inter- val between uterine contractions. OVARIES. 149 In protracted labors auscultatioii is of value in indicating to us the time for manual or instrumental interference to save the life of the child. The indications of danger to the child are feebleness, or excessive frequency of the foetal pulsation ; irregularity in its rhythm ; absence of the second sound ; its complete cessation during uterine contraction, and the slow- ness of its return in the interval. Irregularity and feebleness are the most threatening to the life of the child. <Callout type="warning" title="Irregular Heartbeat">When the foetal heart is irregular or weak, immediate medical intervention may be necessary.</Callout> When the sound of the foetal heart is heard it is a positive proof of preg- nancy ; but its absence is not always proof that pregnancy does not exist, for the foetus may be dead, and in some rare cases the sounds may exist and be quite inaudible for a time, and then appear. This phenomenon is not easily accounted for. Tumors of the Uterus, whether developed on its surface, in its walls, or within its cavity, give rise to enlargement of the organ, which causes it to occupy a position coiTesponding to that occupied by a gravid uterus. The position and extent of these enlargements are determined in the same manner as we determine the size and position of the uterus in pregnancy. Deposits in its walls or on its sui-face give rise to nodules which feel through the abdominal walls like hard balls, vary- ing in size and shape, seldom occurring singly. The whole mass can usually be moved fi'om one side to the other. The connection of these tumors with the uterus, as determined by the uterine sound, leave little doubt as to their true character, and by this means we readily distmguish them from all other abdominal tumors. Ovaries.— The ovaries in a normal state lie in the pelvic cavity, and their position cannot be determined by physical exploration ; but when they become the seat of those forms of disease which cause their enlargement, and have attained such dimensions that there is no longer room for them in the pelvic cavity, they ascend above the brim of the pelvis, and occupy 150 PHYSICAL DIAGNOSIS. more or less space among tlie abdominal organs. As they pass out of the pelvis, they are first noticed in the right or left iliac region, according as the right or left ovary is affected, and they are then recognized as ovarian tumors. After, be- fore these ovarian enlargements have attained sufficient size to attract the attention of the patient, they will have reached a central position in the abdominal cavity. They are of more frequent occurrence than aU other forms of abdominal tumors ; Fig, 20. Diagram showing the Gradtutl Enlargement of a Tumor of the Right Ovary till it fills a large portion of the Abdominal Cavity forcing the Intestines into the Lumlar Regions.— 'Qmani. and their existence is determined almost exclusively by the physical signs which they furnish. Inspection. — In the early part of their development an un- even projection or prominence of one part of the abdomen will disclose the seat of the tumor, occupying usually the iliac or lumbar region of one side, and extending upwards to or be- yond the umbilicus ; while in more advanced cases no inequal- ity will be visible, but the rounded form of tlie abdomen, while the patient lies on her back, offers a strong conti'ast to the flattened oyal appearance of ascites, or the central rounded form of a uterus distended with pregnancy. Palpation, — Ovarian tumors when small have a firm, elastic feel, but when large they are soft and fluctuating. In some cases, by passing the hand gently over the abdomen, the ex- tent of the tumor will be readily appreciated. At other times the limits of the tumor cannot be ascertained by gentle palpa- tion, for it occupies the whole of the abdomen excej)t the con- cavity of the diaphragm. In such cases, by making firm, but not forcible pressure on various parts of the abdomen, we often detect at once a general sense of fluctuation, and ascer- tain inequalities which neither the eye nor the hand when passed gently over the surface will enable us to detect ; and sometimes if the abdomen is not tense, we can feel masses which convey the impression of more or less flattened or spherical bodies attached to the inside of a fluctuating tumor. In some cases the sense of fluctuation is very indistinct ; in others, it is even more evident than in cases of extensive ascites. Percussion. — The sound elicited on percussion is flat over that portion of the abdomen where the tumor comes in con- tact ^ith the interior surface of the abdominal wall ; while at the sides and above where the intestines have been pushed aside and upwards by the tumor, the percussion sound will be tympanitic ; by this change in the percussion sound we are enabled to mark out the boundaries of the tumor. Differential Diagnosis. — Ovarian tumors may be confounded in their diagnosis with uterine enlargements, as pregnancy, fibroid tumors of the uterus, etc., ascites, hydatids of the omen- tum, /cecal accumulations in the intestines, and enlargements of the liver, spleen, and Iddneys. They are distinguished from pregnancy by a stethoscopic 152 PHYSICAL DIAGNOSIS. examination of the tumor,
Key Takeaways
- Ovarian tumors can be detected through physical signs such as an uneven projection or prominence in the abdomen, and by palpation.
- The absence of foetal heart sounds does not always indicate non-pregnancy; it could also mean a dead foetus.
- Differential diagnosis is crucial to distinguish ovarian tumors from other conditions like ascites and uterine enlargements.
Practical Tips
- Regularly check for any unusual lumps or changes in your abdomen, especially if you are pregnant or have a history of gynecological issues.
- If you suspect an abdominal tumor, seek medical attention immediately to undergo proper diagnosis and treatment.
- Be aware that the absence of foetal heart sounds does not definitively indicate non-pregnancy; always consult with a healthcare professional.
Warnings & Risks
- Irregular or weak foetal heartbeat can be a sign of danger to the child, requiring immediate medical intervention.
- Ovarian tumors may mimic other conditions like ascites, making accurate diagnosis challenging without proper physical examination and auscultation.
- Ignoring persistent abdominal pain in the lumbar region could indicate an abdominal aneurism, which is life-threatening.
Modern Application
While many of the techniques described in this chapter are now performed with more advanced medical equipment, the principles of physical diagnosis remain relevant. Modern ultrasound and imaging can provide clearer images, but understanding the signs and symptoms through palpation and auscultation remains a critical skill for initial assessment.
Frequently Asked Questions
Q: How can one distinguish between ovarian tumors and ascites during a physical examination?
Ovarian tumors typically project forward in the center of the abdomen, while ascites causes uniform abdominal enlargement. Additionally, the percussion sound over an ovarian tumor is dull as high as it extends, with tympanitic resonance below, whereas ascites results in flatness at the most dependent part of the abdomen.
Q: What are the signs that indicate a foetal heartbeat might be weak or irregular?
Weak or irregular foetal heartbeats may include feebleness, excessive frequency, irregular rhythm, absence of the second sound, complete cessation during uterine contraction, and slow return in the interval between contractions. These signs require immediate medical attention.
Q: Can you distinguish between an ovarian tumor and a hydatid cyst through physical examination?
Ovarian tumors are usually more tender on firm pressure, have a tympanitic percussion sound over them, and can be pushed upwards or from right to left. Hydatid cysts, however, do not produce these signs; they are typically detected by their uneven surface and tympanitic percussion sound.