DESCRIPTION OF THE METHODS OF EXAMINATION AND THE OBTAINABLE RESULTS.
obtained the rational history, the physical signs are next to be determined. There are a number of diagnostic measures at our disposal, for the examination of the internal genital organs, the vagina, the uterus, the ovaries, the tubes, the ligaments, which although they are not different from the same measures as used in surgery, still are somewhat peculiar from the position of the above organs. Certain of the methods of examination are not at all special, such as acupuncture, the exploratory incision, the diagnostic excision, and they will, in connec tion with the chemical and microscopical examination of the excretions, secretions and tissues be spoken of together with the description of special diseases of the genital organs. Aside from these, the following methods are at our disposal: a. Examination by means of the sense of touch: Palpation of the ab domen, the touch, including the combined examination by the vagina, rectum, urethra, bladder, the use of the sound.
b. Examination by sight: Inspection, mensuration, the speculum.
c. Examination by the hearing: Percussion and auscultation.
The older writers, Meissner and others, claimed that they also reached a diagnosis by means of the smell, but to-day taste and smell are not in cluded among our diagnostic measures. In addition, however, there are instances where, in order to reach a more exact diagnosis, it is necessary to dilate the genital canal, in particular the cervix, by bloody or non bloody operative means.
Other authors have divided the methods of examination differently, as, for instance, West into manual, instrumental and ocular inspection, Hegar and Kaltenbaall and Schroder into manual and instrumental, Kiwisch and Amann into external and internal means, etc. We will, however, describe the methods of examination in the order in which practical experience has sanctioned their usage.
The general routine differs, of course, according to circumstances, but ordinarily it will be as follows: Inspection of the abdomen (possibly the mamma;), palpation, mensuration, percussion and auscultation, in spection of the external genitals, simple and combined touch of the vagina, and, if necessary, of the rectum and the bladder, the use of the sound and of the speculum. Dilatation of the cervix for diagnostic pur poses, as well as artificial prolapse of the uterus, always follow resort to the other methods, and, therefore, are spoken of last and as preparatory to therapeutical measures. The above routine scheme is the simplest, but it may often have to be altered.
In making an examination, also, it is essential in our own interest to follow a certain routine. It is wrong simply to proceed far enough in our examination to reach a diagnosis which will explain the symptoms, for thus we may overlook essential abnormalities, either on account of faulty estimation of the cause of the symptoms, or else because those de tected give rise to no symptoms. It is our business to make a complete exhaustive examination, and to search the genital system as well for the presence as for the absence of abnormalities.
Sometimes external causes render an exhaustive diagnosis impossible.
Aside from the objections of the individual, which are, however, rarely insuperable,—and the higher the individual in the social scale, the less the resistance,—there occur narrowings and occlusions of the genital canal, which render the touch and the specular examination impossible. The puerperal state, certain kinds of hemorrhage, contra-indicate the sound, as also inflammatory affections of the uterus or its surroundings, processes which necessitate examination with the greatest possible care.
In no other branch of medicine may injury be so readily inflicted during an examination, as in gynecology. The more skilled the examiner the more carefully and gently will he examine, and aside from the risk of inflicting injury, we should proceed gently in order not to add pain to the disagreeable nature of the examination. The simple vaginal touch may even cause inflammation, denudation of epithelium and hemorrhage; the bimanual palpation may lead to tearing of adhesions, rupture of cysts, etc.; the sound and the speculum, if roughly •used, may cause great and even fatal injury, as also the dilating measures and discission of the cervix. Here, as in case of every manipulation, we must estimate the worth of the exploratory method as regards the obtainable results with the possible dangers to which we subject the patient.
In general, it is of indisputable importance to reach an exact diagnosis at the first examination, but this is often difficult or else impossible. In case of version and flexion of the uterus, tumors of this organ or of its annexes, suspicion of pregnancy or carcinoma, repeated examinations are essential, in order to determine the influence of distension of the rectum and of the bladder, of bodily exertion, of menstrual hyperemia, on the position of the genital organs, and on the alterations in size or con sistency. In difficult cases, especially of tumors, a control examination is especially necessary.
The intermenstrual period should be elected for examination and local treatment, for the reason that then the conditions approximate nearer the normal, and there is less danger of inflicting injury. Simp son, however, in 1844, pointed out that the changes present during men struation may be utilized for purposes of diagnosis, especially since the cervix is patent, and it is possible to penetrate partially into the uterine cavity, and to recognize abnormalities, the determination of which would otherwise call for diagnostic dilatation. It is peculiarly important in case we suspect fibroids, intra=uterine polypi, or foreign bodies in the uterus, to examine during the period of menstruation.
The examination had best be undertaken at a time of the day when the individual is under normal conditions. After eating or exertion an examination had better, if possible, not be undertaken, also during the course of an intercutrent disease, which renders the patient locally or generally more sensitive.
The results of the examination should be recorded. It is of great assistance to use a scheme like those devised by J. B. Schultze, Spencer Wells, Beige], Kocks, and others, in which the findings may be outlined.