Bodies which lie in the anterior fornix, between the bladder and the uterus, on the anterior uterine wall, and the broad ligaments and tubes, may be felt to the best advantage through the bladder; still this manner of examination is inconvenient, and is attended by certain risks, so that except in rare instances we had better be satisfied with the slightly less exact results of the combined vaginal examination. The recto-vaginal and the urethro-vaginal septum, and tumors which lie deeply between the bladder and the uterus, or the uterus and the rectum, may be carefully examined by inserting in the first instance a finger of one hand into the rectum, and the thumb of the same hand or a finger of the other into the vagina, the combined recto-vaginal examination; and in the second instance tile finger of one hand is inserted into the urethra or the bladder, and that of the other hand into the vagina, the combined urethro- or vesico•vaginal examination. In case of atresia vaginae, we may examine by the rectum and the bladder, as also in case of congenital faults in de velopment of the vagina and the uterus, of abnormalities in the course of the ureters, in case of tumors which occupy the wall of the uterus or to one side of the organ, and which have their origin in some developmental anomaly.
Before resorting to a digital examination, the hand should be most • carefully washed, after the manner described further on, and the vulva and the vestibule are to be inspected, exposing the patient as little as possible. Examination under cover carries with it the danger of infec
tion. In case of suspicion of an infectious discharge, or in case of pro fuse leucorrhcea, the vagina should first be douched with lukewarm water. Frequently the patient has been subjected to treatment by astringents or caustics, which have changed the appearance of the parts in one way or another; so that unless we are careful to inform ourselves carefully in regard to the case before resorting to examination, we may easily draw false conclusions.
The vaginal examination may ordinarily be made by the index finger alone, although frequently, in case of the combined examination, two fingers are introduced. Madame Boivin's opinion that by two fingers the examination is more perfect, and that we may roach higher in the pelvis, is questionable. Only in case of very wide introitus vaginae, is the inser tion of two or more fingers necessary. The more expert the examiner the less will he ever need to use two fingers, and the inexpert will often not feel anything even with two. If the thumb is abducted so that it forms an angle of about 110° with the index, and if the other fingers are sharply flexed in the hand, then it is possible by means of strong down ward pressure on the perineum, to reach into the pelvis one to one and a half inches deeper than the length of the finger, from the tip to the metacarpo-phalangeal joint.