CHAPTER VI THE PHYSICAL EXAMINATION (Continued) (Part 1)

CHAPTER VI THE PHYSICAL EXAMINATION (Continued) III. The examination (continued) : 6. Inspection of the abdomen, p. 64. Method of performing it, p. 65. Appearances to be noted, p. 65. En- teroptosis, p. 67. 7. Palpation of the abdomen, p. 68. Method of performing it, p. 69. Points to be determined by palpation, p. 69. Palpation of the kidneys, p. 70. 8. Percussion of the abdomen, p. 71 ; Auscultation of the abdomen, p. 72 ; Mensuration of the abdomen, p. 74 ; Gauze records of abdominal tumors, p. 74; The X-rays in diagnosis, p. 76. III. THE EXAMINATION (Continued) 6. Inspection of the Abdomen Attention will be directed to the abdomen to a greater or a less degree according to the nature of the disease present in any given instance. In the case of late pregnancy, and of tumors of abdominal evolution, whether originating in the pelvis or not, investigation of the abdomen is of chief importance. In suspected uterine disease the vaginal and bimanual examina- tions usually precede the examination of the abdomen. In the case of a large abdominal swelling the abdomen is first inspected. For the examination of the abdomen it is not so necessary that the patient should lie on a hard surface as in the case of the vaginal examination. However, the table is most convenient for the physician because he can stand up and make his inspection, palpa- tion, percussion, and mensuration when in a position comfortable to himself; not, as in the case where the patient is on a low bed or couch, with bent back and strained muscles, conditions which are not conducive to most careful investigation. The patient on a table is comfortable enough for the brief time required for the examination. All the patient's clothing has been loosened and the corsets 64 INSPECTION OF THE ABDOMEN 65 removed, as previously described. The sheet covers the legs, thighs, and pubic region. The raised skirts cover the chest, or, if the skirts have been removed, another sheet is used for this pur- pose. To investigate the abdomen to the best advantage the patient's head should be raised a little on a pillow and the thighs should be slightly flexed. Too much flexing of the thighs or raising the head and thorax high will decrease the portion of the abdomen available for examination. For purposes of description the abdomen may be divided Margin of ribs B Crest of ilium Fig. Spine of pubes 18. — The Abdomen Divided into Quadrants and the Bony Landmarks Indicated. arbitrarily into four regions, by two lines, one a vertical line pass- ing through the ensiform cartilage, the umbilicus, and the symphysis pubis, and the other passing through the umbilicus at right angles to the vertical line. The four regions so made may be called the right upper quadrant, the right lower quadrant, the left upper quadrant, and the left lower quadrant. On observing the abdomen one notices symmetry or asymmetry, distention or retraction, increased or diminished motion of the abdominal walls on respiration, and the appearance of the skin. 5 66 PHYSICAL EXAMINATION To detect symmetry, stand at the foot of the examining table and look at the abdomen from below. Tumors of the ovary as well as tumors of the kidney are apt to cause asymmetrical enlargement of the abdomen; whereas, tumors of the uterus and ascites more commonly produce symmetrical enlargement. One notes bulging in the flanks and a flattening of the anterior aspect of the abdomen due to ascites, or to lax abdominal walls, with or without an abnor- mal amount of fat in the panniculus adiposus. A tumor rising from the pelvis, unless of great size, is usually outlined by the abdominal walls. In ovarian cysts the abdomen is irregularly ovoid in shape with its point of greatest protuberance below the umbilicus, and there is no bulging in the flanks. In the case of multilocular cysts the loculi may be distinguished by sight in exceptional cases through a thin abdominal wall, so nodules of a malignant growth in an ovarian cyst can sometimes be dis- tinguished by the eye. Large multiple fibroids also show occasion- ally through the skin as lumps of irregular shape; an interstitial fibroid forms a protuberance of a smoother outline that is generally situated in the median line. Observe the movements of the abdominal walls. The normal movements on inspiration and expiration extend over the entire surface from ensiform to pubes. In cases of large tumors springing from the pelvic cavity the movement is confined to the epigastric region if the distention is great, also if there are adhesions between the tumor and the parietes there may be motion only in this region. Sometimes, when there are no adhesions present, the abdominal wall can be seen to glide up and down over the surface of a tumor of moderate size. Waves of peristalsis in the intestines may be noted in a patient with thin flaccid walls and retracted abdomen, also pulsations of the abdominal aorta. In pregnancy the situation of greatest in- tensity of fetal movements may be observed. Separation of the recti, due to distention of the abdomen during previous pregnancies, often leaves a ventral hernia through which a tumor, the pregnant uterus, or the abdominal contents ma}' protrude. Palpation of the abdominal and pelvic organs is ren- dered most easy in these cases. v The appearance of the skin of the abdomen is of interest as showing discolorations from blisters and counterirritants, indica- INSPECTION OF THE ABDOMEN 67 tions of previous treatment, also the presence of edema or skin diseases. Enlargement of the superficial veins indicates pressure on the deeper vessels. Excessive distention of the abdomen renders the skin white and glossy in appearance, whereas, when the walls are lax, the skin has a shriveled or puckered look. The lineae albicantes, red and purple when recent, and white and glistening when old, are to be looked for especially over the flanks. They indicate previous stretching of the skin, but are not pathognomonic of pregnancy, as they occur in virgins who have grown rapidly and then lost subcutaneous fat. Pigmentation of the linea alba (linea nigra) and increase of pigment about the umbilicus and lower abdomen occur in some women during a first preg- nancy. This pigmentation persists, but is of no diagnostic importance in a subsequent pregnancy. When the patient is sick in bed with peritonitis, the characteristic way in which she holds herself, with knees drawn up to relieve all strain on the abdominal parietes, is to be noted. Enteroptosis. — In some cases it is advantageous to put the patient in the standing position for the purpose of inspecting the abdomen; especially is this desirable in suspected ptosis of the abdomi- nal viscera, a condition often associated with uterine disease. Here we must inspect not the abdomen alone, but the entire trunk. The patient stands, first, facing the phy- sician, entirely nude except for a sheet held by a nurse draping the lower limbs and pubic region. Then she stands so that he sees her in profile. In typical enteroptosis one notes a long, nar- row thorax, with flat and sunken epigastric region. The waist is long, the abdomen is prominent, the shoulders are rounded, and when seen in profile the lower back is nearly flat instead of pre- senting, as normally, a forward curve, with shoulders and hips well back and spine bent forward in the lumbar region. There is gen- erally an absence of adipose tissue in these patients and the muscles are apt to be slender and flabby. Fig. 19.— The Body Pose in Enteroptosis. 68 PHYSICAL EXAMINATION 7. Palpation of the Abdomen To palpate the abdomen successfully, the patient should be pre- pared as for inspection, that is, in the dorsal position with the head slightly raised on a pillow, all clothing loosened, the feet supported, and the pubic region, thighs, and legs covered by a sheet. The physician, standing on the patient's right, places both hands, warmed, and with finger nails cut short, on the abdomen. No abrupt or rapid movements should be made, and, for the purpose of distracting the patient's attention and thus favoring relaxation, it is advisable at this juncture to ask some question as to the health, not directly referable to the abdomen. By care and patience the tendency of the abdominal muscles to contract when stimulated by manipulation may be overcome. Oftentimes more than one sitting is necessary to accomplish this result, and in this event the diagnosis must be held in abeyance until after a second examination. It is better to make two or more attempts, except in urgent cases, rather than resort to an examina- tion under an anesthetic, because with increasing experience the physician learns an added amount from each palpation, and hav- ing gained the patient's confidence and treating every case accord- ing to her individuality, he is able more frequently to dispense with an anesthetic. The utmost gentleness should obtain always. The harder the pressure, the greater the resistance of the abdominal walls and the greater the blunting of the physician's tactile sense. Further- more, it has happened several times in the experience of the writer, that a student novice has ruptured a thin-walled or necrotic ovarian cyst or a circumscribed collection of peritonitic fluid, by too vig- orous palpation. A thin, relaxed abdominal Wall permits of palpation of the promontory of the sacrum, and the pulsations of the abdominal aorta are to be felt distinctly. The anterior superior spines and the crests of the ilia, the symphysis pubis and the borders of the ribs, body landmarks, are always to be made out. Thick and tense abdominal walls interfere with palpation. It is well to have a definite system to follow in palpating the PALPATION OF THE ABDOMEN 69 abdomen. Begin with the lower quadrants and proceed to the upper quadrants. (See Figure 18, page 65.) By making firm but gentle, deep pressure, the patient at the same time taking a deep breath, the hands, flat on the abdomen, are brought together and a fold is grasped between them so that an estimate is formed of the thickness of the abdominal walls and their degree of tension. Avoid as far as possible digging into the flesh with the tips of the fingers, using instead the palmar surfaces of the last phalanges, the location of the trained tactile sense. We may learn by palpation, of the presence of a tumor, also its situation, size, shape, mobility, consistency, and point of attach- ment. We determine a point of tenderness on pressure, indicating localized peritonitis. In a majority of cases we may palpate the normal kidneys, more easily if they are enlarged or displaced. We palpate the edge of the normal or enlarged liver, and a displaced liver, as in enteroptosis, also a distended gall bladder, or an en- larged spleen. A loop of bowel distended with feces and also the distended urinary bladder may be made out by palpation. Suppose a tumor is present; first we determine its situation by making gentle, firm pressure with both hands, noting in which quadrant or quadrants of the abdomen it is situated. The ab- dominal walls should move with the hands over the underlying organs or the tumor. Tumors situated in the structures of the abdominal wall move with the wall on inspiration and expiration over the organs underneath. Tumors of the abdominal and pelvic organs that are adherent to the abdominal parietes limit the motion of the walls on respiration. Exceptionally, in cases where the walls are lax and the tumor is not excessively large, the physician is able to pick up the abdominal wall and determine if it is adherent to the tumor beneath. All the abdominal organs normally move more or less during respiration, — those organs nearer the diaphragm, as the liver and kidneys, moving the most, while those in the bottom of the abdomen are less affected. The size of the tumors can be learned only approximately. It is to be borne in mind that some tumors vary in size at different times: for instance, an ovarian cyst is smaller after there has been free catharsis from the bowels, and a fibroid tumor of the uterus is larger just before the catamenia and smaller just after. The shape of the tumor is made out by palpating it in several 70 PHYSICAL EXAMINATION directions. To this end the examiner shifts his position to the left side or to the foot of the examining table. The mobility of the tumor is ascertained by grasping it between the two hands and moving it about. Changing the patient's position to the lateral position may cause the tumor to fall by gravity to the dependent side. Ovarian tumors tend to gravitate into the abdominal cavity if the patient is put in the knee-chest position. The excursions of a movable tumor show us something as regards adhesions and the point of attachment and length of the pedicle. Traction on the pedicle generally causes pain re- ferred to the situation of the pedicle. The consistency of a tumor is often a difficult matter to pass on. Waves of fluctuation are made out by a combination of palpation and percussion. The hand of an assistant is placed, ulnar edge down, in the longitudinal axis of the abdomen and firm pressure is made. This is to eliminate the wave which may be transmitted by the fat of the abdominal wall. The physician taps one side of the abdomen and notes with the other hand, placed on the opposite side, oscillations which may be transmitted through the fluid. If a cyst is filled so that the fluid is under great pressure and if the cyst walls are thick, the fluid waves may be indistinguishable. So also, if the fluid is of a thick consistency, fluctuation may be absent. Peristaltic contractions of a piece of intestine are sometimes to be distinguished and also the rhythmical contractions of a pregnant uterus. To determine either of these it is necessary to let the hand rest gently on the abdomen for a considerable length of time. The point of attachment of a tumor may be learned by moving the tumor while the hand is held on a neighboring organ and noting whether the organ moves too, or by moving the organ and noting the behavior of the tumor. Palpation of the Kidneys. — Palpation of the kidneys is best done with the patient in the dorsal position. The physician stands at the patient's side facing toward her head, his left hand is placed under the flank and his right hand over the flank, while the patient takes a deep breath. This process is repeated, the hands coming together a little more with each expiration. Time, gentleness, and gradual movements are important factors in this manipulation. PERCUSSION OF THE ABDOMEN 71 The right kidney, being a little lower than the left, is more accessible to palpation. With practice it will be found that there are com- paratively few cases, — and these patients having very stout and rigid-walled abdomens, — in which the lower poles, at least, of the kidneys can not be felt. In the case of movable kidney, generally the entire kidney can be outlined, especially where it is enlarged. Pressure on a tuber- culous or hydronephrotic kidney will frequently force turbid urine through the ureter into the bladder. If the bladder has been emptied by catheter previous to the examination and clear urine obtained, such a procedure assists materially in establishing the diagnosis, for a second catheterization following palpation draws off cloudy urine. To determine the extent of the downward excursion of a mis- placed kidney the flank is palpated either in the sitting or in the standing position. In the sitting position the patient sits on the foot of the table with her feet in a chair, and bends forward slightly. In the standing position she stands facing the table and about a foot from it. Placing both hands on the table she leans forward so that part of her weight is taken on the hands; thus the abdom- inal muscles are relaxed. This manipulation can be executed best with the assistance of a nurse or another woman, because the patient can not hold up her loosened clothing and bear part of the weight on her hands at the same time. Personally, I have learned to place the chief reliance on the dorsal position for palpation of the kidneys, except to make out the amount of extreme downward excursion, when sometimes the standing, and at others the sitting, position gives the better result. 8. Percussion, Auscultation, and Mensuration of the Abdomen The combination of palpation and percussion for the detection of fluid waves in the abdomen has been described in the discussion of palpation. Percussion is best practiced with the patient in the dorsal position. By it we determine the situation of the lower margin of the liver- dullness, the area of stomach and colon tympany, splenic dullness, the dullness due to fecal accumulations in the bowels or urine in 72 PHYSICAL EXAMINATION the bladder, and the dullness caused by free fluid in the peritoneal cavity or by the fluid or solid constituents of a tumor. Unfortunately we have no standard of comparison in percussion. We can not compare the percussion note of one side of the abdomen with that of the other, and the conditions are constantly varying, due to changeable quantities of fluid, solid and gaseous matters in the stomach and bowels, and the encroachment of one organ on another. Also, there are to be considered the variations caused by the normal mobility of the abdominal organs. Nevertheless, percussion is a valuable adjunct to palpation. Its chief use in gynecological diagnosis is in differentiating between ascites and a cystic ovarian tumor. In the case of ascites, the flanks, being the dependent portion of the abdominal cavity and there-