CHAPTER IV THE PHYSICAL EXAMINATION (Part 1)

CHAPTER IV THE PHYSICAL EXAMINATION I. The preparation of the patient, p. 23. II. The preparation of the examining table, p. 26. Care of the instru- ments, with list of a full kit, p. 28. III. The examination: 1. Preparation of the physician and placing the patient on the table, p. 31; The dorsal position, p. 33. 2. Inspection of the external genitals, p. 33. 3. Palpation, p. 34: (a) The vaginal touch, p. 34; (6) The combined vaginal and abdominal touch, p. 38. Having taken the history as outlined in the preceding chapter, the next procedure is the physical examination. It is not neces- sary to follow exactly the same routine in all cases; nevertheless it is most essential to have a definite system and to proceed accord- ing to it in all but exceptional instances, because in this way, and in this way only, are sources of error, the omission of important signs, reduced to a minimum. First let us consider I. the preparation of the patient, then II. the preparation of the examining table and the instruments, and lastly III. the examination itself So much does a good diagnosis depend on careful preliminaries and on a multitude of little things that no apology is necessary for the space devoted to them. I. THE PREPARATION OF THE PATIENT It is absolutely essential that the rectum should be empty in order that the physician may make a satisfactory bimanual ex- amination, also, in the case of abdominal palpation, if the bowels are distended by feces or gas the ability of the examiner to appre- ciate the condition of the abdominal contents will be interfered with. Therefore the patient, if there is need and if time serves, should be instructed to take a cathartic the day before the exam- ination or an enema immediately before. 23 24 PHYSICAL EXAMINATION If a patient presents herself with the statement that the bowels have not moved for several days it is better not to make an examination until they are solvent, except in cases of emergency. Unless there is some suspicion of disease of the urinary organs the bladder is to be emptied just before the examination. In certain urinary cases, where it is desired to obtain a catheter speci- men of urine at the examination, the patient should be asked not to empty her bladder before the examination. As a rule it is better to have no douche or special wash given before the examination, because the examiner wishes to form an opinion as to the character of the discharge, if present. It is a simple matter for him to wipe away the discharge later with sterile cotton or some antiseptic solution. The most important matter in connection with the preparatory treatment of the patient and the one most often overlooked is the loosening of all constricting clothing about the waist. Simply to loosen the corsets and leave the drawers buttoned about the waist is not sufficient. So often women come to the examining table with corsets and skirts loosened, and investigation reveals one or two tight, constricting bands still left. Closed drawers should be removed. The union suit is a foe to an accurate diagnosis and should be removed. If the patient considers her condition of ill health important enough to consult a physician she should be ready to offer no hindrance to a proper examination. With any encircling girdle about the upper abdomen it is mani- festly impossible to compress the abdominal walls and to palpate the contents of the abdomen and pelvis. Such palpation is difficult enough with all conditions favorable, therefore do not handicap it by omitting to have all clothing loosened. If the patient is in bed she should be prepared by having her put on a fresh pair of stockings. Should the Sims position be used an extra towel will serve for covering the right thigh. Much depends on the physician's tact and the manner in which he goes about the preparation for the physical investigation. Women do not mind an examination which they consider necessary if the physician shows proper consideration for their feelings and knows how to go about the examination. If the matter is treated as disagreeable and to be put through as quickly as possible, the PREPARATION OF THE PATIENT 25 result is apt to be that the physician's frame of mind will be re- flected in the patient and she will be ill at ease and consequently will not give herself up to the investigation, not relaxing the ab- dominal muscles and thus limiting the facts which may be gleaned through the tactile sense. The patient should be made to feel that the examination is to be conducted with as little pain and discomfort as is possible and that this is an important consideration to the examiner. She may be told a fact too often lost sight of, that pain, caused by roughness or vigorous handling, makes unconscious resistance and rigidity of the abdominal muscles, thereby dulling the sense of touch in the doctor's hands and preventing him from reaching deep-lying structures — consequently the examination is less successful. Often it is inadvisable to make a thorough investigation and a complete diagnosis at one sitting. Sometimes it is necessary to examine the patient on several different occasions before all the conditions have been found favorable and all the facts have been brought out. Therefore do not be led to express an opinion on the case prematurely. In the case of young girls it is generally advisable to use an anesthetic before making a local examination, although it is not always necessary, much depending on the nervous temperament of the patient. In making an examination of a virgin in whom menstruation has been established an anesthetic is seldom required if great tact and gentleness are used. It is far preferable to make the first examination without ether if possible, because often facts of importance, such as regions of tenderness, brought out during the examination, are lost in an ether examination, to say nothing of the unfavorable after-effects of the anesthetic on the patient. Should the first investigation show the need, another examination with ether can be made. Too much can not be said of the importance of the tactful hand- ling of the patient previous to the examination. To see one skilled nurse in a large hospital clinic put forty women on the table for examination during the course of an afternoon, no complaints, no objections, and one following the other with military precision, is an object lesson of no mean value. Few nurses acquire such expertness, and to few is it needful. Much may be learned by studying, when the opportunity offers, the way it is done. 26 PHYSICAL EXAMINATION The local examination should be made during the intermenstrual period. Only in the case of hemorrhage and unusual conditions is it necessary to examine during menstruation. II. THE PREPARATION OF THE EXAMINING TABLE AND THE INSTRUMENTS Some hard surface on which the patient is to lie is a necessity for a proper examination. A soft bed or couch into which she sinks takes away all space under the buttocks for the unused fingers of the examiner's hand in the vaginal examination. Besides, most beds and couches are so low that the physician is in an uncom- fortable position while examining and so many of his muscles are tense that he can not concentrate his entire attention on what his fingers are feeling. Furthermore, with the patient on a low couch the physician can not get his eyes on a low enough level to look into the vagina unless he sits on the floor in an awkward and constrained position. A table, the size, shape, and height of an ordinary kitchen table, is on the whole the best surface on which to put the patient. Port- able or fixed supports for the feet are a useful addition and also a movable slide projecting from the right-hand lower corner of the table is a convenient adjunct. My table is stoutly built of walnut, has large casters on all four feet, and is of the following dimensions: — Length, 44 inches; breadth, 24 inches; height at bottom end, 33 inches; height at head end, 31 inches. It is to be noted that the foot or examining end is higher than the head end. This is to cause the viscera to gravitate away from the pelvis and to allow of more pillows for the head without in- clining the trunk downward toward the pelvis. The table is covered with a hair pillow one inch thick, encased in a dark-colored, enameled canvas cover. This cover is buttoned to the under edge of the table top, as the removable sides of a carriage are fastened on. Fixed or portable rests for the feet are an advantage, because with the feet slightly elevated above the surface of the table and at a short distance beyond the table's edge the abdominal muscles are more thoroughly relaxed and the patient is more comfortable PREPARATION OF TABLE AND INSTRUMENTS 27 than she is with heels close to the buttocks, and slipping off the table. In private houses the kitchen table is always available or, if it is best in occasional instances to examine the patient in bed, an ironing board or bread board may be placed on the mattress under the patient's hips, which should be at the edge of the bed, the feet resting in two chairs. A folded blanket, or two thicknesses of a comforter, should be laid on the table or board to take away the hardness. In this way the patient is reasonably comfortable during Fig. 1. — The Examining Table. the short time occupied by the examination and the physician can do his work to the best advantage. There are few points of superiority and many disadvantages in the complicated and costly tables sold in the instrument shops. The patient is not at ease on an unstable surface and she does not like to feel that by the pressure of levers she may be tilted into all sorts of positions ; she is not in a state of mind to appreciate the beauty of the ingenious mechanism concealed in the table, and would rather lie on a solid, warm wooden table than on a hard, cold one, made of glass and iron. 28 PHYSICAL EXAMINATION The ordinary vaginal examination need not be a strictly aseptic operation, and it calls for clean, not aseptic furniture. Suppose we have the table placed with its end toward a good light. We cover it with a folded comforter and a sheet, unless it is already provided with a permanent cushion. When the patient lies on her back with hips and heels at the edge, the only portion of the table which will come in contact with the region about the vulva and anus is a narrow part of the middle of the end, some two inches wide and six inches long. Therefore for every patient a fresh towel is opened just as it comes from the laundry and a newspaper is folded into it so that the original folds of the towel are reproduced. This towel, about six inches wide and a foot long, is now placed in the middle of the examining end of the table and one end tucked under the comforter or cushion. The surface to sit upon is thus some six by nine inches, according to the size of the towel. In this way each patient sits on an abso- lutely fresh towel, and the table is protected from the vaginal discharges or solutions used by the physician, by the newspaper which has been folded into the towel. It is seldom necessary to soil the sheet or cushion. If by any chance it is soiled, as in case of hemorrhage, the sheet or towel is removed and the enameled canvas surface of the cushion is washed and a fresh sheet or towel put on. A pillow for the pa- tient's head is placed at the head end of the table. Care of the Instruments Very few instruments are necessary for the routine gynecological examination. A uterine dressing forceps, a sound, and a small- sized bivalve speculum are frequently all that will be required. It is best to keep all instruments out of the patient's sight, because she does not admire them nor look at them from the same point of view as the doctor, and it is not at all reassuring to feel that all the bright instruments of seeming torture may be used on her. My full kit contains the following instruments: Flexible uterine sound; Uterine probe; Bozeman uterine dressing forceps; Uterine tenaculum, single; PREPARATION OF TABLE AND INSTRUMENTS 29 Uterine tenaculum, double, or vulsellum ; Uterine scissors; Silver uterine probe ; Small-size Brewer bivalve speculum; Graves bivalve speculum; Smallest size Sims speculum, also No. 4 size; Eclebohls speculum (included in the kit for cases in which curetting or removal of a piece of tissue is necessary for diagnosis) ; Hunter vaginal depressor; Emmet curette forceps; Bozeman-Fritsch uterine douche ; Two uterine applicators; Uterine sharp curette with flexible shaft; Set of Hanks metal uterine dilators; Wart hen uterine dilator; Silver female catheter; Kelly meatus calibrator ; Set of Kelly double-ended steel urethral sounds; Kelly cystoscopes, Nos. 8, 10, 12; Alligator bladder forceps ; Two Kelly ureteral catheters; Kelly proctoscopes, two sizes; Kelly ureteral searcher, and rubber bulb and tube for suction ; Head mirror; Stethoscope ; Pelvimeter. Added to these are: Two sterile two-ounce bottles; Compressed tablets of cocaine hydrochlorate ; Sterile absorbent cotton; Sterile gauze; A bottle of creolin ; Cover glasses. A collapsible tube of a sterile, soluble lubricant sold under the names of Lubrichondrin, Glycerine Emollient, Muco, or K-Y Jelly. It is my practice to have one set of instruments in a drawer within easy reach of my right hand as I sit in front of my cxamin- 30 PHYSICAL EXAMINATION ing table; another set is in a bag ready to be carried to consulta- tions at the patients' homes. After use the instruments are scrubbed with soap, hot water, and a nail brush, rinsed with boiling water, dried at once, and put away clean. In cancer cases and those in which infectious matter is pretty surely present the instruments are boiled in soda as well as scrubbed with soap and water before being put away. Before use, the instruments which it is thought will be used, are placed in a shallow enameled iron tray and boiled for five minutes in a one- per-cent solution of washing soda in water ; the soda solution is then poured off and hot water substituted. No instruments are ever let lie for any length of time after use without being washed. Until cleansed they are always kept immersed in water so that discharges and blood can not dry on. III. THE EXAMINATION 1. Preparation of the physician and placing the patient on the table. 2. Inspection of the external genitals. 3. Palpation: (a) The vaginal touch. Dorsal position. (b) The combined bimanual vaginal and abdom- inal touch, including points in the anatomy and the findings on palpation. (c) The rectal touch. (d) The bimanual recto-abdominal touch. (e) Positions of the patient used in gynecological examinations other than the dorsal; the Sims position; the knee-chest position; the lithotomy position; the raised pelvis posi- tion; the standing position. 4. Odor as a diagnostic sign. 5. The collection of the discharges and tissues for bacteriological examination. 6. Inspection of the abdomen. 7. Palpation of the abdomen. 8. Percussion, auscultation, and mensuration of the abdomen. 9. Instruments and tteir use in diagnosis. THE EXAMINATION 31 1. Preparation of the Physician and Placing the Patient on the Table The physician prepares himself by washing his hands carefully and if they are cold by warming them, and by pulling up the sleeves of his coat and his cuffs so that they will not come in contact with the patient. As to rubber cots and rubber gloves, they interfere with the tactile sense, how- ever used, and should be employed only in exceptional in- stances, as in cases of suspected gonorrhea and of fetid dis- charge, also in rectal examinations. They serve to protect Fig. 2. — The Examining Hand, Showing Protective Sleeve. coming patients and also the physician from contamination, as inoculation with syphilis, and favor the cause of asepsis. The physician who is personally neat and washes his hands care- fully before as well as after a vaginal examination, need have no fear of carrying bacteria from patient to patient. The examination can not be so well made with cots or gloves as without them, therefore do not use them unless necessary. As to protecting the sleeves, it is a good plan to wear sleeves made of "Stork sheeting" or thin rubber, with elastics at the wrists and elbows, pulled on over the coat sleeves. These rubber sleeves can be frequently cleansed and they prevent carrying infection from one patient to another. They obviate the necessity of removing the coat, a procedure which is undesir- 32 PHYSICAL EXAMINATION able because it seems to indicate to the patient formidable un- dertakings. Of the importance of washing the hands before the examination too much can not be said. One never knows what bacteria he may have on his hands and under his finger nails. Every one necessarily washes his hands after the examination; how much more essential, from the standpoint of the patient's safety, is the preliminary wash. He who would practice gynecology must have the handwashing habit. It is my custom to prepare a basin full of warm creolin solution, Fig 3. — The Dorsal Position. one per cent, and place it on the instrument table within reach of my right hand. As before stated, the examination is not and need not be a strictly aseptic operation; therefore some antiseptic, which