Percussion of the abdomen should be performed with the woman in the dorsal position; though, if the examiner suspects the presence of free fluid in the peritoneum, or ascites, much may be learned by percussing in different positions and noting the accompanying changes in the percussion-note.
Percussion should then be performed with the woman upon her back, upon the right side, upon the left side, sitting up, and upon the hands and knees. An encysted fluid accumulation will give practically the same result in percussion in all positions, while free fluid will gravitate to the most dependent portion.
Auscultation of the abdomen is best performed with the stethoscope. By it we may hear fetal heart-sounds, uterine souffle, placental bruit, peritoneal friction sounds, and the peristaltic sounds of the intestinal tract. All of these sounds are of importance, and the presence or absence of any of them may have an important bearing upon the diagnosis of the case.
Examination of External Genitals and Pelvic Structures.—To examine the external organs of generation and the pelvic viscera the woman should be placed upon a table. In some cases the physician may be obliged, for want of proper facilities or on account of the physical condition of the patient, to make his examination upon a bed. Such an examination, however, is never so satisfactory or so thorough as the examination made with the woman upon the examining-table. A great number of gynecological tables have been introduced. The one which seems to the writer the best, on account of its simplicity and the perfect relaxation of the abdominal muscles furnished by it, is shown in the accompanying illustration ([Fig. 1]). It is a plain wooden table, at the foot of which are attached the upright supports for holding the stirrups for the feet, such as have been devised by Dr. Edebohls. By this arrangement the feet and legs are supported without any effort on the part of the woman; when the buttocks are drawn well down to the foot of the table there is a certain amount of flexion of the pelvis upon the trunk, and the most complete attainable relaxation of the abdominal muscles is secured.
When the woman has been placed in this position the examiner should investigate thoroughly, and in order, the following structures: The anus, the perineum, the labia majora, the nymphæ, the fourchette, the orifices of the ducts of the vulvo-vaginal glands, the hymen or its remains, the vestibule and the small glands of the vestibule, the external urinary meatus, and the clitoris.
To determine any pathological condition of these structures it is necessary that the physician should be familiar with the appearance in the normal woman, and to gain such essential knowledge we should avail ourselves of every opportunity offered to make a critical examination of the external genitals of women, going over all the different structures in order.
Fig. 1.—Woman in the dorsal position with feet supported in Edebohls’ stirrups.
Vaginal and Bimanual Examination.—Having examined and noted the condition of the external genitals, the physician should next proceed to examine the vagina. The index finger of the right or the left hand should be gently introduced into the vagina. The condition of the vaginal walls, and the direction, consistency, form, etc. of the vaginal cervix, may be determined. The shape and size of the os uteri should be noted. The ulnar edge and the tips of the fingers of the other hand should then be placed upon the abdomen, immediately above the symphysis pubis, and gently pressed backward and downward toward the vaginal finger ([Fig. 2]). In this way the various pelvic organs, the uterus, Fallopian tubes, ovaries, and ureters, may be palpated between the two hands, and their position, size, shape, and consistency may be determined. Such an examination is, of course, made much more easily in a thin woman than in a fat one. A thin woman a few weeks after labor may be examined most easily, on account of the relaxation of the abdominal and vaginal walls.
