CHAPTER V THE PHYSICAL EXAMINATION (Continued) (Part 2)

described already, there are several other positions into which the patient is put for pur- poses of examination. 54 PHYSICAL EXAMINATION They are: — the Sims, the knee-chest, the lithotomy, the raised pelvis, and the standing positions. The Sims position is not so frequently used now as in the years following the invention of the Sims speculum. Still, it is of great service both for the use of the speculum and other instruments, for practicing the bimanual touch , and for examination of the anus and rectum. For some reason not altogether clear, the illustra- tions introduced into all but one or two text-books on gynecology to show this position, do not figure it correctly as it was devised by Sims or as it is used in the hospital where he did his work, the Woman's Hospital in the State of New York. As commonly shown, the patient is lying on her left side with thighs only partly flexed on the abdomen, in the middle of a long table; her head is generally on the left side of the table, her hips in the middle, and so far from the bottom edge that the gen- itals are entirely inaccess- ible for examination. Suppose we have finished with the dorsal position and wish to put our patient in the Sims position. Pull- ing the sheet off and holding it in front of her we give her a hand and ask her to stand in the chair at the foot of the table. Then we pull out the little slide for a foot rest in the right-hand lower corner of the table and place the pillow for the head diagonally about midway along the right edge of the table. Now we ask her to raise her skirts and to sit on the left-hand corner of the table, sitting as far over to the left as she can and turning on her left side and drawing up her knees as she lies down. Throw the sheet over the hips as soon as she gets down. Next ask her to put her left arm over the left edge of the table and help her to do it. Fig. 12. — Diagram of the Sims Position. PALPATION 55 See that her head is on the pillow on the right side and that she is, as it were, doubled up like a jack-knife. Then the physician stands on the left of the table facing the patient's hips, pulls them (asking at the same time for the patient's assistance) to the left, until the back of the sacrum is even with the left edge of the table, and the lower margin of the buttocks corresponds with the lower edge of the table. The feet are now on the foot rest, or, in default of this, on the back of a chair padded with a folded blanket, or on a table. The upper, the right knee is advanced a little be3'ond its fellow, and the inner edge of the sole of the right foot rests on the instep of the left foot. A fresh towel opened out is made to cover the lower buttock and thigh by tucking one end into the drawers behind, and carry- ing the other end between the thighs in front. The free end below is tucked under the covering of the table. The upper buttock and thigh, the legs and feet, and the rest of the body are covered by the sheet. In this position the pelvis is inclined at a slight angle to the table, the abdominal contents fall away from the pelvis, leaving the pelvic organs free from pressure; the abdominal walls are relaxed and the vagina, ballooned by air admitted by the speculum, can be most easily inspected. It is difficult to put very stout women, or patients with large abdominal tumors, in this position and in these cases the Sims position is of less value than in thinner subjects. The important points are to get the patient's back on a level with the left edge of the table and the head on the right edge of the table. Unless the patient is put in the correct position it is of no value whatever. Unless the thighs are sharply flexed on the abdomen and the hips are at the edge of the table, the physician can neither look into the vagina nor make manipulations to ad- vantage. The bimanual vagino-abdominal or recto-abdominal touch is made with the patient in the Sims position by introducing the left forefinger in either vagina or rectum and the right hand between the thighs, asking the patient to raise her right thigh until the hand is in place and then letting it drop again. The Sims position is useful also for palpating uterine and ova- rian tumors: with the patient in this position, relaxation of the 56 PHYSICAL EXAMINATION abdominal walls may be obtained often, when it can' not be with the patient in the dorsal position. The knee-chest position, or knee-elbow position, as it is some- times called, is another gynecological position commonly wrongly figured in the text-books. The patient stands in the chair at the foot of the examining table facing the table. She raises her skirts in front and places one knee near one corner of the table, the other Fig. 13.— The Knee-Chest Position. knee follows and takes its place at the opposite corner of the table. Then she bends forward and places her hands in the middle of the table while the physician throws the sheet over her. The feet and legs are left projecting over the table's edge, but the position is not uncomfortable, for all the weight comes on the knees and hands. Now the patient is on her hands and knees on the table. The physician folds a good-sized pillow once and PALPATION 57 places it in the middle of the table. The patient is asked to place her head and chest on the pillow with her face to one side, letting herself down on to her elbows as she does so. The physician next goes to the foot of the table, throws the skirts above the hips under the sheet and drapes each thigh with the sides of the sheet. Note now whether the thighs are vertical. They are apt not to be, as the patient generally throws her chest too far forward, thus slanting the thighs. If they are not vertical they are easily made so by asking the patient to move her chest back a little as the pillow is moved for her in the same direction. The knee-chest position is most useful for speculum examina- PJjr i JH B flt Fig. 14.— The Knee-Chest Position. Side View, Showing Vertical Thighs. tions of the vagina, bladder, and rectum, the abdominal pressure being removed, and the viscus in which the speculum is placed being ballooned by the atmospheric pressure admitted by opening the external orifice. To replace a retroverted or retroflexed incarcerated uterus, or an incarcerated tumor of the pelvis, often necessary to establish a diagnosis, the knee-chest position is invaluable. The lithotomy position is the dorsal position with the thighs flexed on the abdomen. The position is maintained by leg holders, of the Von Ott, Robb, or the Clover's crutch patterns, by different forms of slings holding the flexed thighs to the shoulders of the 58 PHYSICAL EXAMINATION patient with straps, or by leg holders attached to the operating table. The patient is placed in the lithotomy position just as in the dorsal position, with the addition that the thighs are kept flexed by some device. Without any apparatus whatever it is possible, and often convenient, especially in short operations, such as curetting, for one assistant to hold both legs with one hand and have the other hand free to assist the physician. To do this, the assistant, generally a nurse, places herself on the left side of the table (the patient's right side), facing the physician, who Fig. 15. — The Lithotomy Position. is seated in the chair at the foot of the table. She reaches across the patient's flexed limbs with her left arm, letting the right knee rest in her left axilla and grasping the left leg with her left hand. Thus her right hand is free to hold instruments for the doctor. The lithotomy position is used for examinations under ether, for operations, and for investigations where it is necessary to scrub up and asepticize the vulva and surrounding regions. The raised pelvis position, used only in cystoscopic examina- tions, is an exaggerated lithotomy position. It is best obtained on a table which has a mechanism for the Trendelenburg posture, PALPATION 59 but may be secured by placing a hassock or hard cushions covered with towels under the sacrum, so that the pelvis is elevated about ten inches above the level of the table, the legs being held by a Robb leg holder or by an assistant standing on a stool or box. This position tilts the pelvis backward and removes abdominal pressure from the bladder. The standing position is of occasional use in determining the degree of prolapse of the uterus and vaginal walls when full ab- dominal pressure is exerted, also the axis of the uterus under these conditions, and the holding power of a pessaiy. M.' 1 ■^^^ ^\ Fig. 16. — The Raised Pelvis Position. The patient stands facing the physician with her right foot resting on a round of a chair eight or ten inches from the floor. The physician kneels on his left knee in front of her, or sits in a low chair resting his left elbow on his left knee. He anoints his left forefinger, and steadying himself with his right hand on her left hip, finds the vulva by sweeping the anointed middle finger of his left hand over the anal region, and then introduces the fore- finger, just as in the vaginal examination in the case of the dorsal position. Having the patient bear down or cough gives an idea as to the excursion of the uterus with forced expiration. 60 PHYSICAL EXAMINATION 4. Odor as a Diagnostic Sign The sense of smell is sometimes an aid to diagnosis, as in detect- ing the characteristic odor of the vaginal discharge from uterine cancer, and the odor of urine or feces in the vaginal discharges in the case of urinary or fecal fistula?. Menstrual blood has a different odor from other blood. Certain vaginal discharges have a pecul- Fig. 17. — The Standing Position. iarly foul odor. The odor exhaled by a patient suffering with septicemia is characteristic, although, like other odors, not capable of definite description. Diabetic urine has a sweet smell and urine may be distinguished from other discharges by administering spirits of turpentine or asparagus to the patient by the month and noting the odor of violets or asparagin in the urine. COLLECTION OF DISCHARGES AND TISSUES 61 Acetonemia, a form of intoxication with acetone occurring in diabetes, in infectious fevers, in intestinal fermentation, in gen- eral sepsis, and sometimes following gynecological operations, may be distinguished by the sweetish odor of the breath, described as like that of a pippin apple. 5. The Collection of the Discharges and Tissues for Microscopic Examination Materials Needed. — 1. Half a dozen absolutely clean cover glasses. 2. A few culture tubes of hydrocele agar or blood serum (furnished by the pathologist). 3. Platinum wire loop. 4. Alcohol lamp. 5. Long-handled sharp knife. 6. Long-handled sharp- pointed scissors. 7. Uterine tenaculum. 8. Uterine dressing for- ceps. 9. Needle-holder, curved needle, and catgut. 10. Gauze packing. 11. Small bottle of ten-per-cent formalin. Bartholin's Glands. — If the discharge from the glands of Bar- tholin is to be collected for examination for gonococci or tubercle bacilli, the labia are separated and the vulva is wiped dry with sterile cotton pledgets. Grasp the gland to be investigated be- tween the thumb and forefinger, make gentle pressure, and transfer the discharge, which exudes from the mouth of the gland's duct, to a cover glass by means of a platinum wire loop or uterine applicator which has been passed previously through the flame of an alcohol lamp. Place a clean cover glass upon the first one, press the two gently together to spread the discharge evenly, slide the two apart, and allow to dry. The dry cover glasses may then be reapplied face to face and held together by an elastic band. They are then placed in an envelope which is labeled as follows: — Name of patient : Date: Source of material: Examine for (organism): Sent by Dr. The preparation properly labeled is then sent to the pathol- ogist for examination. Skene's Glands.— The orifice of the urethra and the introitus vagina? are wiped dry with sterile cotton pledgets. Introduce the finger into the vagina and make gentle pressure from above down- 62 PHYSICAL EXAMINATION ward along the course of the urethra. As the ducts of Skene's glands open into the urethra just inside the urethral labia, any discharge from these ducts will contain a certain admixture of urethral discharge also. The urethra can hardly become infected without accompanying infection of Skene's glands, but this mixture with urethral discharge is unimportant from a clinical standpoint. If it is essential to examine the discharge from Skene's glands apart from that from the urethra, then the latter canal must be walled off with a small cotton pledget and pressure made only over Skene's gland. Transfer the discharge obtained to cover glasses as de- scribed under Bartholin's glands. The Cervical Canal. — The patient is placed in the Sims position by preference, although the procedure may be successfully carried out in the dorsal position. A speculum is introduced and the vagina cleansed with sterile cotton and water and then dried with dry cotton. A good exposure of the cervix can usually be obtained without the use of a tenaculum. The use of a tenaculum is often accompanied by bleeding which may contaminate the cervical discharge. Sometimes it is necessary to draw the cervix down with a tenaculum. In this case the instrument should be firmly fixed at the first attempt and held in place. A sterile tampon screw is most useful in obtaining cervical discharge. The instru- ment is introduced into the cervical canal not beyond the internal os and twisted until some of the discharge has been caught in the threads of the screw. Whether obtained with the screw or with the platinum wire loop the smear is made as described in the case of the glands of Bartholin and Skene. Cultures. — If cultures for the purpose of obtaining a bacterial growth from a discharge are to be made, the culture tubes are used. Collect a drop of the discharge on the sterile small wire loop which comes with the tube and smear it over the slanting surface of the material in the tube. Replace stopper, label care- fully, and return to the pathologist. It is possible to introduce the small wire loop into most cervical canals without dilatation, and it is much better to take the culture or smear without dilating the canal, because in the process of dilating the discharges are partly removed and mixed with blood and tissue. Removal of Tissue from the Cervix for Examination. — The Sims position usually offers the best exposure of the cervix for the COLLECTION OF DISCHARGES AND TISSUES 63 removal of pieces of tissue for examination. In removing a suspicious piece of tissue for microscopic examination it is wise to cut out some of the apparently healthy tissue as well as the diseased portion, for it occasionally happens that the pathologist receives nothing but necrotic tissue and can form from it no diag- nosis whatever. A raw surface left by removal of tissue should be closed by suture or tamponed until all bleeding has been checked. Tissues removed by the curette, scissors, or knife for the purpose of diagnosis, are to be plunged intact and immediately into a ten- per-cent solution of formalin in water; then they are properly labeled, and sent to the pathologist.