INTRA-PELVIC TECHNIC (Manipulative Surgery of the Pelvic Organs)
The intra-pelvic examination should, as a general thing be the final examination. It should have been preceded by the oral examination, the anamnesis, which through its revelation of history and symptoms will determine the advisability or the necessity of the intra-pelvic examination.

I wish again to emphasize the fact that all of women's ills do not arise within the pelvis and that every woman applying for treatment does not need an intra-pelvic examination, yet at the same time I would remind the reader of the dominance of the reproductive organs and their function through some thirty years of a woman’s life.

The question naturally arises, what conditions or symptoms determine the necessity of an intra-pelvic examination? While this may be left to individual judgment, and while I still believe that there is a great deal of meddlesome gynecology, the presence of certain symptoms and conditions as elicited by the anamnesis demand such an examination unless positive contraindications for it exist.

1. Disorders of menstruation, amenorrhoea, dysmenorrhoea, menorrhagia or metrorhagia when not easily controlled. In cases of women other than virgins the examination may properly be made as soon as the patient presents herself.

Fig. 7. Showing the use of the unflexed third and fourth fingers in examination and treatment, also the approximation of the fingers with only the vaginal and abdominal walls intervening in bi-manual examination before attempting to palpate the separate organs.

2. The presence of abnormal discharges (either in kind or amount) mucous, pus or blood.

3. The presence of pain in the pelvis or in some sympathetically related part as the dorsal, lumbar or sacral regions of the spine, hips, thighs, bladder, rectum, etc.

4. The presence of pain or disturbed function elsewhere in the body concurrent with the menstrual periods, as headache, backache, indigestion, etc., occurring immediately before, during or after the menstrual period.

5. Disordered psychic or mental conditions concurrent with menstruation.

6. Obscure cases in which it is necessary to eliminate pelvic pathology as a causative or contributing factor.

While it may he true that many cases of pelvic trouble can be cured without an examination, it is a fact that any physician attempting to cure a pelvic disease without an intra-pelvic examination and a correct diagnosis is working in a haphazard and unscientific manner. It is just as sensible to attempt to cure a general disorder without an examination and just as great an injustice to the patient. It is only in virgins that such an examination may be dispensed with and in these much can be learned by a recto-abdominal examination. It sometimes becomes necessary in such cases to make an examination under anesthesia.

Every intra-pelvic examination should be preceded by an inspection of the external genitals. This is first a matter of precaution on the part of the examiner as by it he or she might be saved an accidental syphilitic or chancroidal infection. It is further the first step in the diagnosis. Some disease of the external genitals may be the cause of the symptoms that are suspected to arise within the pelvis. Ulceration, inflammation, new growths, deformities or abnormal discharges should he looked for. Especial attention should, be given to the clitoris and the possibilities of adhesions or accumulations of smegma about it.

We will assume that the patient to be examined is at least a married woman and perhaps one who has borne children. She is placed on the examination table in the dorsal position with the knees flexed and abducted. (Fig. 6.) She is covered with a sheet to minimize exposure.  The bladder and rectum should previously have been emptied. Ordinarily the physician both for examination and treatment stands at the side of the table and reaches under the thigh of the patient. In some cases it is better to stand at the end of the table between the separated knees of the patient. This position enables the examiner to use his body weight against his elbow so that more force may be used and the fingers not only passed deeper into the pelvis by the invagination of the pelvic floor but the examination made more thorough and less tiresome. The use of sterilized rubber gloves is always preferable. In their absence the physician's hands should be thoroughly cleansed with soap and water. While the vagina is lined with pavement epithelium similar to that of the skin and the ease of infection here has been exaggerated, still this is no excuse for anything less than surgical cleanliness. The nails of the index and middle fingers should be trimmed short and freely anointed with a good lubricant. The following can be recommended as a good one not only for the hands but for instruments as well. It is non-greasy and washes off the hands easily. Into one pint of a saturated solution of Boracic Acid stir one-fourth of an ounce of Gum Tragacanth. Ten drops of oil of lavender or of carbolic acid may also be added. Set aside until dissolved, stirring occasionally with any sterile instrument. If it should be too stiff add water.

It has been my custom to use my right hand as the intra-pelvic hand not only because the tactile sense is better developed in that hand, but also because, being right handed, I am more dexterous with it than with the left. It is advised by some that the right hand be used  to explore the right side of the pelvis, and the left hand for the left side. Personally I prefer the use of only one hand for intra-pelvic examination and manipulation. By extending the unflexed third and fourth fingers along the natal cleft (Fig. 7) instead of flexing them into the palm of the hand the pelvis can be a little more deeply explored.

The use of rubber gloves is recommended as a routine practice. Emergencies arise when they are not at hand and soap and water sterilization must be depended upon. Gloves should always be used when there is any suspicion of venereal disease.

The examiner is now to have the severest test of his tactile sense and his manipulative skill. He is to determine the size, shape, position, mobility and consistence of tissues and organs, as it were, floating in a medium of almost their own consistence. Patience, practice, a knowledge of location and the ability to visualize this location are the means to expert diagnosis.  Abnormalities cannot be recognized unless one has a knowledge of the normal. So no occasion should be lost to acquire this knowledge and to educate the tactile sense to the feel of the normal pelvic contents. Only after repeated examinations can this be done but not until then is the examiner able to detect abnormalities.

As the fingers pass into the vagina the size of its opening, its interior capaciousness, the tone of the pelvic floor or its resistance to pressure downward and backward and evidences of lacerations should be carefully noted. As the fingers are passed backward any swelling, induration, tenderness or other abnormality of the walls should be carefully looked for. The relation of any of these to urethra, bladder, vulvo-vaginal glands, rectum or ureteral location should be noticed and further examination pursued later.

The fingers should now be passed deeper into the pelvis and the cervix, the chief intra-pelvic landmark, located. It is found about three inches from the vulva, approximately in the middle of a line connecting the ischial spines. In the non-parous woman it will be recognized as a firm, somewhat hard, conical protuberance about one inch in diameter, and projecting at a right angle, for about three-fourths of an inch into the upper portion of the vagina. In the center of its end there is a slight depression, the external os. Childbearing makes certain changes in the cervix.  It becomes softer, broader, and seemingly shorter. The os becomes more patulous, often admitting the tip of the finger, and instead of being a round depression it may be felt as a transverse slit or small scars may be felt radiating from it. If it has been severely lacerated it may be divided into two or more distinct portions. In some diseased conditions it may become very much enlarged. Attention should be given to all these changes from the normal.

The cervix should point backward and slightly downward (Fig. 1). Its position and direction are of some aid in diagnosing displacements of the uterus, but a diagnosis should never be made from the direction of the cervix alone. The body of the uterus should always be located.

The cervix should now be tested for mobility. Under normal conditions with the fingers on either side or front and back, it is freely and painlessly movable in all directions. If its motion is restricted or painful either adhesions or inflammation are present. If adhesions they will restrict motion toward the side opposite their location, i.e., if they are on the right side of the pelvis they will restrict motion toward the left. If they are of recent formation stretching them will cause pain. If pain is caused on the side toward which the cervix is forced it is caused by pressure upon an inflamed organ or tissue, an ovary, uterine tube, abscess, etc. The cervix is sometimes immobilized by malignant involvement of the adjacent tissues. Hypermobility of the cervix less frequently occurs and is the result of undue laxity or loss of tone of the pelvic floor, often the consequence of injuries to the Perineum,

The next step in the examination is the palpation of the uterus. For this both hands are necessary, one on the abdomen to make counter-pressure and force the uterus down upon the fingers of the other hand, which remains in the vagina, so that it may be more easily and readily felt by these fingers. The intra-vaginal fingers are decidedly the more important and effective element in the examination. It is true that a great deal is learned through the sense of touch in the external hand, but while it has the thickness of the abdominal tissues through which to feel, the internal fingers have only the thinner vaginal wall and upon these most reliance must be placed for palpatory findings.

Some systematic plan should be pursued and the following is suggested especially for the inexperienced. To these the intra-pelvic examination is for a long time unsatisfactory and disappointing in that they are unable to differentiate or even definitely feel the different pelvic organs. As one gains in experience and efficiency the organs become more easily palpated and the examiner may then modify his routine and adopt the method by which he gets most accurate and quickest results.

First determine the thickness of the tissues between the anterior vaginal wall and the skin without the presence of any intervening organs. To do this approximate the fingers of the two hands by placing the external hand upon the abdominal wall (either bare or at most with only a thin garment over it) at a point slightly below midway between the umbilicus and the os pubis and to one side of the median line, about the outer edge of the rectus muscle. The hand should be placed upon the skin slightly lower down than the point it is ultimately to rest upon and the skin pushed up to this point. The most usual mistake is to place the hand too low down; too close to the os pubis. The fingers should be slightly curved and a gentle downward pressure made in the direction of the pelvic axis. At the same time the fingers within the vagina press upward to one side of the cervix until the fingers of the two hands are brought together, only the vagina and abdominal walls intervening (Fig. 7.) The thickness of the tissue between the two hands will vary greatly in different individuals as they are thin, stout or muscular. It should be carefully estimated as preparation for the next step.

The intra-vaginal fingers are now placed deeply in the pelvis just in front of the cervix and without relaxing its pressure the external hand, and the tissues with it, is moved toward the median line and the uterus is brought between the fingers (Fig. 10). It will be recognized by the additional thickness intervening between the fingers and its firmer consistence as compared to the tissues of the abdominal and vaginal walls.

In making such an examination every effort should be made to secure relaxation on the part of the patient and nothing should be done by the examiner to defeat this end. The patient's head, and sometimes the shoulders as well, should be elevated to secure relaxation of her abdominal muscles; her hands should be at her sides and she should be instructed to breathe naturally and easily. It is sometimes well to engage her in conversation during the examination as this tends to natural respiration. Advantage may be taken of the relaxation which follows a deep expiration and the fingers pressed deeper into the pelvis and the examination facilitated. Continuous firm but gentle pressure should be maintained by the abdominal hand. Quick, jerky, gouging movements excite muscular resistance and increase the tension of the abdominal walls. If failure to locate the uterus should occur repeat the procedure carefully, feeling more deeply into the pelvis and centering your attention upon the touch perceptions of the internal fingers.

Another method, observing all the details heretofore mentioned, is after locating the cervix, press it upward, and forward with the two fingers in the vagina and at the same time insinuate the fingers of the abdominal hand deeply into the pelvis, behind the uterus and bring it forward. Without relaxing their pressure the fingers in the vagina are passed to the front of the cervix and the body of the uterus is brought between the two hands.

After the uterus is located it should be determined whether or not it is in its normal position and location. If it is not the direction of its deviation should be ascertained. Its size, whether normal or smaller or larger than it should be, and be determined.  Tenderness on pressure; freedom from growths; consistence whether soft and fluctuating, firm and regular or hard and nodulated, are of importance as is also the angle formed by the body and cervix. It should be possible to carry it out of its normal position to a considerable degree without pain or discomfort. If this is not possible the motion which is limited, or produces pain, should be carefully determined and the cause for the limited motion or pain located.

Fig: 8. Recto-abdominal Palpation.

In palpating the ovaries it must be remembered that normally they are lateral to the uterus, slightly posterior and higher in the pelvis than its body. They are opposite a point on the abdominal wall about two inches medial to the anterior superior spines of the ilium and an inch and a half below this point. (Fig. 3.) It requires considerable practice to examine the normal ovary, especially if the patient has thick or unyielding abdominal walls. Sometimes one is forced to the conclusion that the ovaries are normal even though they cannot be found after a careful examination, if there is no tenderness about their normal location. In examining for them the intra-vaginal fingers are pressed backward, upward and outward by the side of the cervix while the abdominal hand over the site of the ovary is pressed backward and downward in the axis of the pelvis.  The fingers of the two hands are now approximated, the internal hand being relied upon for palpatory findings. It is sometimes well to first approximate the fingers of the two hands with only the abdominal and vaginal walls between them to determine their thickness before attempting to palpate the ovary.

If the ovary is not found at the first attempt, while still maintaining the external pressure, press the vaginal fingers deeper into the pelvis, change them a finger's breadth either outward or toward the median line and repeat the attempt until the ovary if found. Gentleness and relaxation as suggested in palpating the uterus are of great assistance. If not found in their usual location the ovaries when displaced tend to fall downward and backward into the recto-uterine excavation. To examine this region press the intra-vaginal fingers into the pelvis posterior to the cervix and the abdominal hand downward and backward in the median line as in the palpation of the uterus. Approximate the fingers of the two hands behind the uterus, slightly outward from the median line and if prolapsed the ovaries can usually be felt.

Pressure upon the normal ovary gives rise to a peculiar sickening pain. When they are located their size, tenderness and mobility should be determined.

The uterine tubes in their normal condition are even more difficult of palpation than the ovaries.  The method given for palpating the ovaries will locate them if they are swollen or filled with fluid. Under these conditions they are recognized by their tortuous course and the irregular bulgings which occur along them. In severe cases the tube may be so enlarged as to fill the entire side of the pelvis. In cases of thin and relaxed abdomens the normal tube may be felt as a small soft cord by palpating out from the angle of the uterus in the direction of its course. Even under the most favorable conditions it is the firmer isthmus and not the ampulla that can be felt. In severe tubal inflammation the tube and ovary may be so agglutinated as to form a single mass in which neither organ is separately distinguishable.

The normal ureters can only occasionally be palpated. They run from the base of the bladder backward and outward and upward through the pelvic connective tissue, about one-half to three-quarters of an inch on either side of the cervix. When they are inflamed or thickened they can be felt as tender cords. Occasionally a stone impacted in their pelvic portion can be palpated through the vagina or rectum. An attempt to palpate them should be a routine part of every examination. Tenderness or induration along their course would be suggestive of inflammation, an impacted stone or stricture.

Recto-abdominal palpation (Fig. 8) as has heretofore been suggested is sometimes advisable in the case of virgins. The information secured is limited but at times valuable. Only one finger can be used in the rectum without anesthesia, as a rule, and only the structure lying low in the pelvis can be reached with this. The cervix can easily be felt through the anterior rectal wall. Retrodisplacements are as a rule easily detected by this method. Often when a mass is found low in the posterior part of the pelvis by vagino-abdominal palpation it is well to further examine it through the rectum. Its value is frequently of a negative character. If there is the absence of tenderness, induration or a mass in the recto-uterine excavation one is fairly safe in assuming that there is no serious disorder there. Should any of these he present when an attempt is made to approximate the abdominal hand and the finger in the rectum their nature and relationship to the pelvic organs should he determined.

In this examination the gloved or cotted index finger should be used and it should be pased as high into the rectum as possible. If is turned forward and while counter pressure is made with the hand on the abdomen an effort is made to differentiate the organs and conditions, that may be present.

Recto-vagino-abdominal palpation is sometimes perforrned. With one hand on the abdomen making counter pressure the index finger of the other hand is introduced into the rectum and the thumb into the vagina. Occasionally a case may be seen in which some additional information can be secured by this method.

Figure 9.  Erect Position

Examination in the erect posture (Fig. 9) becomes necessary in extremely rare cases. Occasionally it may be impossible to determine the amount of descent of the uterus in a case of suspected prolapse unless the patient is examined while standing. For this the examiner sits in a chair and the patient stands in front of him with one foot upon a stool and the vaginal examination is made in this position.