4. Pains. Their kind, site, association with certain causes (exertion, defæcation, micturition, coitus, menstruation, etc.), their intensity (whether they make the patient incapable of work or bedridden). 5. General Health.-Appetite, digestion, sleep, any disorders of the nervous, digestive, respiratory, and circulatory systems. Previous illnesses (chlorosis, gonorrhoea, syphilis ?) Any and what previous medical treatment. : In many cases the patient tells the physician at once the reason of her visit-she complains of flooding, of discharge, of pain or she names directly her suffering-she says she has a "falling of the womb," or a swelling in the belly. In such cases, the physician examines the part complained of. In women who have been married a long time without having children, it can be taken for granted that the desire for offspring has led to the consultation. In the unmarried, on the other hand, one often finds that the fear of a possible pregnancy brings them to the physician. They generally make vague and (often without hesitation) the most untruthful statements, especially with regard to the date of the last menstruation, with the one desire that the practitioner may terminate the pregnancy by the passage of the sound. The Gynecological Examination and Minor Examination is usually avoided during menstruation, but when hæmorrhage is abnormal examination may be imperative. Sub-mucous myomata are sometimes to be felt during menstruation within the os uteri. In cases of continuous hæmorrhage (from abortion or carcinoma) patients do not generally come to be examined. Valuable time is thus frequently lost, because the woman looks upon each loss as menstrual, and therefore awaits its ending. A suitable position of the patient is of great importance for an exact examina tion of the sexual organs, and for any associated local treatment. To obtain this we use the examination couch of G. Veit-Schröder (Fig. 1). In case the physician prefers not to have so striking a piece of furniture in his consultingroom, there are a number of examination tables, of which by far the simplest is that of Auvard. FIG. 1. (After Hofmeier.) He makes a simple table, 90 cm.1 high, with two pairs of movable supports, 40 cm.2 long (see Figs. 2 and 3). The first position (Fig. 2) is for all lesser manipulations; the second (Fig. 3) is only used for simple examination and for the introduction of Fergusson's speculum. The first position is the so-called "lithotomy position,” FIG. 2. in which the patient, with slightly raised head, and legs bent at right angles to the body, so lies that the vulva is close to the free border of the table and perpendicular to this. If the vaginal douche be used, at the moment of sitting down the clothes must be drawn upwards and backwards, and a pail must be placed under the table into 1 90 cm. 35.5 inches. = 2 40 cm. 15.7 inches. which there hangs a piece of waterproof sheeting, which is fastened to the table. Before examination, the bladder must be emptied, when there are tumours of the abdomen, by means of a male catheter. The emptying of the bladder before examination must only be omitted in diseases of the bladder and urethra (gonorrhoeal urethritis, e.g.). When the abdomen is greatly enlarged, palpation of its surface is employed at once with both hands (as in the diagnosis of ovarian tumours). FIG. 3. In other cases, after disinfection of the hand, the combined method of examination is carried out unless the disease is directly visible on the outer genitalia directly the glance is directed to these parts (condylomata, inflammation, swelling, prolapse and rupture of perinæum, etc.) The combined or "bi-manual" examination 1 consists in the introduction of one forefinger, or where this is 1 [On bi-manual examination :-In following the directions given for the bi-manual and other examinations, it must always be remembered that the patient is supposed to be lying in the lithotomy position at the edge of the table, and the examination is made from the middle line. In England, examination with the patient lying on the left side is almost universal, and the bi-manual can be made in this position almost as well as when the patient is lying on her back. The patient's clothes are thoroughly loosened at the waist so that the surgeon's left hand can be placed directly on her abdomen: the right forefinger is passed into the vagina, and between the right forefinger in the vagina and the left hand on the abdomen, the uterus and its appendages and any tumour that may be present is thoroughly seized and examined exactly as described in the text. In this (lateral) position, however, the uterus and any small movable tumour is apt to fall to the left side (on which the patient is lying), and after the chief features of the case have been made out, it will often be found advisable to turn the patient on her back, retaining the finger of the right hand in the vagina, and with the knees drawn up (which, together with the abdomen, may be completely covered by a rug) to complete the bi-manual examination in the dorsal position. This will establish insufficient, the index and middle fingers, into the vagina, and in the simultaneous palpation of the abdomen with the other hand. The finger inserted must be introduced over the perinæum in order to cause no pain to the sensitive urethral region. While passing the finger through the vagina one estimates its capacity, the dilatability or bulging of its walls (that of the posterior vaginal ос FIG. 4. wall produced by the overloading of the rectum, that of the vaginal vault through tumours or exudations), the presence of swellings in the vagina itself and their origin. As the finger passes along the anterior vaginal wall in the exact relations of the pelvic organs and any tumour that may be present. Note that this corresponds almost exactly to the method of Thure Brandt described in the text, with the important exception that in the latter method the surgeon stands on the left of the patient, palpating the abdomen with his right hand and examining the vagina with his left forefinger. In the English method, the surgeon stands on the patient's right; he palpates the abdomen with the left palm and fingers, and uses his right forefinger for vaginal examination.-J. W. T.] the middle line, it meets the portio vaginalis, that part of the cervix uteri which projects into the vagina. With regard to this, one estimates its length, its shape (whether conical or flattened), its direction (normally the under surface of the portio looks downwards and backwards and stands in the middle line between the spines of the ischia), its consistence-the condition of the os uteri and the presence of any swellings. Considerable practice is necessary in the judgment of consistency, striking softness is suggestive of pregnancy. The expert practitioner diagnoses" erosion" from the velvety softness of the parts surrounding the os uteri, and swellings (such as follicular hypertrophy and papillary cancer). These can cause enormous enlargements of the lips of the portio; on the other hand, as in carcinoma, they may completely destroy it so that the finger at the top of the vagina enters into an ulcerated cavity. Or the portio may be wanting, as in congenital absence of the uterus, or after total extirpation, or spread out (as in Hæmatometra and submucous myoma). At the os uteri one estimates its size and shape (a small transverse or circular opening in nulliparæ, broad enough to admit a finger and fissured in multipara) whether within it any growths are to be felt (polypi, ovum, or membranes), whether it is lacerated, and if the laceration extends to the vaginal roof. Now, as the outer hand lies quietly on the abdomen, it presses, with outstretched fingers, the lower part of the abdominal wall gradually inwards toward the pelvis, while the finger within the vagina raises the portio somewhat upwards and forwards. By this means the fundus is made to approach the anterior abdominal wall and so to become perceptible to the hand outside the abdomen (Fig. 4). The latter now, with the finger tips behind the uterus, presses more deeply until the finger within the vagina is brought to the vaginal roof in front of the cervix. In this way the uterus is seized between both hands, |