Gynecological Examination

Gynecological Examination, in the narrow sense, denotes all methods currently used for external and internal examination in female diseases. Before every G. e., the patient must be prepared by emptying the bladder (see Figure 1), as a full bladder may sometimes be mistaken for a tumor and, in any case, by displacing the uterus and its appendages, not only does it hinder determining the exact position of pelvic organs, but it may even give a completely distorted picture of their arrangement; emptying the intestine is also necessary, as without this, the topography of pelvic organs is altered and the examination itself is significantly hindered, may become painful, and give an incorrect impression of the condition of the sexual apparatus.

Figure 1. Catheterization of the bladder.

— G. e. is divided into subjective and objective, which are equally important for diagnosis. —By subjective gynecological examination is meant the anamnesis with indication of previous diseases, then the patient's complaints that may lead the physician to ask questions in a certain direction; it is necessary to question the patient about menstruation, their onset, character and type, deviations from the latter, about discharges (quantity, character, color, time of appearance, admixture of blood, etc.); further questioning should touch upon pains, their character, time of onset, duration; are there complaints that might indicate a tumor, sometimes indirect, in the form of complaints of abdominal enlargement, pressure on neighboring organs; what is the condition of the intestine, is there a tendency to constipation, which is so common in women; what is the character of defecation and the character of stools; are there special complaints or do they appear when the patient is speaking, the character of the patient's psyche, tendency to hysteria, neurasthenia or psychasthenia—all this may be revealed when questioning the patient. During objective examination, which begins already during the collection of anamnesis, one can notice and evaluate the general condition of the patient (apathetic, excited, depressed, signs of physical and moral suffering, sometimes giving a special appearance to the patient's face), the condition of the tongue with indications of febrile condition or phenomena in the gastro-intestinal apparatus; one can also note changes in respiration, pulse, temperature; it is necessary to pay attention to the condition of the skin, its color, its elasticity, presence of skin diseases that may indicate reflex phenomena; on the development, condition and changes in the mammary glands, finally the patient's constitution, the possibility of classifying her to one type or another. Objective examination begins with the abdomen and is usually performed with the patient lying on her back. First, the abdomen is inspected, is there bloating, is it uniform or is it partial, occupying one of its regions, which appears protruding, which may depend on some tumor lying in the abdominal cavity or on contraction of some muscle compartment, reflexly tense and representing a manifestation of the body's self-defense; are there no edemas of the abdominal coverings, where the edema may be strongly widespread, representing as it were a partial phenomenon of general body edema, or only local, like edema of the lower part of the abdomen in its ptosis. Attention is paid to the presence of hernias, divergence of the rectus muscles, scars after operations, etc.—When palpating the abdomen, attention is paid to the thickness of the coverings, amount of deposited fat or, conversely, to emaciation. Palpation complements the inspection of the abdomen and allows one to judge the presence or absence of any deeply seated tumors in the pelvis, for which it is necessary to deeply press the examining hands into the pelvis; a more superficial palpation, combined with percussion, is sufficient to determine the presence of fluid in the abdomen (ascites), as well as ballottement of formations located in the abdominal cavity (cysts and dense ovarian tumors).—Percussion allows one to understand what

Figure 2. Right-sided parametritis after miscarriage: 1—tympanites; 2—sharp dullness.

Figure 3. Exudative pelveoperitonitis. Bilateral salpingitis: 1 and 2—clear tympanites.

Fig. 4.

Veit-Schroder's chair. caused the enlargement of the abdomen, is there ascites (with it, with transfusion of fluid, the borders of dullness change when the patient's position is changed) or a tumor (when dullness remains localized and does not change its character when the tumor is moved). To differentiate tumors located in the abdominal cavity from tumors lying in the cellular tissue close to the pelvic bones, G. G. Henter proposed a special method: with tumors in the cellular tissue, one can obtain on percussion of the spina ili ant. superior, muffling of the tone, whereas this will not be obtained when the tumors are located in the cavity of the peritoneum itself (see Figures 2 and 3).—Auscultation of the abdomen rarely finds application in gynecology, being necessary only to exclude pregnancy or in suspicion of echinococcus (hydatid noise) or of adhesion to the abdominal wall (friction noise). Measurement of the abdominal circumference is necessary when observing large tumors or ascites to establish their increase and rate of growth, as well as for more precise determination of the position of the tumor with uneven abdominal enlargement, for which different measurements may be needed, which are measured with a tape measure or pelvimeter. Local examination of the sexual organs is usually performed with the patient lying down. At this time, it is very important that it be performed not on a soft bed, but on a more convenient hard couch or, best of all, on a higher table, which may have the character of a chair-table, like the Veit-Schroder (see Figure 4), or an ordinary small but more or less high table, with a headboard and with support for the legs in the form of a shelf, on

Figure 5. Spino-gluteal

position on the chair for examination. which a basin can also be placed, or in the form of a ladder. As for the position of the patient, the position on the back or spino-gluteal (see Figure 5) is most often used; in England and America, the position on the side is preferred (see Figure 6); in some cases, the Trendelenburg position with the pelvis elevated is necessary (see Figure 7), and sometimes the knee-elbow. The necessary preparation in the form of emptying the bladder and rectum has already been mentioned above; in cases suspicious of infection, examination with rubber gloves is preferred, but of course a certain habit of using them is necessary. The question of which hand to use for examination is decided differently depending on skill: many use the right hand as more developed, others prefer the left hand for G. e., leaving the right for obstetric maneuvers; finally some use both hands, handling them equally; the use of both hands is especially important when carefully examining both walls of the pelvis. It should be noted that in all examinations there should be good lighting and full visibility to the eye of all examined parts. Anesthesia is necessary only in some cases: with very tight, unyielding coverings in nulliparous women, with excessive sensitivity, sometimes in virgins.

Figure 6. Right lateral position. Examination of external parts begins with inspection, which is performed according to a strict system: the pubis, hairiness, its type (male or female), skin irritation, etc.; development of external genital parts, are there indications of hypoplasia, underdevelopment or childish type; the urethral opening, discharges from it, paraurethral sinuses, the area of the clitoris, presence of maculae gonorrhoicae, openings of Bartholin's glands, the vestibule, the hymen or its remnants, color of mucous membranes, scars on the perineum, protrusion of vaginal walls, perineum, area of the anus, fissures, hemorrhoidal nodules, inguinal glands, thigh folds and condition of the skin around the sexual parts. Internal examination should always be performed bimanually, as the external hand helps the internal one, fixing or shifting that part of the sexual organs which is being palpated at the moment (see Figure 8). The question of whether to examine with one or two fingers is decided depending on with what subject one is dealing (parturient or nulliparous), on the sensitivity of the patient and on the nature of the disease. It is useful to begin the examination

Figure 7. Trendelenburg position.

with one finger, introducing the other additionally, as with two fingers it is possible to penetrate deeper and better orient oneself to the position of the organs, if there are no contraindications. When examining virgins, it is sometimes not possible to introduce not even one index finger, but even the little finger, but still in extreme necessity and insufficiency of other methods of examination (per rectum) one has to resort to examination under anesthesia or disregard the integrity of the hymen. During internal examination, in addition to inspection, during straining the protrusion of the vaginal walls is determined, the integrity of the pelvic floor is palpated, the fossa maternitatis is determined—proof of previous births, the vagina is palpated, its length, rugosity or smoothness of the mucous membrane, presence of any growths (condylomata acuminata), cysts, scars, etc., the vaginal vaults, their depth, protrusion through them of tumors, infiltrates, fluctuations, smoothness of the mucous membrane of the vaults, tenderness; then the condition of the cervix is determined—its shape, size, direction, the external os, its shape, tears, smoothness or roughness around it (erosions), the relationship of the cervix to the body, changes in the angle between the body and the cervix;

Figure 8. Combined vaginal-abdominal examination.

then—its size, shape, density, swelling (pulsation), nodularity; when lifting the uterus, the condition of the uterosacral ligaments is outlined, their thickening, tension and tenderness; through the lateral vaults, with great participation of the external hand, the condition of the pelvic walls is determined, the condition of blood and lymphatic vessels (phlebitis, lymphangitis), thickening in the sacroiliac joint area, inflammation of pelvic muscles (piriformis of Genter, cushion of Vasten), condition of the coccyx, its ankylosis; the area of the sciatic notch, obturator foramen is palpated, sensitivity of nerves passing here; sometimes, for better palpation, it is necessary to change the examining hands or turn the hand 180°.—In many cases, for more precise orientation, it is necessary in addition to vaginal examination to resort to examination per rectum, which is performed after an enema, usually in a glove or on a finger; this examination gives especially much data when examining the broad uterine and uterosacral ligaments, Douglas' space and the pelvic walls. To determine the mobility of the uterus and the presence of changes in the cellular tissue, e.g. when deciding on the operability of cervical cancer, combined examination per vaginam and per rectum is very important, which is performed by inserting the thumb into the vagina and the index finger into the rectum, or else (according to Ott) with the index and middle fingers (see Figure 9). This method often gives a great deal of data.

Examination with mirrors of course requires special lighting, for which special reflectors are used, hand-held or on some stand or worn by the examiner on the forehead. Examination by means of mirrors aims mainly at inspection of the vaginal part of the uterus, sometimes also of the walls of the vaginal canal. Vaginal mirrors are of different kinds; tubular mirrors (of milk glass or rubber) are inserted so that they are held at the rear end with a flared opening, while the front end, beveled, is positioned at the entrance to the

Figure 9. Combined rectal-vaginal-abdominal examination.

Figure 10. Insertion of a tubular mirror through the vaginal entrance.

Figure 11. Trelat mirror.

vagina with pressure on the posterior cul-de-sac and its posterior wall (see Figure 10).—Blade mirrors are made of metal and consist of two or three blades (Trelat, see Figure 11), connected at the rear, more solid part, by a special lock and opening like a duck's bill; these mirrors are inserted with the blades folded together into the anteroposterior diameter of the vaginal entrance, then turned to the transverse diameter and as the lock is screwed open, they mainly stretch the upper part of the vagina and provide access to the vaginal part of the cervix. These mirrors have the advantage that they are well retained in the vaginal canal, then they allow certain manipulations on the cervix, such as grasping the cervix with forceps, sounding, in extreme cases—trial excision and curettage. Depending on the construction of the lock, there are different forms of blade mirrors: Kusko (Cusco) [see Table I (pp. 43-44), Fig. 4], Trelat, Collin-Landau [see Table I (pp. 43-44), Fig. 5], Nott, etc.—Spoon mirrors consist of two or more parts—a posterior spoon, retracting the posterior vaginal wall, and an anterior elevator, pressing on the anterior wall and forming a transition to plate mirrors [Simon mirrors; see Table I (pp. 43-44), Fig. 2]; in the Fritsch mirror set, the elevator is curved and not as long as in Simon mirrors [see Table II (pp. 45-46), Fig. 10]; the Sims mirror [see Table I (pp. 43-44), Fig. 3] is double-sided, with one spoon smaller in size than the other; either end of the mirror is used; for the anterior wall, any elevator is taken, and if necessary, smaller lateral elevators are additionally used. In vaginal operations, spoon mirrors of various systems are usually used, as they allow completely free various manipulations on the cervix and vaults, up to colpotomy and hysterectomy. Their inconvenience lies in the fact that this requires a certain number of assistants, at least two. Therefore, attempts were made to create self-retaining mirrors, such as Auvard, Akhsharumov, etc., with a weight attached to the posterior spoon. There are also rather complex mirrors with numerous screws, widely opening the vagina, self-retaining and eliminating the need for assistants. Mirror examination is usually performed with the patient in the supine position, but it is also possible in the lateral position. Special methods of examination. In some cases, it is necessary to resort to

Figure 12. Lazarevich sound.

special methods of examination, for example to trial excision: this operative intervention consists in cutting out a piece from the affected area (e.g. erosion on the vaginal part of the uterus) or from some tumor to determine the nature of the tumor; special instruments like forceps for cutting out small pieces of tissue have been proposed, but usually this can, and is even more convenient and simple, be done with an ordinary scalpel. Uterine sounding aims to determine the length and width of the uterine cavity, the presence of tumors or growths in it, the direction of the uterine axis, which clarifies its position, sometimes also the degree of mobility of the uterus. Different authors—Martin [see Table I (pp. 43-44), Fig. 8], Lazarevich (see Figure 12)—have proposed sounds with centimeter markings, differently curved or made of easily bendable material. A necessary requirement for sounding is that it should not be performed blindly by touch, but always under direct vision, with the aid of mirrors, preferably spoon mirrors, with traction on the cervix (see Figure 13), and of course with the strictest asepsis. Uterine sounding is now used relatively rarely, mainly in those cases when it is necessary to determine whether the enlarged uterus belongs to the uterus itself or to a tumor (e.g. fibromyoma or gestational sac in ectopic pregnancy in the second half); furthermore, sounding is important for determining a bicornuate uterus. The dangers in the use of a sound are very many in the form of the possibility of introducing infection with the sound, perforation of the uterus in abnormal positions of the uterus, etc. Trial curettage aims to determine the presence of pathological elements in the uterine cavity, mainly malignant tumors (cancer, sarcoma), remains of the ovum (placental polyp). For such curettage, anesthesia is usually required, as dilation of the cervical canal, although not requiring large dilators [usually Nos. 8-9 Hegar, see Table II (pp. 45-46), Fig. 14], is painful. The most careful observance of asepsis is mandatory. Dilation of the uterus by the introduction of laminaria is used less frequently than metal dilators. After dilation, curettage of the uterine cavity is performed, of all its walls, if possible systematically, so as not to miss any area where a lesion (polyp, localized

Figure 13. Uterine sounding.

Figure 14. Glass tip with double current.

Figure 15. Fritsch-Bozeman's cannula in assembled and disassembled form. initial degree of malignant neoplasm). The instruments used are curettes or spoons (see Curettage, fig.) of various types and calibers, mostly small. Many operators complete curettage by washing out the uterine cavity through special catheters (Reyin, see figure 14; Doleris; Fritsch-Bozeman, see figure 15), and then wiping with tincture of iodine [on a Playfair probe, see table II (p. 45-46), fig. 18] or injecting iodine with a Braun-Record syringe [see table II (p. 45-46), fig. 19]; the introduction of a gauze tampon for 10-20 hours is not considered mandatory by many authors, unless there are special indications for it. In very rare cases, there is a necessity for digital examination of the uterine cavity, for which anesthesia, very significant dilation of the uterus (up to Hegar nos. 17-18) or, much better, anterior hysterotomy are necessary. Trial puncture of the posterior fornix has its indications in the form of a large accumulation in the posterior fornix, when it is necessary to determine whether it is an accumulation of pus or blood, fresh or perhaps also already suppurated. Puncture is performed under illumination with troughed specula, under complete asepsis, most often under anesthesia, at the place of the posterior fornix below the cervix where fluctuation is noted; the mucous membrane of the vagina at this place is incised, the needle of the test syringe is injected, and aspiration is performed (see figure 16); if pus is determined, the needle remains, and a curved, pointed dressing forceps is introduced along it, then the needle is removed, the dressing forceps is parted and enlarges the opening; upon the release of the pus, a drainage tube and gauze tampon are inserted. A trial laparotomy can be called any laparotomy that ends with closure without removal or with incomplete removal of the affected parts after it becomes clear that it is impossible to provide any radical aid, e.g., in the dissemination of a malignant tumor along the peritoneum. Sometimes a trial laparotomy is performed instead of abdominal puncture, having the advantage over the latter that it clarifies the state of affairs. Trial laparotomy is performed with the observance of all usual precautions.

Puncture of the posterior fornix.

Figure 17. Apparatus for tubal insufflation.

Investigation of tubal patency. Recently, a new research method has been used in the form of pertubation, i.e., testing the patency of the Fallopian tubes for air—an issue extremely important in solving the problem of eliminating sterility; this method, of course, is not therapeutic, but exclusively diagnostic, since with its help it is found out whether the tubes are patent to air; in this case, other things being equal, methods previously used against sterility, but used blindly, e.g., dilation of the uterus, curettage, incision of the os, are possible and give some hope of success. Proposed in 1920 by Rubin for performing pneumoperitoneum through the uterus and tubes, the method was used for testing the tubes for the first time by Graff; the apparatus consists of a cannula inserted into the cervix and filling the uterine cavity and tubes with oxygen; beforehand, oxygen from a bomb enters, under the control of a manometer, into a special reservoir, and from there it is directed into the uterus. The apparatus, which has undergone many changes in the modification proposed by Mandelstam, consists (see figure 17) of a special conical cannula that hermetically closes the cervical canal and is connected by means of a rubber tube to the outlet knee of a Woulff bottle filled one-third with a 5% solution of hydrogen peroxide or some other disinfectant solution; the inlet knee of the bottle is connected to a metal manometer and an ordinary double rubber bulb from an atomizer; the cannula and rubber tubing are boiled. Experience with this apparatus has shown that the tubes even in a physiological state can be impassable due to swelling of the mucous membrane before and during menstruation, and therefore, to determine their patency, one must use the period of rest, i.e., after menstruation; with tubal patency, the pressure in the manometer remains below 100 mm of mercury, with impassability it rises above 120-150 mm. Contraindications for the use of the method are all acute and subacute inflammatory processes, uterine bleeding, suspicion of uterine and ectopic pregnancy, suspicion of cancer of the uterine cavity. To avoid infection, before performing tubal insufflation, it is necessary to perform the erythrocyte sedimentation reaction and refuse insufflation in cases of accelerated sedimentation. When listening with an ordinary stethoscope, from the side of the abdomen one can clearly hear the gurgling of air entering the abdominal cavity through the tubes. One can also judge the patency of the tubes by observing the pressure in the manometer (see above).—It must also be pointed out that sometimes pos-

Figure 18. Blockage of both tubes at the abdominal openings.

sible are complications in the production of tubal insufflation. Although these complications were observed as an exception, they must still always be taken into account and all possible contraindications weighed more strictly. Thus, Mandelstam described a case of subcutaneous emphysema that occurred, according to the author's explanation, apparently on the basis of a rupture of the tube in the mesosalpinx; others noted cases of exacerbation of a chronic inflammatory process and even cases of air embolism. Attempts to use X-rays to determine the contours of the uterine cavity and deviations from the norm broke down on the fact that it was not immediately possible to find a suitable agent that would give a shadow on the plate. Nemenov proposed tincture of iodine. Only recently has Lipiodol been proposed, which has justified itself and made it possible to determine not only the contours of the uterus and tubes, but also their patency and, as a result of it, the accumulation of the introduced substance in the peritoneal cavity (see figures 18 and 19). Among Russian authors, Arnshtam, Reinberg, Ginzburg, Strokov work in this field. During the initial attempts to obtain clearer images of the organs of the abdominal cavity, the production of pneumoperitoneum was proposed, in which a trocar is introduced into the abdominal cavity through a small incision in the skin; the stylet of the trocar is removed, and a known amount of gas (oxygen, nitrogen, carbon dioxide, recently ordinary air) is introduced through the latter, pumped by an ordinary double rubber bulb. Such filling of the abdominal cavity with air gives, when taking an X-ray, clear pictures of various organs of the abdominal cavity with their contours. To finish with the examination

Figure 19. Blockage of both tubes at the uterine openings.

Figure 20. Hysteroscopy according to Illgner. Inspection of the uterine fundus.

To determine the patency of the tubes, one may mention the method of Ott, who in 1925 proposed the injection of finely ground charcoal into the posterior Douglas' pouch, which, by the flow of fluid in the abdominal cavity, will be drawn to the openings of the tubes and, in case of their patency, will exit through the cervical canal and can be detected on a tampon applied to the cervix.—By analogy with the cystoscope, the hysteroscope of David and Ilgner was constructed for examining the uterine cavity (see Figure 20), as well as the mirrors for illuminating and directly examining the abdominal cavity and uterus, proposed much earlier by Ott [see Table II (art. 45-46), Fig. 13]. Finally, there is also the laparoscope, which also operates on the principle of the cystoscope, but is introduced into the abdominal cavity through a trocar, through which first a physiological salt solution is poured into the abdominal cavity, and then the illuminating apparatus is introduced. Examination of secretions. The female sexual tract, located between the urinary apparatus and the excretory part of the gastrointestinal tract, is in very unfavorable conditions for maintaining cleanliness, which are further worsened by sexual life, and therefore the sexual tube, especially the external parts and vagina, is extremely rich in the most diverse flora, among which not only relatively harmless saprophytes, but also to a large extent disease-causing microbes are found. For the gynecologist, it is extremely important in many cases to become acquainted with the nature of this flora, and it is necessary to take for examination secretions from different parts of the sexual tube, namely: from the lower third of the vagina, then from the upper part and the fornices, further—from the cervical canal and very rarely from the uterine cavity, which is more often necessary in obstetric practice. It is necessary during sampling to carefully ensure that the contents of the lower part are not introduced into the upper part, namely when introducing mirrors, when taking a sample from the upper part of the vagina; for taking a sample from the cervix, a Doederlein tube is usually used (see Figure 21). Smears are examined dried, then fresh in a hanging drop (spores, Trichomonas, etc.), and finally cultures are made on different nutrient media (broth, agar-agar, etc.); inoculations are also made on animals. For staining, different methods can be used, including the very important Gram staining for determining gonococci (which decolorize with it). The determination of the degree of purity of vaginal flora according to Geurlich has become widespread in gynecology: the greater the purity, the greater the predominance of rod-shaped bacteria over cocci and other forms of bacteria and the amount of squamous epithelium over leukocytes, and vice versa (see Vagina, Figs. 6, 7, and 8). Morphological examination of blood is of great importance: percentage of Hb, number of red and white corpuscles, leukocyte formula; all these data can be recorded on a special hemogram. In some cases of general sepsis, it is extremely important to determine the bacteriology of the blood, for which smears and cultures on media are made. This is of great importance for prognosis. Serological examination of blood. This includes the Abderhalden reaction for cancer, but it is more easily confirmed by other methods, of which biopsy is more frequently used. Wright, Bordet, and Janin reactions for detecting gonorrhea are used less frequently and are disputed by some authors. For determining syphilis, the Wassermann reaction and the Sachs-Georgi reaction are widely used. The Botelo and Davis reactions for cancer are by no means typical.—Rate of erythrocyte sedimentation. The Fahraeus reaction, initially proposed for determining early pregnancy, quickly and firmly took root in gynecology, and now it is performed in almost all patients, being especially important for prognosis in cases where the patient is awaiting surgical intervention. (Technique of the reaction—see Erythrocyte sedimentation.)—Of the less commonly used blood examination methods, one may mention the examination of the rate of blood clotting, coefficient of blood viscosity, specific gravity of blood, alkalinity of blood, etc.