K*Mh  (ti.  d-)
The Advantage of Atmospheric
 Distention of the Rectum, with
 Dislodgment of the Small In-
 testines, in the Bimanual Ex-
 amination of Uterus, Ovaries,
 and Tubes.
HOWARD A. KELLY, M.D.

   Baltimorer Md.
       wpbintbo raoM

Thb American Journal of Obstetrica

      Vol. XXIX.. No.õ.ISM.
      NEW YORK

WILLIAM WOOD & COMPANY, PUBLISHERS

        1894
.-ZTfc. 
 
  the  advantage  of atmospheric distention of the
rectum, with dislodgment of  the  small  intestines,
       in the bimanual examination of uterus,
                   ovaries, and tubes.
   I have on several previous occasions drawn attention to im-
 portant rnodifications of the ordinary  bimanual  examination—
 such as  a deep invagination of the pelvic floor in making the
 pelvic organs  more accessible—the bimanual  examination by
 abdômen and rectum, assisted by simultaneous traction upon the
 cervix with corrngated tenaculum  or tenaculum forceps, called
 for  this reason "trimanual examination," thus  producing an
 artificial  retroposition and descensus uteri,1 as well as the pos-
 sibility of throwing the fundus into  an  artificial sharp retro-
 flexion and examining the anterior face of the uterus by means
 of the tinger in the rectum.2
   In spite, however, of these unusual facilíties for investigation,
 cases present themselves from time to time in which the broad-
 ligament structures can only be detected and outlined with con-
 siderable difhculty, and only after a patient persisteuce in seek-
 ing them out.  Not that the finger can find nothing in the pelvis:;
 on the contrary, it is embarrassed by finding  too much, for the
 touch  is constantly impeded in  the course of the examination
 by the viscera  which crowd down  into the pelvis  from above,
 forming  a sort of pelvic  enteVocele. Some impairment of the
 tactile sense is also experienced from the constant contact of
 the finger with the rectal mucous folds.
   Coils of small intestines in  the pelvis containing flnid often
 feel  tense and fluctuating, and thus readily impose themselves
 upon the examiner as large cystic ovaries, or leave him in doubt
 as to their true  natnre.
  i American  Journal of Obstetrics, February, 1891.
  2 New York Medicai Journal, November  25th, 1893, and Annals of Gyne-
cology and Pediatry, January, 1894. 
•2
KELLY : THE ADVANTAGE  OF ATMOSPHEKIC
  The complete removal of these impediments may be satisfac-
torily  effected in the following  manner:  The patient is placed
in the knee-breast posture, with shoulders on the table and hips
high and thighs vertical.  The anal orifice is opened by a small
 Fig. 1 shows the relations of the collapsed rectum (R) to uterus (U) and ovaries COv),
the small intestines 0, i) fllling the pelvis.
speculum or tube, allowing the air to rush into the rectum.  The
explanation of this phenomenon is that, upon assuming the knee-
breast posture, the small  intestines gravitate along the anterior
               Fin. 2-                           Fm. 3.
 Fig. 2 shows the relations of the bowel distended with air to uterus and ovary after the
small intestines have been displaced.
 Fig. 3 shows the íacility with which the digital examination can be made through the
rectum thus distended and applying itself widely to the posterior surface of the uterus and
broad ligament.
abdominal wall into the upper abdômen toward the diaphragm,
creating a suction  at  the most elevated  portion, which is the 
DISTENTION OF THE  RECTDM.
3
pelvic extremity,  by means of which the whole ampulla and
rectum balloon out with air as soon as the ânus is opened, and
the distended rectum  applies itself broadly over  the posterior
surface of the uterus and left broad ligament.
  Before  makino;  such an examination both rectum and  blad-
der should be thoroughly evacuated.  The  pelvis  being thus
elevated,  as  soon  as the  atmospheric  dilatation is effected the
tube is removed, the ânus closes, and the patient is placed in the
dorsal position with thighs ílexed  upon the abdômen, and the
bimanual  examination is at once  made per rectum and abdô-
men.
  The index  finger  coated with  vaselin, introduced within the
ânus,  experiences at  once the remarkable sensation of entering
a large cavity filled with  air, in which the customary resistance is
.absent.   The communication with the upper bowel between the
utero-sacral folds is, under these circumstances, readily found,
and the finger  is  conducted behiud the broad ligament, when,
on using the  outside hand in assistance, uterus, broad ligaments,
ovaries,  and  tubes are at once palpated directly through the
rectal wall, without resistance and with  startling  distinctness.
   The true  pelvic víscera thus  seem, as it were, to be skele-
tonized in the  pelvis, lying so clearly exposed to touch that
the minuter  surface peculiarities, fissures  and elevations, and
changes in consistence, can be detected, and a diagnosis  made
more satisfactorily,  more  rapidly, and with  far less  effort than
under ordinary conditions.
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