THE DIGITAL EXAMINATION OF THE INTERNAL PELVIC ORGANS.
Hippocrates, Soranus, Aretaeus and others used and taught one of these methods, the exploration by the vagina, and this method remained the sole one used up to the end of the last century. The anal and the urethral openings were also used for purposes of manual and of instrumental exploration, but only surgically for the removal of foreign bodies from the rectum and the bladder. A new era, as Schroeder says, was inaugurated in gynecology when the examination by the finger, previously utilized only for vaginal touch, was combined with the use of the other hand externally, whereby the pelvic organs are so steadied and depressed that hereby alone the greatest certainty in diagnosis is attaina ble. This method which had been used obstetrically one hundred years previously by Puzos, and later in obscure cases of pregnancy by Baud e• locque, Joerg, Schmitt, and others, lapsed into neglect, until about forty years ago, when it was resuscitated by Busch and Kiwisch, and placed on a firm basis by them and by B. S. Schultze, Hoist, Veit, Schroeder, Sims, IIegar and Kaltenbach.
While the simple vaginal touch only informs us in regard to the cer vix, and in an incomplete way in regard to the body of the uterus and its adnexa, the most important conditions of the pelvic organs are unex plained, and therefore it is difficult to understand why the combined ex amination is not correctly practised by all physicians, and why in even modern text-books on gynecology, the subject is superficially considered. And yet it is the sole method by means of which the shape, movability, consistency, connections, tenderness, size of all the pelvic organs, may be determined, which often makes the use of instruments, in particular the sound, possible, and which cannot be displaced by any other method of examination.
According to the opening used for examination, we differentiate be tween the vaginal, the rectal and the vesical touch. Each one of these methods of examination is assisted by the use of the other hand, which is placed on the abdomen, and brings the organs nearer the examining finger; in other words the examination is a combined one, or, as Sims has termed it, a bimanual. In addition then to simple vaginal touch, we have the
combined vaginal, the most frequent, and the combined rectal and vesi cal touch. As a further means of assistance in these methods, we must mention artificial prolapse of the uterus and dilatation of the cavity of this organ, for which procedures the vagina is also utilized.
In addition to the above methods of examination, we may resort to a further method which is from two of the passages at the same time, as, for instance, by the vagina and the rectum, by the vagina and the bladder, by the bladder and the rectum. Each of these methods may be performed by means of two or more fingers of one hand, or by means of one or more fingers of both hands, or by the help of instruments, as, for example, a catheter in the bladder. Further combinations of these methods may finally be made, as from the vagina and rectum and abdomen, or else from the vagina, rectum, bladder and abdomen, where, of course, the help of an assistant is always necessary.
Almost all the pelvic organs, according to circumstances. may be ex amined from either of the three passages, although not with the same results and ease. In general, the direction may be given to use that passage which leads most directly to the object to be examined, and by the shortest route, and secondly by that which enables us to feel the organ with the least opposition. The most usual method is the combined vaginal and abdominal, by which, unquestionably, the most exact informa tion is obtainable. All those parts, however, which lie above the inser tion of the posterior vaginal wall, and which are in the posterior portion of the pelvis, may be examined at least as well, and occasionally even more easily and more directly on account of the lessened thickness of the intervening tissue layers, from the rectum combined with abdominal pal pation.