The fingers of the external hand and the internal finger may be brought together in front, the vaginal wall and the abdominal parietes and the bladder alone interfering, and laterally only the layers of the broad liga ment. The uterus may be thrown forwards for more careful palpation, if the internal finger pushes the cervix upwards and backwards. In case the external fingers are placed just over the symphysis and pressure be made deeply into the pelvis, the uterus is pushed downwards and a trifle backwards, and this is to be avoided, for it is preferable to begin by palpa tion of the posterior portion of the pelvis first, and thence working for wards.
In case the conditions are favorable, and by securing proper fixation of the uterus, we may estimate its form and size, the relative size of the cervix and of the body, the curvature of its anterior surface, the thick ness, consistency, sensitiveness, as also the presence of even minute tumors of its surfaee.
We next proceed to determine the movability of the uterus. The in ternal finger pushes the cervix forwards, while the external hand de presses the fundus towards the hollow of the sacrum, and, if the condi tions are favorable, the external hand may examine the anterior surface of the uterus, and determine the necessary points in regard to it.
Since now by these manipulations the uterus is pushed out of position, it is evident that the bimanual palpation cannot alone. determine the position of the organ, but that the simple vaginal touch must always pre cede the bimanual. Where, however, the touch has determined the fact that the cervix is deviated to one or another side, or that in one or another form there is present a tumor or increased resistance, then by the bimanual palpation we may detect the reasons. The absence of the body of the uterus from its normal position, the size, shape, consistency of the questionable tumor, the continuity of the tissues between this tumor and the cervix, give us information.as to the condition of affairs, especially in conjunction with what is gained by testing the mobility of the uterus.
There is a similar liability to error in the estimation of the shape of the uterus. Pressure on the organ may cause flexion of the body back wards or forwards on the cervix, and here careful simple vaginal touch is a safeguard against error. The combined examination will tell us
the nature of the flexion, the thickness and consistency of the uterine wall, and as to whether the flexion may be overcome, and if so, if the organ will remain straight or resume its flexed form. These facts are noted by pressing the uterus down against the internal finger. In case of anteflexion, the internal finger is placed in the anterior fornix, and the external hand endeavors to lift the body of the uterus upwards, and then the internal finger is transferred to the posterior fornix, and it estimates how much the organ is straightened by the external hand. In a similar manner we may estimate the amount and the behavior of backward and lateral flexions.
The other pelvic organs may be examined even as can the uterus. Generally it is possible to approximate the fingers in the anterior fornix without difficulty, so that they are only separated by the abdominal parietes, the vaginal wall, the bladder and the cellular tissue, and we may detect slight unevenness or tumors with ease. The finger in the vagina directed towards the symphysis may touch the anterior pelvic wall, the round ligaments, the utero-vesical pouch, and the latter all the better the more the external hand is able to move the uterus and to thus put the ligaments on the stretch. It is much more difficult to approxi mate the fingers in the posterior fornix. This is generally only possible where the abdominal and pelvic walls are relaxed and thin. Under fav orable conditions, however, the fingers may meet in the centre of the posterior pelvic space, and may feel the sacro-uterine ligaments which are like tense cords, in case the uterus is pushed greatly downwards or forwards.
The lateral fornices may be similarly examined. We examine first the sides of the uterus, then the broad ligaments and the tubes within them which simulate between the fingers rolling, thin, round cords. Behind and externally the ovaries may be palpated as regards their posi tion, form, size, surfaces, sensibility and motility.' Only very exception ally is it possible to feel the ovarian ligament. We must further in the examination of the lateral regions, determine the mobility of the uterus to one or another side, as also the condition as regards tenseness of the lateral ligaments.