After concluding the examination the finger is withdrawn and the secretion, etc., on it is looked at.
b. The combined Vaginal Examinalion.—For the proper performance of this method of examination not only must the vagina be patent for the finger, but its walls must be thin and distensible, especially in the rid•de-sac. A short vagina with tense thick walls, or one where, as the result of the presence of tumors, or of inflammatory affections, there exists limited distensibility, interferes with or prohibits this manner of examination. By means of methods to be spoken of later, this tenseness may frequently be diminished, but again often this is not possible. As contra-indications to the method may be mentioned, recent inflamma tions of the uterus, its adnexa, the pelvic peritoneum and cellular tissue, hematocele, pyosalpinx, hematometra, bematosalpinx, thin-walled cysts of the ovary and ligaments, for the reason that much manipulation may increase the inflammatory trouble, or else cause rupture. Large tumors filling the pelvis, if they cannot be pushed above it, render the bimanual palpation almost or entirely nugatory. A further factor which interferes is the inability to palpate. Not only must the vagina allow of the pene tration of the finger, but we must be able to depress the abdominal walls. Great deposits of fat in the abdominal walls or in the mesentery, the pendulous abdomen, painful inflammatory affections of the abdominal walls, these interfere greatly with or prevent the performance of the bi manual palpation. Much distension of the bladder and rectum must of course, be relieved. This examination will also be very difficult to per form in cases where there is excessive deposit of fat in the thighs, mates, or external genitals, whereby the vagina is longer and the parts to be pal pated are higher up. The means which we noted under palpation, for rendering it easier of performance, are also applicable here, and in ease of necessity, we may resort to anesthetization.
In order to perform the bimanual, we choose a position whence both the vaginal touch and palpation may be resorted to at one and the same time. In Germany generally the bimanual palpation is performed with the patient lying in the dorsal position and with flexed thighs, and the simple vaginal touch is followed at once by the bimanual. In this posi
tion the abdominal pressure is slight, when the buttocks are it is negative, the movements of each hand are free, and we are able to make considerable pressure on the abdomen. The most ill-adapted posi tion is the upright, and only under very exceptional circumstances, for instance where the abdominal walls are greatly relaxed, is it possible to reach any results. The side and the side-abdominal positions, on the contrary, are often useful, especially when it is desired to determine the relation which the uterus bears to other organs, or tumors, since thus its movability is best tested. In the lateral position it is also possible to penetrate quite deeply into the pelvis, but it is necessary for the upper thigh to be held up by an assistant or by a bolster placed under it, else the play of the palpating hand and its forearm is limited. The knee elbow position is unsuitable for the bimanual, because the movable in ternal organs gravitate away from the examining finger, and the palpating hand cannot be used to advantage.
The position of the examiner, the choice of the hand, the introduc tion of the finger, are similar to what holds for the simple vaginal touch. Indeed the simple touch should be followed at once by the combined, the finger not being withdrawn from the vagina. The hand on the abdomen aims at pressing the movable abdominal organs downwards, and fixing them in such a position that simply the abdominal parietes on the one side, and the vaginal walls on the other, separate them from the fingers of the two hands.
The patient being in the dorsal position, the extended hand is placed on the abdomen, the tips of the fingers being directed towards the ensi form cartilage, and the abdominal walls are depressed. In thin indi viduals we come at once upon the promontory and the anterior surface of the sacrum. If the uterus be now lifted up on the finger in the vagina, or in case the organ is enlarged, the fundus is readily felt, or in case of anteversion the posterior surface of the organ, and while this is palpated by the external hand, the finger in the vagina examines the vaginal por tion of the cervix, and the anterior surface of the body of the uterus.