A Text-book of Diseases of Women

by Charles B. Penrose

Fig. 2.—Bimanual examination.

This is called the bimanual method of examination, and the student will find that as he acquires practice in this method he will gradually depend less upon examination by the uterine sound and the speculum, and will rely altogether upon his sense of touch, his ability to palpate.

It matters not which hand be used in making the vaginal examination. It will, however, be found that the hand that is used the more frequently will become the more proficient.

In making the bimanual examination the structures should be palpated methodically in order. The vaginal finger notes the condition of the cervix uteri. If the fundus be in the normal position, the uterus can then be taken between the abdominal hand (upon the fundus) and the vaginal finger (upon the cervix) ([Fig. 3]). The shape, size, mobility, and consistency are noted. The vaginal finger is then passed anteriorly and laterally toward either uterine cornu, while the abdominal fingers pass over to the posterior aspect of the same cornu. The ovarian ligament and the proximal end of the Fallopian tube may thus be felt. Passing farther outward, the whole of the tube and the ovary may be examined. The same procedure is then applied to the opposite side.

Fig. 3.—Bimanual examination; median sagittal section of the pelvis.

The condition of the ureters may be determined by placing the vaginal finger in either lateral vaginal fornix and drawing it outward and forward, when these structures will pass over the end of the finger. When the ureters are indurated by inflammation they can be plainly felt.

By the method of examination here advised the physician will always make a visual examination before making a digital one. There are several advantages derived from this procedure. In the first place, no examination of a woman is thorough unless a careful visual examination of the external genitals has been made. The discovery of discharges and of lesions of the external genitals may throw much light upon the condition found higher up in the pelvis. Again, the examiner protects himself. A great many unfortunate cases of syphilis have been acquired by physicians from a primary sore upon the examining finger. A preliminary visual examination enables one to guard against this danger. The primary sore occurs upon the end of the examining finger or upon the web between the index and middle fingers—the part of the hand that is pressed against the fourchette.

The hands of the physician should, of course, be surgically clean before making an examination, and the grease or oil which is used as a lubricant should be clean. The hands should always be washed, after separating the parts to make the visual examination, before the finger is thrust into the vessel containing the lubricant. It is best to place a small portion of the lubricant on a plate or a saucer for each individual patient, and thus avoid the danger of contaminating the rest. Carbolized oil, borated vaseline or cosmoline, and a thick sterile solution of soap are good lubricants. Neutral green soap diluted with boiled water to the consistency of thin jelly is a very agreeable lubricant which may easily be washed from the hands and the vagina.

If practicable, the woman should receive a vaginal douche of bichloride-of-mercury solution, 1:4000, and the vulva should be washed, before making a bimanual examination. The examiner should always clean the external genitals of all discharges before introducing the vaginal finger. In this way we avoid the danger of carrying septic material from the external genitals to the upper portion of the genital tract. This preliminary cleansing is not desirable before the external genitals have been examined; for much may be learned from observation of the discharges which bathe or escape from the various structures. If practicable, a cleansing vaginal douche of bichloride-of-mercury solution should be administered after the bimanual examination.