it and refuse to allow it; and, of course, the practitioner must keep this in mind.

SIMON'S METHOD OF PASSING THE HAND INTO THE RECTUM.

This consists in passing the whole hand through the sphincter ani into the rectum, and even up to the transverse colon. The patient is deeply narcotised; the hand is passed cautiously through by inserting first two fingers and the others successively until the entire hand is passed; incision of the sphincter ani may be necessary. Sometimes an incurable incontinence of fæces has resulted.

The unanimous opinion of gynecologists is that this severe method of examination is unnecessary. Careful bimanual examination, aided when necessary by anæsthetics, gives equally good results.

For specialists it is of use to know that valuable results in minute precise rectal examination can be got by first injecting air into the rectum. The whole rectum up to the sigmoid flexure can be dilated, the sphincters made out and the bony pelvic wall carefully explored. It is necessary to add, however, that this is an adjunct to the rectal method of examination of use only in certain instances.

CHAPTER IX.

THE VOLSELLA.

LITERATURE.

Goodell-Some Practical Hints for the Treatment and the Prevention of the Diseases of Women: Medical and Surgical Reporter, January 1874. Hegar-Zur gynäkologischen Diagnostik : Die combinirte Untersuchung, Volkmanns Sammlung, No. 105. Simpson, A. Russell-The Use of the Volsella in Gynecology: Contributions to Obstetrics and Gynecology, p. 183.

We have already seen that one of the most striking anatomical features and properties of the uterus is the considerable range of its mobility in almost every direction. It can be pushed upwards from its normal position 1 or 2 inches, and is displaceable forwards or laterally in a very marked degree. If laid hold of with the instrument known as a volsella, it can be drawn downwards (by a force not exceeding five or six pounds) until the os externum lies close to the vaginal orifice. This procedure facilitates, in suitable cases, diagnosis and treatment of gynecology so much that it is well worthy of the allotment of a special chapter to its discussion. We take up

1. Description of instrument;

2. Method of use;

3. Mechanism of the displacement it causes;

4. Uses;

5. Contra-indications.

1. Description of Volsella.-At fig. 76 is seen the useful volsella employed by Russell Simpson. As it is generally the anterior lip of the cervix that is laid hold of, the slight pelvic curve given to the blades is unnecessary since the volsella lies along the straight anterior vaginal wall. Fig. 77 shows Hart's volsella, where this straightness of the blades qua the vagina is secured, and the handle and fingers of the gynecologist are kept away from the vaginal orifice by the bend on the handle. Every volsella should have a catch on it. Sometimes it is useful to have an instrument whose blades pass over one another, so as to separate for instance the lips of a split cervix: such is Hank's instrument.

2. Method of Use. (a). Without previous passage of Speculum.-The

patient is placed in the ordinary left lateral posture. Two fingers of the right hand are passed into the vagina and the anterior lip of the

Fig. 77.

Dr Hart's Volsella,

cervix touched. The volsella, held in the left hand, is guided along between the index and middle exploring fingers; the anterior lip of the cervix is seized and drawn down. Rectal examination is now made. (b.) With the Speculum.-For this, see Chapter X.

3. Mechanism of displacement it causes. The uterus is drawn down so as to lie behind the symphysis pubis. If drawn down fully, as it may be in exceptional cases, it has its long axis in the vagina and the os externum near the vaginal orifice.

The vaginal walls are inverted, ie., when the os externum is at the vaginal orifice we have a deep pouch behind and in front of the uterus. The relations of the bladder and rectum are given in fig. 78.

4. Uses. (a) In diagnosis.-(1.) The cervix which may seem "ulcerated," as it is commonly called, is easily demonstrated by the

Fig. 78.

Mechanism of Displacement of Pelvic Floor Segments when Volsella is used (A. R, Simpson). a Symphysis Pubis; 6 Bladder; c Uterus; d Perineum; e Rectum; ƒ Volsella.

volsella, to be singly or doubly lacerated. For this purpose the anterior and posterior lips are laid hold of, and when brought together the ulceration is seen to be due to laceration with eversion.

(2.) Abdominal tumours can be shown to be connected with the uterus or not as the case may be. If the patient be placed in the dorsal posture and the tumour be laid hold of by an assistant, then when the uterus is drawn down, the tumour can be felt to descend if fixed to it.

(3.) To the examination per rectum the volsella is a valuable addition. If one finger be placed in the rectum, and the cervix laid hold of with a volsella and drawn down, the mobility of the uterus can be estimated; if it be anteflexed by cicatrized utero-sacral ligaments, these can be felt tense (fig. 40); the whole posterior uterine surface may be palpated for small fibroids. The ovaries are made more accessible; and the uterus, especially if small, can have its length estimated by the rectal finger.

This method of examination of the uterus by rectum and volsella, judiciously conducted, is of the very greatest value.

It is evident that it will also help one as to the diagnosis of displacements of the uterus; but its value in this respect is somewhat lessened by the displacement its use causes. Thus it makes a retroversion less