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 or 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.

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 can not 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 structures 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 be 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 be determined.

Fig. 8. Recto abdominal Palpation.

Fig. 8. Recto-abdominal Palpation.

In this examination the globed or cotted index finger should be used and it should be passed as high into the rectum as possible. It 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 performed. 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.

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.

Fig. 9. Erect Position.

Fig. 9. Erect Position.