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.

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 be 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 be 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 fur 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.

Fig. 6. Dorsal Position

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.

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.