CHAPTER IV THE PHYSICAL EXAMINATION (Part 2)

docs not coagulate the albumen of the discharges, has an odor of its own, does not corrode instruments, nor irritate the tissues, is indicated. Any table will serve on which to lay the pan of instru- ments, basin, and sterile cotton. A low table is preferable to a high one. Its surface should be covered with a fresh towel. The usual position employed in gynecological examinations is INSPECTION OF EXTERNAL GENITALS 33 the dorsal position. The Sims position, the knee-chest position, the elevated pelvis position, the lithotomy position, and the stand- ing position will be described later. The Dorsal Position. — Everything being in readiness, the patient steps into a hard-bottomed chair placed at the foot of the table and raises all her skirts behind, the physician meanwhile standing in front of her and holding up a sheet, so that she is screened from him as she sits on the little folded towel on the edge of the table. She lies down and puts her feet in the supports. To prevent straining the back it is well to ask the patient to draw up her knees as she lies clown, otherwise her back will reach the cushion while her feet are still in the chair, putting her into a sort of Walcher position, one of great discomfort. The sheet is now thrown over the recumbent woman so that she is entirely covered. Holding the lower edge of the sheet in the left hand the physician raises the patient's skirts in front with his right hand under the sheet. Then by carrying the middle point of the sheet upward to the pubic region both thighs are draped and only the vulva and anal regions are exposed. A woman does not object to an exposure of the genitals that is manifestly necessary so long as the surrounding parts and the body are covered up. This method of covering with the sheet is applicable to every sort of a case, and should be employed always unless the patient is anesthetized. If the examination is at the patient's home the table is prepared in a good light in her room and she either walks to the examining table, or, if unable to walk, is carried from the bed. 2. Inspection of the External Genitals There is no valid objection to an inspection of the vulvar region; in fact, a proper diagnosis can not be made without it. The physi- cian seats himself in the chair used by the patient to get upon the table, and spreads a fresh towel over his knees. By placing the fingers of each hand on the labia majora the labia are drawn gently apart and he notes the condition of the hymen, whether with one or more openings, unbroken or broken ; the amount and character of the vaginal discharge; the appearance of redness about the orifices of Bartholin's glands or Skene's glands. 3 34 PHYSICAL EXAMINATION If redness appears about the orifices of Skene's glands, the well- anointed finger should be introduced for an inch into the vagina, pressing backward toward the sacrum with the dorsum of the finger as it is slipped into the vagina, and gentle pressure made with the tip of the finger along the course of the urethra from above downward to express pus from the glands. He notes further the condition of the meatus urinarius, whether closed or open; the prepuce, whether adherent to the glans clitoriclis or not, and injuries of the perineum. The surface of the perineum between the fourchette and the anus should present a convexity; if it is flat or concave it means an injury to the pelvic floor or perineum. Palpation is to be combined with inspection in determining the nature and extent of injuries in this region. (See Chapter XX, page 372.) One must be on the lookout for skin affections. Pedi- culi are occasionally found among the poorer classes; and all sorts of anomalies of the external genitalia are to be looked for. In- spection of the vagina will be taken up in the chapter on the use of instruments. 3. Palpation Palpation includes the vaginal touch, the combined bimanual vaginal and abdominal touch, the rectal touch, and the combined bimanual recto-abdominal touch. The examination of the abdo- men will be considered in another chapter. (a) The Vaginal Touch. — The physician has washed his hands with care, his nails are always trimmed short and are clean, and his hands are warm. He stands facing the patient, who is in the dorsal position on the examining table. Now comes the question which hand to use for the vagina. I prefer the left hand for the reasons that the left hand is less frequently used for ordinary pur- poses than the right; therefore, the skin covering the terminal phalanx of the left forefinger is softer and capable of higher training of the tactile sense; less strength is required of the examining hand at the vagina than of the hand on the abdomen, which is engaged in gross manipulations, the right hand is usually the stronger except in the case of left-handed persons; the left hand is generally a trifle more flexible than the right hand, an important PALPATION 35 consideration with reference to stowing away the unused fingers, and finally, using the left finger for the examination leaves free the highly trained right hand for the delicate manipulation of instru- ments. Whichever finger is chosen, that one should be used in all but unusual cases, because it is desirable to educate one finger to feel correctly. It is the exceptional physician who can become ambi- dextrous. Having decided on the left forefinger, it should be lubricated because the external genitals are dry, and pushing in the external parts causes the patient discomfort ; it is the skin which is in need of lubrication rather than the vagina, which is supplied normally with a lubricating medium, therefore anoint the external labia and these in turn will lubricate the finger. The best lubricant is some- thing of the nature of lubrichondrin, sold under the name of "muco- lubricans'' or "K-Y,'; prepared from cartilage treated with heat, a mildly antiseptic jelly containing eucalyptol or gaultheria, or some other substance to give it a pleasant odor. It is soluble in water. It is kept in a sterile, collapsible tube and is free from all danger of contamination. The oils and vaseline are peculiarly ill suited for lubrication because they cling to the finger and instru- ments and are well adapted to receive, retain, and distribute patho- genic organisms. Soaps are irritating to many patients, particu- larly in inflammatory conditions of the external genitals. The physician squeezes from the tube an ample quantity of lubri- chondrin on to the dorsal aspect of his forefinger, anointing only the terminal and second phalanges. By bringing the hand downward until the little and ring fingers touch the table just under the cleft of the buttocks, the tip of the anointed forefinger seeks the perineum. When it is reached the back of the bent forefinger is drawn upward over the fourchette, thus lubricating the labia and the vestibule, the knuckle falling into the depression at the introitus vagime. A second sweep with the finger, it is straightened, and the tip settles into the vagina. It is to be noted that the lubricant has been put only where it is needed and that there is none on the unused hand and on the patient's linen. In introducing the finger into the vagina one bears in mind the condition of the hymen as noted at the previous inspection. If the hymen is tight great gentleness should be used and sufficient 36 PHYSICAL EXAMINATION time allowed for dilatation. Room in the vagina is always to be gained by pressing backward toward the sacrum, as the perineum and pelvic floor are dilatable in this direction only. The structures which hug the under surface of the pubic arch, the clitoris, vestibule, anterior vaginal wall, and urethra should be avoided as far as possible, as in that region sensation is most acute. The examining finger may be likened to a small speculum as it carries down the perineum and opens the vagina. In many cases it is possible to use the finger in the place of a speculum. As soon as the middle knuckle of the examining finger has passed the hymen the hand is turned so that the thumb is upward. The three unused fingers are carried behind the anus in the cleft of the nates and the thumb is moved to the left or right of the median line out of the way of the clitoris. The perineum and pelvic floor can be pushed in to a variable extent by the web between the index and middle fingers and thus the examining finger reaches farther. It is seldom necessary to employ two fingers for the vaginal examination, although there are cases where more may be learned with two than with one. The palmar surface of the last phalanx of the forefinger is the chief seat of the trained tactile sense. As a rule, particularly in virgins, two fingers cause the patient a great deal of discomfort and therefore accentuate the disagreeable features of the examination, tending to distress of mind and body and consequently preventing the relaxation so essentia] for a successful investigation of the contents of the pelvis. The scope of the vaginal touch depends, in a measure, on the ana- tomical peculiarities of the examiner's hand. A physician having thick, chunky hands with short fat fingers can not hope to be as good a gynecological diagnostician as one having a slim hand with long, tapering fingers. In women of spare build who have borne children, practically the entire inner surface of the pelvic cavity may be palpated by a long finger or fingers introduced into the vagina. It is not unusual to touch the promontory of the sacrum and the sacro-iliac synchondroses, besides all parts of the pelvic floor, not to mention the structures occupying the pelvis. (See Fig. 4.) The examining finger as it enters the vagina notes the following points: — The state of the hymen, whether with large opening or small, whether rigid or easily dilatable ; the vaginal walls, whether PALPATION 37 with rugae or smooth, whether of normal temperature, or hot, as in the case of inflammatory affections of the pelvic organs, or in fevers; whether the walls of the vagina are in apposition, or lax or separated; the amount of secretion, a dry vagina giving an en- tirely different sensation from a moist one; the condition of the pelvic floor and perineum; in the case of a parous woman search for a groove in either sulcus or the middle line, remembering the normal conformation of the perineum, that is to say, a convex surface in the vagina as well as on the skin outside; sometimes it is well to introduce the well-anointed forefinger of the right hand in the anus and palpate the tissue lying between the two Fig. 4. — Half a Female Pelvis, with Hand in Position as for Vaginal Examination. fingers in order to get a correct idea as to injuries which may be present. The vaginal touch informs us as to the contents of the rectum, whether empty or containing hard fecal masses, semi- solid feces, or dilated by fluid or gas; also whether or no the blad- der is distended. In order to practice this sort of palpation successfully re- quires a long experience and a thorough familiarity with the normal conditions, also the variations of the normal in different individuals. Abnormalities of the vagina are to be detected by touch; such are cysts, partial septum, narrowing of the lumen by cicatrice-, 38 PHYSICAL EXAMINATION the sequelae of old inflammatory action, or from congenital defects of development; also roughness, as in granular vaginitis. On palpating the anterior wall of the vagina the urethra is felt, and thickening or sensitiveness of this structure — evidences of inflammation — are detected. So also the base of the bladder is to be touched to determine thickening or points of tenderness, in- Fig. 5. — Diagrammatic Drawing, Illustrating the Bimanual Touch. dicating the situation of ulcerated areas in the bladder mucosa. The ureters when thickened are easily palpable running from the bladder base toward the sacro-iliac synchondroses. The upper course of the pelvic portion of the ureters can be best detected by rectal examination. (6) The Combined Bimanual Vaginal and Abdominal Touch. — When the tip of the examining finger reaches the posterior PALPATION 39 fornix of the vagina the physician's right hand is laid gently on the lower abdomen, palm down with the heel of the hand just above the symphysis pubis. Very gentle and slowly applied pressure is made with this abdominal hand, all sudden movement being avoided as calculated to excite pain and consequently resistance of the abdominal muscles. The balls and not the tips of the fingers are used. The pelvic organs are carried down by the pressure above until they are within reach of the finger in the vagina, and conversely they are raised by the finger below until within touch from above. In the case of the bimanual vagino-abdominal touch we hold between our hands (the finger in the vagina and the hand on the abdomen) the contents of a box, the cavity of the pelvis. It is sometimes a help in making the bimanual examination for the physician to rest the elbow of the hand making the vaginal touch on the knee of the corresponding leg, his foot being placed on the chair which is close to the table. Factors outside of the condition of the bowels and rectum limiting what can be felt by the bimanual touch are, the amount of adipose tissue present, and the rigidity or laxity of the muscles of the abdominal walls. A rigid perineum has been referred to already as lessening the amount of invagination of the pelvic floor that may be made by the web between the fingers of the hand at the vulva. In fat women both the vaginal and bimanual touch are in- terfered with. Other things being equal, it is impossible to make as accurate a diagnosis in a fat woman as in a thin woman. The fat in the perineal region reduces the scope of the vaginal touch. A greater hindrance is the fat in the abdominal walls; with two or three inches of fat in the panniculus adiposus the tactile sense is much blunted. It is like feeling through six or eight thicknesses of blankets. Naturally, then, we do not hope to make as good a diagnosis as when the abdominal walls con- tain little fat. A rigid abdomen is a bar to diagnosis by touch. One can feel very little through a stiff sheet of pasteboard. If there is present peritonitis or great sensitiveness of the abdomen from any cause we expect to find rigidity. Many patients become rigid through anxiety and fear of painful manipulations by the physician, others 40 PHYSICAL EXAMINATION reflexly because of the discomfort caused by the laying on of the hands. Therefore, not only is the utmost gentleness imperative, but also it is a matter of supreme importance not to arouse the patient's fears by brusk behavior, or by the uncalled-for display of instruments. As to gentleness, the flat hand on the lower abdomen makes light pressure and the physician inquires whether it causes pain. Distracting the patient's attention by a question or two often prevents rigidity. Next, the hand is arched by flexing slightly all the fingers so that the balls of the fingers press in deeply. It is very essential not to make the tips of the fingers press, the same rule holding here as in massage. Make pressure with the palmar surface of the last phalanges, for the tips of the fingers and the finger nails cause pain, and, also, less can be felt with the tips. Ask the patient to take a long breath; as she does so, gently hold the abdominal wall in. Repeat the process and the examiner's hands are brought nearer and nearer together with each expiration. Judgment is necessary in performing this maneuver because too rapid or too forcible pressure will cause the abdominal muscles to contract, thus defeating the objects of the examination. Assist- ance is gained in some rare cases by drawing down the cervix with a tenaculum held by an assistant. In this, way the back of the uterus and the broad ligaments are reached and also tumors and other attachments are made out. The bimanual or conjoined examination is the keystone of the gynecological diagnostic arch. Nothing takes the place of the trained touch, and it is doubtful whether, in the march of progress, any form of investigation will supplant it. Specula for the vagina, the bladder, and the rectum, bacteriology, and the microscope with its findings as to the nature of the blood and tissues, and the x-rays, detecting a stone in the bladder, ureter, or kidney, all have their uses. The bimanual touch is the most important. The finger in the vagina notes, first, the situation, size, conforma- tion, consistency, and sensitiveness of the cervix; lacerations, their location and extent ; whether or no the tissues of the cervix are of normal consistency, or soft as in septic conditions or after labor, or indurated as in chronic metritis. The friable, bleeding PALPATION 41 cervix of cancer is rarely mistaken for any other condition, except possibly a sloughing, pedunculated fibroid. Cysts of the Nabothian follicles can be diagnosticated as shot-like bodies; a stringy, tenacious plug of mucus in the os can be differentiated from a thin discharge; in rare cases the cervix may be out of reach, being forced upward into the abdomen by a tumor in the pelvis so that it may lie on a level with the upper border of the