CHAPTER VI THE PHYSICAL EXAMINATION (Continued) (Part 2)

fore occupied by fluid, are dull to percussion. The intestines, filled more or less by gas, float on top of the fluid, and give an area of resonance in the umbilical region. Shifting the position of the patient to one side sends the fluid (unless by chance it is walled off by adhesions) to the dependent side, and the resonance is to be found on the upper side and flatness below. In rare cases, when the ascitic fluid greatly distends the abdomen, there may be no change in the area of dullness on shifting the position of the patient. In the case of a large ovarian cyst, the resonance is in the epi- gastric region, the intestines having been forced there b}^ the tumor and the dullness is over the area occupied by the tumor. Change of posture does not alter the areas of dullness and resonance. (See Figures 132 and 133.) If the gut has a short mesentery, the intestinal resonance may be in the upper parts of the flanks, or, in case the intestine is occupied by fluid or solid fecal matter, there may be little or no resonance, the entire abdomen being dull Or flat to percussion. A large deposit of fat in the omentum may cause dullness in any situation. In gastroptosis one detects the displaced stomach by inflating it with gas by giving the patient a dram of bicarbonate of soda in half a glass of water, followed by half a dram of tartaric acid in another half-glass of water. Percussion is performed with the patient in the dorsal position and also in the standing position. The lower margin of the liver is percussed in these two positions and the differences of level noted. Auscultation is of value chiefly in diagnosing pregnancy. The AUSCULTATION OF THE ABDOMEN 73 detection of the fetal heart-sounds, with a rate entire y different from that of the maternal pulse, is one of the absolutely distinctive signs of pregnancy. They are seldom discernible before the twen- tieth week, although certain observers report having heard them as early as the twelfth week. After the twenty-eighth week they should almost always be heard, if the child is alive, at any rate after repeated examinations. Hydramnios or thick abdominal walls may prevent the sounds from being transmitted to the ear. The sounds are usually heard over the child's back. Therefore, since left positions of the occiput are the most common, the heart- sounds are generally to be heard on a line drawn from the um- bilicus to the left anterior superior spine of the ilium. If they are not heard in this region the entire abdomen should be auscultated carefully. Changes in the position of the child may make the sounds audible at one time and inaudible at another, so that, should there be a failure to hear them, more than one exam- ination is to be made. Occasionally the child's position may be changed by manipulation for purposes of auscultation, so that its back comes against the abdominal parietes of the mother. Some plrysicians prefer direct auscultation, with the ear applied to the abdomen, to the mediate auscultation of the stethoscope. The binaural stethoscope is the best means for detecting the fetal heart-sounds. Its mouth should be moistened to do away with the noise generated by the slipping of the stethoscope on the skin. Generally the lightest possible pressure of the stethoscope on the skin is advisable, and to this end it is best to let it rest by its own weight and not to hold it with the fingers. The beating of the fetal heart (130 to 140 beats a minute) has been likened to the ticking of a watch under a pillow. To make the diagnosis sure, the rate should be counted for a minute, and thus it is differentiated from the maternal pulse, which is counted by the physician's finger on the mother's radial artery. The uterine souffle, or bruit so called, is an intermittent blowing- sound synchronous with the patient's pulse. It occurs not only in pregnancy but also in fibroids of the uterus and in other uterine and even ovarian tumors, and is probably due to increased circula- tion in enlarged blood-vessels. It is of no special diagnostic im- portance. The noises made by gas in the stomach and intestines are to be detected by auscultation. 74 PHYSICAL EXAMINATION In cases of peritonitis, one may determine by this means whether the peristaltic movements of the intestines are still present. Fric- tion sounds made by the rubbing together of roughened surfaces of tumors and adjacent structures may sometimes be heard, also the murmur transmitted from an abdominal aneurysm. Mensuration is a means of determining the rate of growth of an abdominal tumor. Exact measurements are impracticable because of the varying state of the bowels as to distention or relaxation, and also because of the yielding nature of the tissues and the mobility of the tumors. Nevertheless, much may be learned, in cases of chronic enlargement of the abdomen, by making careful measurements at repeated examinations several weeks or months apart. These are made partly with a tape measure and partly with a pelvimeter, and, for purposes of comparison, all subsequent measurements should be made under as nearly similar conditions as to time of day, time after menstruation, state of the bowels, etc., as possible. They should always be made with the patient in the same position and with all clothing loosened. Very light contact pressure with the tape or pelvimeter on the skin is best. The measurements to be taken are: — the greatest circumference; the circumference at the umbilicus ; the distance from the cnsif orm cartilage to the symphysis pubis; from the umbilicus to the an- terior superior spine of the ilium on each side; and the greatest diameter of the abdomen as measured with the pelvimeter, the patient standing, one point of the pelvimeter being placed over the most prominent portion of the abdomen, and the other over the spinous process of some definite counted sacral vertebra. Dr. Howard A. Kelly (" Medical Gynecology," p. 17) has devised a method for making permanent gauze records of abdominal tumors and displaced viscera. The patient being in the dorsal position, the physician outlines the tumor and the landmarks, such as anterior superior spines of the ilia, margins of the ribs, symphysis, and umbilicus, on the skin of the abdomen with an aniline pencil. If the skin does not take the pencil marks well, wet it with a little alcohol. Lay a plate of glass over the abdomen and on it place a piece of stiffened gauze (suisse, nainsook, or organ- die). The skin markings are visible through the glass. Reproduce them with a crayon pencil on the gauze. File away the gauze, labeled with the patient's name and the date, for future reference. Fig. 20. — A Permanent Gauze Record of an Abdominal Tumor. (Kelly.) 75 76 PHYSICAL EXAMINATION The X-rays in Diagnosis. — The X-rays are of supplementary diagnostic value in detecting stone in the ureter or kidney, and in determining ptosis of the stomach and intestines when these organs are filled with bismuth in suspension, also the presence of bone in tumors, — conditions important for the gynecologist to recognize. One skilled in the use of the Roentgen rays should be called in, as the neophyte is apt to be misled by the appearances seen in the photographic plates, and to put a wrong interpretation on their showings.