Complete Text (Part 11)

of the thorax. * First. Thoracic diseases involve in their diagnosis the ex- amination of only one or two organs, or their appendages ; while an abdominal affection may require for its diagnosis the examination of ten or twelve organs. Thus a tumor in the left side may be either an enlarged mesenteric gland, or it may be connected with the stomach, spleen, kidneys, ovaries, or uterus ; or it may be a hernia, an abscess, a hydatid cyst, an aneurism, or, lastly, only a lump of faeces. Second. The action of the thoracic organs is regular and rhythmical, and their contents unvarying ; while the action of the abdominal viscera is often in-egTdar and intermittent. An abdominal organ may also at one time be greatly distended with contents, and soon after be empty ; when filled, its con- tents may be soHd, fluid, or gaseous, or all these together. The lungs and heart contain respectively the same quantities of air and blood during every five minutes of ordinary life, but the stomach and bladder can never remain long in one condi- tion, either full or empty. Third. The abdominal organs are packed loosely in a cavity with loose walls. They therefore can be increased or de- 120 PHYSICAL DIAGNOSIS. creased in size, so as to alter wholly their relations to their fellow organs. Thus the uterus, usually the smallest, will, in fulfilling its natural function, become much the largest of all, tiU it crowds even the thoracic organs ; moreover, in disease, a single ovary may sweU into a sac which ■uill fill entirely the abdominal cavity. These constitute the chief difficulties in the physical examination of the abdomen, and they must always throw a certain degree of doubt upon all physical diagnosis directed, to this part of the body. To facilitate our examinations, and to render our inferences more certain, it is weU to divide the abdomen into regions by passing imaginary planes through the body. The divisions which have been proposed by different observ- ers vary somewhat. The following, proposed by Dr. Bright, wiU, I think, be found most useful : The abdomen may be divided into three general zones, — the epigastric, the umbilical, and the hypogastric. The Epigastric zone is bounded above by the diaphragm, below by a horizontal plane passing through the anterior ex- tremities of the tenth rib on either side. In a well-formed chest the cartilage of the tenth rib on either side offers a pro- jection at its lower convex border, which can be felt without difficulty ; a horizontal plane carried backwards through these points will pass between the bodies of the first and second lumbar vertebra. This zone is subdivided into the epigas- tric, and the right and left hypochondriac regions, which cor- respond to the spaces bounded by the false ribs. The Umbilical zone is bounded above by the lower boundary of the epigastric, and below by a horizontal plane passing through the anterior and superior spinous processes of the iha ; this plane, if carried backwards, will pass between the second and third sacral spines. The Hypogastric zone is bounded above by the lower boundary of the umbilical zone ; below, in the centre, by the TOPOGRAPHY OF THE ABDOMEN. 121 upper margin of the pubes ; on either side by Ponpart's liga- ment. This zone occupies the whole cavity of the true pelvis. The umbilical and hypogastric zones have each three subdivisions made by two vertical planes, passing backwards through the spinous processes of the pubes and the points on the tenth ribs abeady alluded to. The subdivisions of the umbilical zone thus produced are termed the central or um- bilical, and two lateral, or the rigJit and left lumbar. The sub- Fig. 17. Diagram shoviing the different Regions of the Ahdomm, and the Organs contained in each, wMch are visible on the removal of the Abdominal Walls. divisions of the hypogastric thus produced consist of the middle or j^^ibic, and the lateral or right and left iliac. The organs contamed m these regions in health are as follows : The Epigastric region contains the whole of the left, and a 122 PHYSICAL DIAGNOSIS. part of the right lobe of the liver ; the gall bladder ; the pyloric orifice of the stomach ; the commencement of the duodenum ; a portion of the colon ; the pancreas ; the aorta, and the csehac axis : and I would earnestly recommend to you, gentlemen, to study both here and in the other regions the position of the parts relatively to one another. The Right Hypochondriac region contains nearly the whole of the right lobe of the liver ; the angle of the ascending and a portion of the transverse colon ; the greater part of the duo- denum ; the renal capsule, and the upper portion of the right kidney. The Left Hypochondriac region contains the rounded car- diac portion of the stomach, at all times, and a very large por- tion of the organ when distended ; the left angle of the colon ; the spleen, and a small portion of the left kidney, with its renal capsule. The Umbilical region is chiefly occupied by a portion of the arch of the colon, the omentum, and the small intestines. It contains, likewise, the mesentery and its glands, the aorta, and the vena cava. The Right Lumbar region contains the caecum, the ascend- ing colon, the lower and middle portion of the kidney, and a portion of the ureter. The Left Lumbar region is occupied by the descending colon, the left kidney, and the ureter. The small intestines likewise occupy the lumbar region on either side. The Pubic or Hypogastric region contains in children, the urinary bladder, with portions of the ureters (also in adults if they be distended), the convolutions of the small in- testines, and in the female, the uterus and its appendages. The Right Iliac region contains the " cul-de-sac " of the caput cob ; the vermiform process, and the iliac vessels. The Left Iliac region contains the sigmoid flexure of the colon, and the iliac vessels of that side. EXAMINATION OP THE ABDOMEN. 123 Methods Employed in the Physical Examinations of the Abdomen. They are the same, with the exception of succussion, as those practised in exploration of the thorax. But they differ in their relative importance. In thoracic examinations, aus- cultation is the most important method ; while in abdominal examinations, auscultation is only employed in determining the existence of aneurisms and of pregnancy. Percussion and palpation are the means by which we gain the most use- ful information concerning the contents of the abdominal cavity. Before considering the signs which indicate the changes occurring in the different affections of the abdominal organs, I will briefly notice the different methods of exploration. Inspection. — By it we note alterations in the shape and movements of the abdomen. It is most satisfactorily per- formed with the patient lying on the back, with the thighs shghtly flexed. In health, the abdomen is of an oval form, marked by elevations and depressions corresponding to the abdominal muscles, the umbilicus, and in some degree by the form of the subjacent viscera ; it is larger relatively to the size of the chest, in children, than in adults, more rotund, and broader inferiorly, in females than in males. Alterations in its shape due to disease, we find to consist, First, in enlargement ., which may be general and symmetrical, as in ascites ; or partial and irregular, from tumors, hypertrophy of organs, as the Kver and spleen ; or from tympanitic disten- sion of portions of the intestines by gas, as of the colon in typhoid fever. Second, it may be retracted as in extreme emaciation, and in several forms of cerebral disease ; es- pecially is this noticeable in the tubercular meningitis of children. The normal movements of the abdominal walls are con- 124 PHYSICAL DIAGNOSIS. nected with the respiration, so that thej bear a certain rela- tion to the movements of the chest walls, being often in- creased when the latter are arrested, and vice versa. Thus abdominal movements are increased in pleurisy, pneumonia, pericarditis, etc. ; but decreased or wholly suspended when disease causes abdominal pain, or in peritonitis. Not imfrequently, when inspecting the abdomen, a distinct pulsation will be visible in the epigastric region, which fre- quently is mistaken for aneurism. The superficial abdominal veins are also at times visibly enlarged, radicating an obstruc- tion to the current of blood either in the portal system, as in cirrhosis, or in the vena cava. Mensuration is mainly useful in determining the exact in- crease or decrease of abdominal dropsies, visceral enlarge- ments, and tumors. It is performed by means of a graduated tape. Palpation. — This method of exploration often furnishes important information. It may be performed with the tips of the fingers, with the whole hand, or with both hands, and the pressure may be shght or forcible, continuous or alternate. In order to obtain the greatest amount of information by pal- pation, the patient should be placed in a horizontal position, with the head sHghtly raised and the thighs flexed ; some- times it is necessary to place him in a standing position, or leaning forward. Indications Furnished by Palpation. — By it we can de- termine the size and position of the viscera, the existence of tumors and swellings, whether they are superficial or deep, large or small, hard or soft, smooth or nodulated, movable or fixed, solid or fluid, and whether or not they possess a motion of their own. We can also ascertain if tenderness exist in any portion of the abdominal cavity, and if pain is increased or relieved by firm pressure. Percussion. — In the performance of abdominal percussion, EXAMINATION OP THE ABDOMEN. 125 the patient should be placed in the same position as for pal- pation, and the percussion should be for the most part mediate. In exploring the abdomen by means of percussion, the plessimeter (the finger being the best) should first be placed immediately below the xiphoid cartilage, pressed firmly down and carried along the median line towards the pubes, striking it all the way, now forcibly, now gently. The differ- ent tones which the stomach, colon, and small intestines fur- nish will be distinctly heard. The percussion should then be made laterally, alternately to the one side and then to the other, until the whole surface is percussed (Bennet). In this manner the different percussion sounds of the stomach, large intestines, small intestines, and the sohd viscerae will be readily distinguished. Thus the percussion sound elicited over a healthy abdomen may be dull, fiat, or tymjpanitic. Over the centi'al portion of the liver, spleen, and kidneys, the percus- sion sound is flat ; over that portion of either of these organs where they overlap the intestines or stomach it is dull, with a tympanitic quality. Over the stomach and intestines it is tym- panitic, more so over the former than the latter. When fluid occupies the abdominal cavity, over the fluid the percussion sound will be flat. A distended bladder or uterus ; an enlarged liver, spleen, kidney, or mesenteric gland ; ovarian, aneurismal, and other tumors, are recognized and their limits determined by the unnatural and increased area of the percussion flatness ; while, on the other hand, gaseous distension of the stomach or intestines is recognized by the increased area of tympan- itic percussion. Auscultation. — For the physical exploration of the abdo- men, auscultation is only of service, as we have said before, in the diagnosis of aneurisms, and in detecting the pulsations of the foetal heart, and the utero-placental murmur in the preg- nant state. Our examinations of the abdominal viscera are sometimes in- 126 PHYSICAL DIAGNOSIS. terfered with and rendered uncertain by clianges tliat occur in the abdominal walls. Generally, the abdominal walls are sufficiently thin, soft, and movable for us to determine with considerable accuracy the situation and condition of the con- tained organs : if, however, everything is masked by layer upon layer of fat, as in some cases of obesity, abdominal ex- aminations will be unsatisfactory. An (Edematous condition of the abdominal walls, as in Bright's disease, may also prevent us from ascertaining the condition of the viscera. When this occurs, the surface of the abdomen presents a smooth, even, shining, waxy appearance, and pits on firm pressure. Su- perficial abscess of the abdominal walls also occurs occasionally, which interferes greatly with the exploration of the abdominal cavity. You can recognize these by the circumscribed bulg- ing, by tenderness on shght pressure, by the redness of the surface, and by the characteristic fluctuation of a superficial abscess. The abdominal muscles are sometimes abnormally devel- oped, or unnaturally rigid as in tetanus, rheumatic inflamma- tion, and in the early stage of peritonitis, and this somewhat interferes with our examinations. jyiseased Conditions of the Peritoneum. Under this head may be included the various resiilts of in- flammatory action, ascites, etc. They all give rise to more or less abdominal enlargement. Acute Peritonitis. — By inspection we recognize in acute peritonitis either a diminution or an entire suspension of ab- dominal respiration, the breathing becoming entirely thoracic. The abdomen enlarges, becomes unnaturally tympanitic, and there is marked tenderness on flrm pressure. The compara- tive results of firm and slight pressure is one of the sti'ong diagnostic marks of peritoneal inflammation. Chronic Peritonitis is ahnost always connected with tuber- PERITONEUM. 127 cular and cancerous deposits in the substance and over the free surface of the peritoneum ; and in addition to the tym- panitic distension of the abdomen, and the tenderness on firm pressure noticed in acute peritonitis, fluid accumulations take place in the peritoneal cavity. Ascites. — A collection of fluid from any cause in the peri- toneal cavity is termed ascites. Inspection. — The abdomen is always uniformly enlarged, and the movements of the abdomen in respiration are either suspended or limited to the epigastric region. The superficial abdominal veins, if the ascites depend upon disease of the liver, will often be found enlarged. Palpation. — If the palmar surface of the hand be applied to the side of the abdomen at the level of the fluid, and hght percussion be performed on the opposite side, a sense of fluc- tuation will be communicated to the hand. Percussion gives flatness at the lower and most depending portion of the abdomen ; while at the upper portion above the level of the fluid, there is a drum-like, tympanitic resonance. When the patient is in the erect posture, the tympanitic reso- nance is confined to the epigastrium and upper portion of the umbihcal region. If in a recumbent posture, the tympanitic resonance will extend into the hypogastrium ; if placed on either side, the lumbar region of the opposite side becomes tympanitic. Other abnormal changes that occur in the peri- toneum are connected with deposits, that may be classed under the head of abdominal tumors. LESSON XIV. Physical Siffns of the c±bnormat Chajiges in the different A.bdominal Orffcins. — Stomach. — Intestines. — Hrer. — Spleen. Stomach. — When this viscus is empty, or not distended with gas or food, there is on insjiection no visible prominence to indicate its position, nor does j^cdpcition furnish us any in- formation as to its condition. Percussion gives a metallic or tympanitic resonance which enables us to distinguish it from the surrounding viscera. The line of dulness which marks the lower border of the liver and the inner border of the spleen determines the upper and lateral boundaries of the stomach. To ascertain the lower border, percuss gently downwards from this line of dulness, until a slight change in the percussion sound indicates that you have reached the transverse colon (see fig. 17). Opposite the inner border of the seventh rib the cardiac orifice or ex- tremity of the organ is situated. At a poiat a little below the lower border of the liver, within a line drawn from the right nipple to the umbilicus, the pyloric orifice of the organ is situ- ated. The lower margin of the great " cul-de-sac " is found generally near the umbilicus. Diminution in the size of the stomach cannot be recognized by physical exploration. An increase in size or distension of the stomach may occur from an accumulation of gas, from large quantities of fluids or solids taken into the stomach ; or it may be enlarged within circumscribed spaces from cancer- ous deposit ia its walls. INTESTINES. 129 Gaseous or Tympanitic distension of tlie stomacli is rec- ognized by an increase in the area of the characteristic tym- panitic resonance of the organ. A distended condition of the stomach from food or drink is recognized by an absence of the normal resonance, and by a continuation of the dull per- cussion of the liver and spleen downwards to the umbihcus. A moderate amount of fluid or soHd in the stomach can be determined by a limited area of duhiess corresponding to the " cul-de-sac " of the organ. Cancer of the Stomach most frequently has its seat at the pyloric extremity of the organ ; but in whatever portion of the organ it may be developed, it can be recognized by circum- scribed dulness on percussion, where in health, when the stomach is empty, we should have tympanitic resonance. The percussion dulness elicited over the cancerous mass, how- ever, has a hollow character which is readily distinguished from the flat percussion sound of a sohd organ. By palpation a nodulated mass is readily detected, corre- sponding to the area of percussion duhiess, which is movable, easily grasped, and readily separated from the surrounding viscera. These signs, taken in connection with the attendant symptoms, are almost always sufficient for a positive diagnosis. Intestines. — In a normal condition the large intestine fur-