DISEASES OF WOMEN.

CHAPTER I.

METHODS OF OBSERVATION.

A THOROUGH familiarity with the means and methods of investigation is the first requisite in acquiring knowledge. The art of observation, which is simply the systematic use of the mental and physical faculties to obtain facts, should be made an essential part of the preliminary training of every student of medicine. From this point of view, the subject which we have to consider resolves itself into two divisions: first, the ways and means of investigation; and, second, the objects to be studied.

Before approaching the study of gynecology, it is taken for granted that much experience and practice have been attained by the student in the art of investigation. The experience of everyday life, from infancy onward, and the ordinary school education obtained before beginning the study of medicine, tend to develop and cultivate the perceptive faculties. Still, the physician and surgeon require special training in the art of observation. Accurately noting structure, form, color, general proportions, and expressions of the human body in health, is the first lesson which every student of medicine should learn. This is the most important step toward the attainment of a practical knowledge regarding the functions of the human body, and its deformities, diseases, and injuries. The correct, rapid, and thorough observer has from the outset great advantages. Important and necessary as this branch of education is, it is almost wholly neglected in schools and colleges. The chief occupation of teachers appears to be to impart knowledge already in existence, rather than to qualify the student to observe and think for himself.

Special attention should be given to this art of observation, because it is the key to science and the first exercise in practice. The

systematic way in which knowledge is presented in books and by oral instruction enables the student to acquire facts in all branches of learning, and to classify them. The mental training obtained in the study of mathematics and logic prepares men to make reasonable deductions from the facts obtained; but in institutions of learning, thorough training in the art of observation is seldom given.

This lack of preliminary education adds greatly to the labors of the student, because he is obliged to acquire knowledge while he is not in possession of the means of obtaining it, and it is mainly because of this defect that practitioners of medicine are led into error in making diagnoses. They fail to observe all the facts, and hence. their deductions are liable to be incorrect.

Acute, clear perception is a gift which all do not possess in a high degree, but it can be cultivated in those of ordinary intelligence, and it should be by those who intend to practice medicine. The practical study of the elements of natural science, which should constitute a large share of the early education of those destined for the profession of medicine, aids much in cultivating the faculties concerned in observation. So also the arts, especially drawing, painting, and sculpture, help to qualify for the actual in professional life. The trained eye and hand of the artist are most valuable in acquiring the art of medicine and surgery, and a share of the days of youth spent at an art-school will save much time and perplexity in the medical school as well as in subsequent professional life.

The first lesson is to obtain a familiarity with the general appearance of the body in health, its structure and the uses of the various organs, the process of development, the slight deviations from the ideal or highest type which occur within the range of health, and finally the relations of the being to his environments or conditions of life. A portion of this subject will be fully discussed in the chapter on the development and structure of the sexual organs of woman, and the conditions of life which are suitable to her development, growth, and maintenance. Subsequently the derangements of the body from disease and injury will come in for the greater portion of time and attention. Here it is that the highest perceptive power is needed, and the most painstaking attention to ob

servation.

The fact should be kept clearly in mind that a knowledge of the science of medicine does not give skill in the art of practice, however much it may help in acquiring that art. Men profoundly versed in the science of medicine may be poor practitioners; and others, whose knowledge of the science is very limited, may attain

some reputation in practice; but the best qualified physician is he who knows most of both the science and the art.

The subject for present consideration is the method of investigation to be adopted in practicing the art of gynecology. Before beginning the actual work of examining patients, it is necessary to know how to do so.

There are several methods of investigating the sick and injured given in text-books and taught in the medical schools, but most of these are better adapted to general practice than to special departments of medicine. The methods which I desire to present here are circumscribed, and perhaps less complicated, because they are limited to the diseases peculiar to women.

In examining patients it is well to first settle definitely in the mind the object to be attained and how to attain it. Some rational system of investigation should be mastered in all its details before undertaking actual practice. To engage in clinical study without such preparation is like trying to read a language without knowing its alphabet.

The system advised is-first, obtain all the facts regarding the case in hand; second, arrange the facts in their natural relation to one another; and, finally, make deductions from the data thus obtained. These will be easily remembered in the following order and association: observation, classification of things observed, and conditions indicated by the sum of the information obtained.

The examination of a patient should begin by a general inspection; and, in order to make that inquiry complete and profitable, certain questions should be raised in the mind of the examiner; such, for example, as what is the general appearance of the patient under observation? What size? Regular or defective in general outline? Lean or corpulent? What temperament? Is the face pale or flushed? Languid or vigorous? Sad or cheerful? Calm or excited? Intelligent or stupid? What diathesis is indicated, if any? In short, does the general physigonomy indicate health or disease?

All these interrogations are made by looking critically at the patient. There are so many questions to be answered in this connection, that one may find some difficulty in promptly remembering them; but by patient practice the mind and eye can be trained to take advantage of a rule of observation employed by critical investigators in other arts, which is this: having a type of normal organization in mind, the observer is able to scan a given case, and detect any deviation from that standard of healthy formation and appear

ance. The artist, in looking at a picture or statue, does not necessarily question every line of the drawing or form by itself, but his trained eye catches any defects that there may be in the work before him.

The classification of facts is simply putting together those which are similar in character. The arrangement of material things in groups is familiar to all. A well-arranged, library, in which all books pertaining to a given subject are placed side by side, is a fair illustration of this kind of classification. Facts and ideas can be arranged in the mind upon precisely the same principle. The advantage of classification is that it aids comprehension and memory. By recalling one group of facts which have been associated in the mind, the rest will follow in easy and natural order. There are two methods of classifying the information contained in the clinical history of a patient. One is to obtain all the facts possible, and then to arrange them in order. The other is to classify them at each step of the examination. The former method requires a mental grasp and tenacity which few possess, and therefore I would advise the latter.

The information obtained by inspection may be classed under four heads: 1. The original character of the organization, whether perfect or imperfect in structure and function. 2. If imperfect, whether from imperfect development, causing lesions of form or lesions of structure, or from inherited or acquired disease, and inherited tendencies to disease, known as diathesis. 3. Evidences of disease, expressed in the face, either acute or chronic. 4. The temperament; which simply means the preponderance of a certain portion or portions of the organization.

To illustrate the value of this process of general inspection of patients, the partial history of a case seen in private practice will suffice. A lady called to consult me regarding her son, a little fellow seven years of age. After a very brief survey of the patient, I saw enough to satisfy me that he had recently had scarlatina, and that when a child he had suffered from sore eyes, and that his father had been subject to rheumatic pains in years gone by. The mother acknowledged that I was right in every particular. A glance at the boy showed that exfoliation of the cuticle, which occurs after scarlatina, was still going on; the face was pale and puffy, indicating commencing dropsy from acute nephritis, a sequel of the eruptive fever. I also noticed that he had a scar upon the cornea of each eye, the result of a former keratitis. The form of his nose and the character of his teeth indicated an inherited syphilis; and from the

appearance of his mother and other facts known to me, I presumed that the father was the one who had transmitted the specific disease.

The age of the patient should be ascertained, because that suggests the possible existence of the diseases which are likely to occur at certain periods of life. Care should be taken to compare the real and apparent age, in order to ascertain if the patient is prematurely old, or well preserved. This interrogation will also serve to keep in mind the fact that, in early life, acute diseases prevail, while degenerations are usually limited to advanced life.

It is important to know the social relations of a patient-that is, whether she is married or single. If married, she is liable to the diseases and accidents attendant upon child-bearing. If she has never been pregnant, her sterility may have resulted either from choice, or because of some defect in her organization. Women who are single are, by reason of that fact, limited in the range of diseases of their sexual organs, and this may be taken for granted unless evidence to the contrary is obtained.

Having made a general inspection of a given case, and ascertained the age and social relations, an examination of the various portions of the body should next be made in systematic order. To do this conveniently, one group of organs or one system should be examined at a time. The various systems are classified as follows:

THE NERVOUS, NUTRITIVE, MUSCULAR, AND SEXUAL

SYSTEMS.

The first three are subdivided as follows: The nervous has two grand divisions, the cerebro-spinal and organic. The nutritive has four subdivisions, the digestive, circulatory, lymphatic, and excretory; and the third has the osseous and muscular.

The present purpose is to outline the methods of investigating the sexual system, but, in order to do that successfully, it is necessary to be able to examine the whole body. No one can be a trustworthy specialist without having a thorough knowledge of the whole organization. All the parts of the body are so bound together by mutual relations that one can not accurately diagnosticate the diseases of one portion without knowing the condition of all the others. On account of that fact I must refer to the principles upon which the examination is made of parts other than the sexual system.

Briefly, it may be stated that the two principal subjects of inquiry are the condition of the function and structure of the organs under examination. Perverted function of the cerebro-spinal divis