The simple vaginal examination may be made with the patient in the dorsal or lateral or erect position. Other positions are less frequently used. Since the bimanual examination should ever follow the simple touch, the dorsal position, certainly in Germany, is most commonly used, while the English and Americans use by preference the left lateral posi tion. [Far from this being the case, gynecologists of no nationality what soever more sharply differentiate the value of the two positions, the dorsal and the lateral, for purposes of the digital examination than the Ameri cans. It is uniformly conceded in this country, that the only position proper for careful digital exploration and the bimanual is the dorsal, while almost all gynecologists of experience use the lateral position, or Sims', for the specular examination and the treatment of the cervix and the uterus.—En.] To examine in the dorsal position, the bladder and rectum are emptied, although in case of deviation of the uterus, it may be necessary to examine while the bladder is full, and the patient lies on the examin ing table, with the buttocks elevated above the level of the table and near its edge, so that the elbow of the examiner may be depressed sufficiently. The knees are flexed and the thighs rotated outwards as much as possible. The clothing should be loosened or removed, and a sheet should be thrown over the patient.
The examiner should be able to use either hand. For exploration of the uterus that hand is chosen which corresponds to the side of the patient on which the examiner stands; for examination of the lateral fornices the opposite hand, and for the pelvic walls the corresponding hand is used. Thus if the examiner stands on the left of his patient, with his left hand he feels, besides the uterus, the right parametrium and the left wall of the pelvis, with the ovary, but the exploration of the left parametrium and of the right wall of the pelvis is best secured through the right hand. Change in the hand, of course, necessitates change in the position.
The finger well anointed with oil, vaseline or glycerine, is carried over the posterior commissure into the vagina, touching the vulva as little as possible. Frequently the labia must be separated by the other hand, in order to put the comtnissure on the stretch.
When the finger has been inserted it is extended with its radial border upwards. The thumb is placed to one side of the clitoris and pressed against the pubes, and the remaining fingers are flexed in the palm of the hand, depressing the perineum as much as possible. The forearm must be brought approximately into the same plane as the examining finger, and the higher we wish to penetrate into the pelvis the more we must depress the elbow, and the pelvis itself may even have to be ele vated. For the rapid detection of lateral deviations of the uterus and abnormalities of the bony pelvis, it is of great advantage if the examining finger, the hand, and the forearm, are held in a line coincident with that of the middle of the patient's body, that is to say, so that the elbow, the wrist, the tip of the examining finger, the symphysis, the umbilicus, and the ensiform cartilage of the patient are in the same axis.
In the lateral position, where one thigh is flexed more strongly than the other against the thorax, we may examine with either hand from either side. In the left lateral position, when the finger has been in serted, the thumb also rests against the symphysis, and the remaining fingers against the perineum; but we can examine with the right hand as well, and then the thumb will lie on the perineum and the three remain ing fingers against the symphysis, a position which the partisans of this method of examination greatly favor. Yet it is far easier to avoid touch ing the clitoris and the urethra, the sensitive parts in the anterior corn missure, by the more movable thumb, than by the less movable middle finger. In this position the anterior surface of the uterus and the pos terior wall of the pelvis are examined to the best advantage with the right hand, and the posterior surface of the uterus and the anterior wall of the pelvis with the left hand; the lateral surfaces of the uterus may be examined with either hand.
This position and the knee•elbow are especially to be used where it is advisable to examine in the absence of abdominal pressure, when the uterus sinks deeper against the pelvic outlet, becomes more movable, gravitates away from its vaginal insertion, and when, therefore, the con nection of the organ with pelvic tumors may the better be determined.
In the upright position the movable pelvic organs sink somewhat deeper, and it is, therefore, easier to reach higher beyond the uterus. This advantage, however, is offset by the impossibility of depressing the soft parts cf the pelvic floor, as in the other positions, and by the fact that the increased intra-abdominal pressure markedly lessens the movability of the uterus. Notwithstanding these objections, this position will often be utilized for examination whenever we are anxious to gain rapid in formation in regard to the condition of the pelvic organs, the influence of abdominal pressure on them, and on the displacements of the uterus. In order to examine in this position, the woman stands upright before the examiner, with feet somewhat apart, the examiner rests on one knee and inserts the finger of the hand of the same side into the vagina, the thumb resting in the anterior commissure, and the remaining fingers against the perineum. • To properly practise the simple vaginal touch, we must avoid every measure which might effect change in the position of the examined parts; thus we must be careful not to make pressure on the abdomen, and we should examine in such an order as will leave to the last any manipulation which moves the genital organs.