THE DIAGNOSTIC EXCISION.
Examination by means of the trocar, harpoon, aspirator, etc., are subject to the same rules in gynecology as are applicable to them in gen eral surgery. We propose to consider here only the diagnostic excision In face of the difficulty of recognizing carcinoma in its early stages, Ruge and Veit, Richter and othets, have laid stress on the necessity of examining under the microscope portions of removed tissue. Generally we may obtain material for examination with the sharp curette. In order that the microscopic examination may yield accurate results, sufficient tissue should be examined, and the examiner should carefully note the layer from which the portion is removed. It is of essential value in diag nosis to know from what part of the mucous membrane or the muscularis the section has been taken. The excision may be performed with the knife, scissors, sharp curette, or curette forceps. Antiseptic precautions should be taken. After-hemorrhage is treated according to the ordinary manner, by astringents, the tamponade, the cautery, suture or ligature, and frequently it may be necessary to follow up the diagnostic excision by operation, as, for instance, in case of cancer where there is often pro fuse hemorrhage or traumatism, which may be checked by thorough curetting.
[A valuable means of diagnosis, to which Chrobak makes no special reference, is aspiration. Not infrequently the diagnosis cannot be com pleted without resort to this means, and reference to it seems essential for the sake of completeness. The instances where, in particular, aspira tion will assist us in diagnosis, are small pelvic tumors, the nature of which conjoined manipulation fails in exactly differentiating. Here the point at issue will chiefly lie between hematocele, abscess, small ovarian cyst. In case of larger tumors which occupy in part the abdominal cavity, aspiration, while it unquestionably essentially assists in diagnosis, should, in the opinion of many gynecologists, yield to the exploratory incision, or at itny rate should only be resorted to by the examiner when prepared to follow it by laparotomy. This is not the place to discuss the merits and relative advantages of exploratory puncture and exploratory incision; we have in mind rather the description of aspiration for diag nosis, as it will ordinarily be forced upon the general practitioner.
For simple puncture through the abdomen the ordinary hypodermic syringe will suffice to remove sufficient fluid for examination. The pro
cedure cannot be said to carry with it any special risk, provided the syringe, its needle, and the site selected for puncture have been disinfected with care. On withdrawing the needle, the puncture site need simply be covered by a piece of adhesive plaster. For aspiration through the vagina, the hypodermic needle is hardly long enough, and the small aspirator syringe which we figure will be found convenient. The needle of this syringe may be guided along the finger and boldly plunged at the desired point, by preference the most prominent point, and one where there is absence of pulsation, or else the vaginal vault may be exposed should in either instance be first carefully disinfected, and after aspira tion it should be tamponed with iodoform gauze.
As the result of aspiration of abdominal tumors the examiner will obtain a fluid which frequently will have to be subjeoted to a microscopi cal and chemical examination before the question of its source can be settled. In general, however, the fluid from an ovarian cyst is straw colored, or brownish, and contains albumin; that from a cyst of the broad ligament is watery, clear, does not coagulate, containing no albumin; that from hydatid cysts may show under the microscope the hooklets of the parasite; that from ascites is pale straw .colored and coagulates on standing. As is well-known, it is claimed by Drysdale that the detection of the ovarian cell or corpuscle is proof of the presence of an ovarian cyst, but these and other points hardly concern the general practitioner, seeing that it is the custom of the majority to refer instances of abdominal tumor to the specialist. As for vaginal aspiration, in addition to its uses already noted, the insertion of the needle, when instead of a marked tumor there is purely bogginess or indistinct fluctuation, will often, by revealing pus, explain a train of otherwise obscure symptoms.
Such are the main points in reference to aspiration of value to the general practitioner. It should be further stated that diagnostic, aspira tion should by preference be performed at the patient's house, in order to ensure rest for a time afterwards. For while ordinarily aspiration with the hypodermic needle is innocuous, it has been followed by in flammatory reaction.—ED.J