THE FORMATION OF THE DIAGNOSIS.
It has also been made clear to the reader that the results from the different methods of examination are not entitled to the same weight, and are not individually to•be considered as absolute. There are grounds for error, aside from the preconceived opinions of the examiner, not alone in the insufficiency of the methods themselves, but as well, and more likely so, in the changes in the genital apparatus, which frequently do not permit the application of correct methods of examination. The proper appreciation of the value of the results from the various methods of examination is something which experience alone can teach, and can only be properly done by minds which are trained to think critically, to judicially weigh results, and which are not inclined to accept blindly as true the authoritative dicta of others. Here the rule should ever be: " Feel for yourself, see for yourself, think for yourself and for yourself alone." If we possess the requisite skepticism in regard to the results from the physical examination, this spirit is still more necessary in regard to the appreciation of the rational signs. We may so readily be led astray by the recital of the woman's symptoms, such care and discrimination is requisite for the sifting of these symptoms, that it is a most difficult task to reach the truth.
Although these remarks are not purely applicable to gynecology, it is still true that in no other branch of medicine is it so difficult to form one's own opinion, and that in no other branch is it so difficult to choose and to follow the correct road.
There are many obvious ways of reaching a diagnosis. It is absolutely wrong. as we have already suggested, to follow one symptom and to be satisfied with the results of the examination if it explains this symptom.
Owing to the fallibility of our judgment, and owing also to the chance of error in our physical examination, we must seek by induction, by the synthesis of our results and impressions, to outline the picture of the symptoms, and we next should test the fidelity of this sketch by subject ing it to the exclusion method.
This constructive method of diagnosis is similar to the formation of a mosaic, from which possibly one stone is lacking, or one is present which does not belong there. The more we change and sift the stones the better and more readily will we reach the perfect object. We change and re arrange our diagnostic atones in accordance with the data furnished us by our pathological and physiological knowledge. One stone fits into another, and obviously he will best attain results who is able to recognize the aptitude of one stone to lie in apposition to another. The wrong stones represent faulty premises, or those which are open to doubt. We should lay aside, at the outset, the obvious truths, then sift out the un• certain, when there remain only suppositions which are lacking in correct anatomico-diagnostic groundwork.
When we have formed our diagnostic picture, then we should ask, What does it, in its entirety, mean? We keep it entire before our eyes, and ask ourselves whence it most strongly points, and what conclusion is justifiable? If we possess many landmarks, and if we lack a few uncer tain ones, then we may. reach an opinion, but must still seek for the nature of the factor. We know the species, we must still seek the genus. Having formed our diagnosis, we must test it by exclusion, ask ing ourselves what else it might be, and why it was not different. Our mosaic is a tree; we must still find out what kind of a tree it is. We are familiar with a variety of trees, and we must ask, Is this tree a maple, an oak, a fir? We must give a reason for each exclusion, until we reach the correct species. For example, we have, by synthesis, reached the conclusion that the body of the uterus is bent backwards; we must by exclusion strengthen this diagnosis by remembering that bodies in the posterior portion of the pelvis may be: Tumors of the sacrum, of the in testine (scybala), of the ovaries, of the uterus (myoma, etc.), of the tubes and the ligaments, inflammatory exudations, hematoceles, retrofiexion. The results of our examination ekclude everything but the retroflexed uterus.
From the above remarks it is evident that exactness lies in the uniting of different results. These are arranged according to their importance and value. To test them it is essential to resort to every known method of examination, and in accordance with system. The physician further must be able to compare the anatomical and clinical data with one another. This ability is acquired not from books, but from careful practical study.
Whenever possible the rule should be to examine twice, particularly in case of tumors of the genitals, for even the skilled observer may reach results at the second examination which had escaped him at the first. Furthermore it is generally important to note the changes in movable organs, which result from their distension and that of their surroundings.
Frequently it is not possible to reach a certain diagnosis. In general the more skilled the observer the less likely he is to be ever sure, because he recognizes his own fallibility.
The forming of the prognosis and the treatment on the strength of a probable diagnosis is also a question of experience and of personal knowl edge. Often by long observation and frequent examination a probable diagnosis is rendered certain, but too frequently it happens that the diag nosis is assumed as exact, and this is a frequent cause of error, which renders the special practice of gynecology, in particular, so difficult.