After we have harmonized to some extent the anatomical conditions and the present symptoms presented by the given case, we must make an exact gynecological examination. We shall not describe here how this is to be done, or dilate upon the extended experience, which, at the present day, is required. The earliest labors of specialists in this department are well known. I only crave permission to make a single observation here. It has reference especially to the practice of this special branch of medi cine by general practitioners. Of course I am ignorant as to how far my experience on this point coincides with that of others.
For myself, at least, I am convinced that physicians in general ought to possess a far greater familiarity with gynecological examination tha,n they have hitherto displayed. There are two reasons which may be ' assigned for this negligence, one being a cert,ain prudery, the other the actual need of extended experience in order to arrive at a positive diag nosis. The first, according to my experience, plays a far more prominent part than is at first believed. Among young practitioners especially, I have noticed for this reason an almost entire neglect of this important practice. I might properly describe this entire conduct as nothing short of a want of sufficient earnestness. The second reason is, of course. always the more important. The early neglect seems to be irretrievable, partly through want of opportunity and instruction, partly through lack of time. But, that both causes still universally continue to prevent the attainment of the proposed end is rather due to the fact that the ex treme importance of the whole question is not yet widely enough weighed and comprehended. That it is certainly necessary to possess wide experi ence in order to attain to sufficient readiness cannot be denied. But, re member that, in the beginning, opportunity for this is almost never want ing, and that in later years, although it is much more difficult, still much may be accomplished.
We have already referred above to the results of the gynecological examination in the cases here alluded to. The ovaries will be found to be diminished in size, indurated, and their surfaces irregular, or enlarged so as to form shapeless masses, perhaps fluctuating (in cases of abscess), or simply enlarged and hard (as in hypertrophy), or exceedingly small and hard (in cirrhosis), or, on the other hand, surrounded by masses of exudation and adherent to surrounding parts. Or, we may detect cystic
degeneration, solid, benign or malignant tumors at the site of the ovaries, or a neoplasm on one side and an inflammatory process on the other, etc.
The condition in the upper portion of the genital tract is of great importance. Evidences of retrograde metamorphosis are especially to be considered. If, after what has been said, we are not satisfied with atrophy of the uterus alone RS a cause, still, this condition, when asso ciated with some other phenomena, will point to certain processes in the ovary. Here, again, we must, of course, exclude that variety which is due entirely t,o the pressure of a tumor adja,cent to the uterus. The vagina and external genitals, also, may possibly present something worthy of note.
It may, of course, happen that the result of the gynecologie,alexamina tion proves to be entirely negative. Obstinate functional disturbances may occur under circumstances when nothing can be detected by the most practised hand; or, on the other hand, palpable changes are present, but are, on account of their limited character, overlooked, partly con scionsly, and partly through want of skill, in spite of the employment of the greatest zeal.
If now, in such cases, the most important support of oar opinion, the condition of the pelvic organs, is wanting, then we must, after weighing the history and the most striking of the symptoms, resort with renewed thoroughness to the most careful Consideration of a third point, which in every caae, moreover, no matter how clear may be the condition, must not be disregarded. This is, certain general phenomena produced in the body by the menopause; the pictures of this character, occasionally pre sented for our observation, are sometimes extremely varied and compli cated. As a rule, we can study them only at the time of the normal climacteric, but traces of them can often be detected even at the prema ture menopause, and they then possess an increased significance, especially if, as we have before stated, certain other evidences escape us. I shall discuss these changes in the entire organism more at length later. For the sake of thoroughness, I must here merely emphasize the importance of never omitting to look for such phenomena. I may be permitted., in concluding this chapter, to refer to uertinent and instructive cases that have come under my observation.