PART V.

EXAMINATION IN GENERAL.

THE examination of a gynecological case is verbal and physical. Verbal Examination.-The aim of this work being to offer a practical guide for general practitioners, I shall not expatiate about all that we might be led to surmise by a number of symptoms elicited by a protracted conversation-conundrums that, anyhow, only find their solution by a physical examination; but I shall briefly state the questions I ask a patient before proceeding any further.

Age. The age ought to be ascertained, because it often gives a measure of the weakness or robustness of the constitution of the patient, may throw some light on the nature of the affection for which she consults us, and may give us a hint in regard to special epochs in her life, such as puberty or the climacteric.

Social Position and Pursuits.-It is useful to know whether we have to do with a society lady, whose greatest fatigue is her social obligations; a shop-girl, who is kept standing or tripping about all day long; or a washerwoman, who stands bent over the tub rubbing linen day after day. It is of importance to know whether the patient spends her day in studying or in artistic pursuits-conditions which, as a rule, are combined with a highly-developed but over-sensitive nervous system. It is necessary to know something about the financial resources of the patient. In the poor recourse to more radical measures is often imperative, while those who possess adequate means may be benefited by a less vigorous but more protracted treatment.

Duration of Sickness.-The knowledge of the length of time during which the patient has been sick teaches us at once whether we have to deal with an acute or a chronic disease.

Condition. It is of the very greatest importance to know whether our patient is single, married, or a widow, or has sexual connection without being married. If she is married, we want to know how long she has been so.

Childbirth and Miscarriages.-Next we want to know how many children she has borne, the age of the oldest and the youngest, and if she has had any miscarriages. A rapid succession of pregnancies is in many cases an important etiological point. Often the disease for which we are consulted may be referred to the last confinement. If

she is sterile, we must find out if it is a natural condition or due to the use of preventives. If we find sterility combined with dysmenorrhea, we nearly always find a flexion of the womb, and most frequently an anteflexion, often combined with a narrow os. If there have been many miscarriages, we must ask if they were spontaneous or induced. If criminal abortion has been performed, that gives often the clue to the origin of the disease, while, on the other hand, repeated spontaneous miscarriages generally are due to a misplacement of the uterus or to syphilis, either in the patient or her husband, or both.

Menstruation. The normal period is twenty-eight days, of which menstruation lasts four (p. 115). Some women have periods of twenty-seven or twenty-nine days; some even of only three weeks. The duration varies likewise a good deal within normal limits. Some women menstruate only a day or two, others for a whole week; but, as a rule, such conditions are allied to symptoms which show that we have to do with something abnormal. The amount of blood lost at the menstrual period is of greater importance than its duration, since one will lose more in a day than another in a week. As a rule, women are able to tell whether they lose much or little, even if they do not use diapers, the numbers of which are often given as measure of the amount of the discharge. Normally, menstruation is only preceded and accompanied by a feeling of heaviness, especially in the loins. Menstrual pain is always a sign of disease. If it precedes the flow for many days, it is probably of ovarian origin, while a pain felt for a day and relieved by the flow is in most cases referable to a flexion of the uterus, and a pain continuing during menstruation points toward a diseased condition of the endometrium.

If menstruation is absent, we ask if it has ever been established. If it has not, we must take the patient's age into consideration (p. 115) and ascertain if she has molimina-i. e. if at regular intervals of four weeks she suffers from abdominal pain, cerebral congestion, and general malaise. If the patient has reached the age of puberty, is otherwise well developed, and has monthly molimina, a physical examination is imperatively called for, in order to find out whether some malformation forms a barrier which prevents the blood from escaping from the genitals. We must inquire if the patient is subject to a regular bleeding from other parts which might have the character of a vicarious menstruation (Part VII., Chap. II.).

If menstruation has been established, we must ask if it is the first time it has failed to appear, or if similar periods of amenorrhea have preceded. We must ask if it has been suddenly suppressed, and if any cause for such suppression is known-e. g. exposure to cold.

Under all circumstances of disappearance of the menstrual flow the physician must think of the possibility of pregnancy, and inquire about nausea and vomiting, and if the patient is unmarried, under

some plausible pretext, obtain an examination of the breasts, which may give such corroborative information that a vaginal examination must be proposed. Even with married women he must remember that they may be pregnant without knowing it, or may be led by the secret desire that something may be done that will put an end to their pregnancy.

So-called menstruation recurring a year or more after the menopause is very suspicious, as it generally is a hemorrhage caused by

cancer.

Discharge. We ask the patient if she has any discharge from the genitals between her periods, and if so what color, consistency, and odor it has. A discharge is always an abnormality. A white, milky discharge is of least importance; a thick, glairy one comes from the cervix, and is often hard to cure; a bloody one comes probably from ulcers or granulations; a purulent one is a sign of a deeper inflammation, which often is of gonorrheic origin, or it may come from ulcers; an offensive one is particularly found in cancer.

Micturition and Defecation. After these questions about the genitals proper we inquire about the condition of the neighboring organs. Very often we find frequent or painful micturition, even without disease of the urinary organs, and constipation.

Pain. The symptom that most frequently brings the patient to seek help is pain. The pain has certain places of predilection, which, according to decreasing frequency, may be arranged in the following list the left iliac fossa, the right iliac fossa, or both; backache, pain under the left breast, pain in the epigastric region, headache, neuralgia on the anterior surface of the thigh (anterior crural nerve), neuralgia on the external surface of the same (external cutaneous nerve), pain in the coccygeal region or in the interior of the pelvis when sitting. As a rule, the pain is increased by walking or other exertions. Frequently coition is painful (dyspareunia). When a pain is felt on one side of the body, it is, as a rule, on the affected side, but sometimes it is referred to the opposite side.

Worse than real pain are sometimes other abnormal sensations, such as itching or burning.

Sometimes patients suffer from a pricking pain in the eyeballs, with, weak eyesight (asthenopia), palpitations, and the different nervous symptoms known as hysteria.

Nutrition and Strength.-Most frequently gynecological patients are thin and anemic, their appetite is poor, and they suffer from dyspepsia. They complain of feeling tired, and are unable to do the same amount of work as before they were taken sick.

Family History.-Sometimes the family history helps to a diagnosis, especially in regard to such hereditary diseases as tuberculosis and cancer.

Special Questions.-In special cases many other questions suggest themselves. For instance, if the patient has an enlarged abdomen, it is of great importance to know in what locality the enlargement was first noticed. If during the physical examination we find great tenderness in a married woman, it is a pertinent question to ask if coition is painful, and, if so, how often it takes place. When there is a deficient development of the genitals, it is proper to ascertain if the patient has a normal sexual appetite and feels any normal satisfaction in sexual intercourse. Venereal affections call for a close examination in regard to the time of their first appearance, preceding or concomitant symptoms (ulcers, rash, sore throat, alopecia), and the health of the husband. Sometimes it becomes necessary to ask the patient if she masturbates, which usually can be done by asking if she suffers from heat in the genitals, if she touches them, if she scratches herself, and so forth. But all such special questions will, as a rule, best be put during or after the physical examination.

Physical Examination.--For the physical examination we must make use of four of our senses-viz. sight, touch, smell, and hearing -and certain instruments or apparatus. Most examinations can be satisfactorily made with the patient lying in her bed or on a lounge, and in private practice, in the home of the patient, most examinations are made in this way. Certain things are, however, felt much better, or are first brought out, when the patient lies on an even, unyielding surface, and office practice is much expedited by having a couch especially made for the purpose. There are numerous examining chairs and tables in the market and in more or less common use. Tables are by far to be preferred to chairs, the latter not allowing so easily and so completely a change from the dorsal to the lateral posture. A common table with a hard mattress may be used, but it is a great improvement to have a table that can easily be made to slant backward, and to that side which is to the right of the physician when he stands at the foot of the table and turns his face to the patient. The most perfect table is, I believe, Daggett's, of Buffalo, N. Y. (Fig. 108). Whatever table is used should be placed near a window, with the foot end turned toward as good a light as can be obtained.

The bladder and the rectum must be empty. If the bladder is more or drawn when the patient is on the table.

FIG. 108.

Daggett's Table.

less full, the urine may be If the rectum is loaded, it

is better to postpone the examination until the intestines have been emptied by means of an enema and an aperient. By neglecting these precautions the beginner may fall into serious errors, such as to diagnosticate pregnancy or tumors that are destined soon to disappear in the water-closet.

I. POSITIONS.-The two chief positions used for examining a gynecological patient are the dorsal and Sims's. Of less importance are the genu-pectoral, the erect, Trendelenburg's, and the ventrai positions.

The Dorsal Position. The patient lies on her back, the head slightly raised on a cushion, the knees drawn up and widely sepa

rated, and the heels placed on the table or in front of it or above its foot-end in some kind of holes or stirrups (Fig. 109). The skirts are pushed up on the abdomen. For a complete examination of the abdomen the corset must be removed, and all bands round the waist. opened, but for an exploration of the pelvic cavity we need only insist on the removal of closed drawers. In this way we save much time and cause the patient less trouble. When she is in position, she should be covered up to the breasts with a sheet, which thereafter is folded in between her legs, so as to leave only the vulva exposed.