Befora the finger is inserted into the vagina, we must inform ourselves in regard to the condition of the external genital organs, their size, con sistency, tenderness, the state of the perineum and the posterior com missure, as regards integrity, the labia miuora, meatus urethrae, and the clitoris, although we must not touch the latter organ overmuch. The position of the introitus vaginae gives us information in regard to the in clination of the pelvis. In the vestibule we must note, the hymen, the myrtiform caruncles, the state of the vulvo-vaginal glands, the condition of the bulb of the urethra, and of the anterior or the posterior vaginal wall, as regards sagging, and lastly we must look for tumors or errors in development. It may happen that in case of double vagina, this may be overlooked if inspection is not resorted to, but simply the finger introduced.
When the finger is in the vagina it must take account of the direc tion,, length, width, temperature, moisture of the canal, and must ex amine the posterior and the anterior walls as regards smoothness, distensi bility, rugosity. On the anterior wall we feel the posterior wall of the urethra, the entrance of the ureters, the anterior portion of the levator ani, the anterior surface of the pelvis, and on the posterior vaginal wall we feel the recto-vaginal septum and the posterior wall of the rectum. We must further take note of the capacity of the pelvic outlet, the dis tance between the tuberosities of the ischium, the condition of the sacro spinous and the utero-sacral ligaments, the anterior surface of the lower part of the sacrum, the shape, direction, movability, tenderness of the coccyx. When the finger has penetrated three-quarters of the way into the vagina, it reaches the vaginal portion of the cervix, which forms a more or less long and conical projection into the lumen of the canal. The essential point about the cervix is the external os, which divides it into an anterior and a posterior lip, and is round or transversely oval in the nulli para, elliptical and transversely slit, in general, in women who have borne children, and with irregular edges. The size and the condition of the os, its smoothness or roughness, tumors within it or in its immediate neighborhood (nabothian follicles, mucous polyps, etc.), the shape, direc tion, length of the cervix, its consistency and that of its mucous mem brane, the tenderness on pressure, are points which may be determined very rapidly. We next carry the finger around the cervix and examine the fornices in regard to the same points as the vagina, and also for pulsa tion, depth, and the insertion of the cervix. In all positions where posi
tive abdominal pressure acts, the uterus sinks somewhat into the vagina and the determination of its insertion is only approximate. In any posi tion where the abdominal pressure is negative, or when the uterus is raised upward by pressure on the cervix, the organ is carried away from the pelvic floor, the sagging vaginal walls stretch out, and their insertion may be determined with exactness. Through the vaginal cul-de-sac we may feel the pelvic inlet. In case there is detected a tumor or increased resistance, we must note the size, form, condition of the surface, con sistency, tenderness, and the relation to the cervix. We may also feel, under favorable conditions, the supra-vaginal portion of the cervix, a portion of the body of the uterus, and the sacro-uterine ligaments. The borders and the consistency of the cervix are above all to be carefully noted.
Whenever a tumor is felt in the vaginal vault, we must at the outset decide as to whether it is the body of the uterus or not, and as to the relations it has to the cervix. The exact continuity of the object with the cervix, the simultaneous movability of the two, the shape, are gene rally not sufficient for diagnosis. In such cases we endeavor to penetrate with the finger as far as possible between the uterus and the supposed tumor, and thus to establish the separation. Only very exceptionally is it possible to detect with the unaided finger the tubes and the ovaries, the latter, under normal conditions, being almond-shaped, rather hard, easily movable bodies.
The simple vaginal touch is of unquestionable value in the determina tion of the form and displacement of the uterus, since the parts are un interfered with by external manipulation, but it cannot always carry the weight of certainty in diagnosis.
After having obtained the above data, we test the movability of the organs which are to be felt by the vagina, in particular the uterus. The cervix is pushed upwards, to the right and left, forwards and backwards, and we note whether the body moves with it, and if after such move ments the uterus returns to its former position. We thus obtain informa tion in regard to the length of the ligaments, their relaxation, the exist ence of remnants of parametric or perimetric exudation, which is often evidenced by thickened bands, and further still we note the weight of the uterus, the position and connection of the organ with others, the presence of ascitic fluid in the abdominal cavity, and finally the sensibility of the uterus and the pelvic surroundings.