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 can not 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 slight ly 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.