The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 1).

Date:
1845
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Licence: Public Domain Mark

Credit: The cyclopaedia of practical medicine: comprising treatises on the nature and treatment of diseases, materia medica and therapeutics, medical jurisprudence, etc., etc (Volume 1). Source: Wellcome Collection.

Provider: This material has been provided by the National Library of Medicine (U.S.), through the Medical Heritage Library. The original may be consulted at the National Library of Medicine (U.S.)

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    nate in the abdomen or within the chest. In the former case, we may expect the border of the ribs to be turned outwards; in the latter, inwards, with, probably, a bulging out of the ribs above this point. In some examples of enteritis and colica pictonum, the nature of the pain is very similar; but the form and size of the abdomen are often very different, and sufficient to discriminate the two diseases. In the one the abdomen is distended, in the other contracted. In some of the severer febrile affections of children, the form and size of the abdomen afford valuable signs to assist us in determining a question frequently of great diffi- culty, viz. whether the principal seat of the disease is in the internal mucous membrane or in the brain. The movements of the abdominal parietes are equally worthy the practitioner's attention. In many cases, these movements are characteristic of particular morbid states, and very considerably assist diagnosis, more especially when viewed together with the motions of the thorax. In peri- tonitis, enteritis, and other inflammatory diseases of the abdomen, likewise in great distension of the cavity from dropsy, pregancy, tumours, &c. &c. the parietes frequently remain motionless during respiration, while the movements of the chest are proportionally increased. The reverse obtains in analogous affections of the thoracic viscera. In cases in which both sides of the chest are rendered immovable by pain or physical incapacity, the abdominal movements are often increased to a remarkable extent. This is particularly observed m the case of double pleurisy, and also in asthma. In the paroxysms of this last affection, however, the form and movements of the abdomen are very different from those observed in the former. In asthma, the walls of the chest and the diaphragm are forcibly retracted, and cling to the imperfectly expanded lungs ; the abdominal muscles are also drawn in towards the diaphragm, but are at the same time forced into violent yet very limited action. II. Manual examination, or palpation.* By the simple touch, or application of the hand without pressure, we judge of the size, form, de- gree of sensibility, and temperature, of the exter- nal walls of the abdomen; and by touch, combined with pressure, (palpation,) we attempt to ascertain yet more accurately the condition of the internal organs. For the performance of the former part of the process, no other position of the patient is requisite but that which permits the free access of the hand to the surface of the abdomen ; but for the successful exploration of the internal parts, it becomes necessary that the patient should assume that posture which is most favourable for the relaxation of the abdominal muscles. This result is best obtained when the patient is laid on the back, with the head moderately raised and bent forwards on the breast, the arms extended by the sides, the thighs bent nearly at right angles on the trunk, the knees apart and turned outwards, and the feet resting on the bed in contact with each other. When so placed, the patient should be made to understand that he is to exert as little muscular effort as possible in retaining his posi- tion ; and we are to take care that such exertion * Palpation, the act of feeling.—Johnson. palpo, or palpor—palpatio. From is not forced upon him by any proceeding of ours which can be avoided. Sometimes the mere cold- ness of the hand, or even the simple touch, has the effect of throwing the abdominal muscles into action. Apprehension of pain from pressure has the same effect; and, likewise, misapprehension of our wishes respecting the condition of the ab- dominal parietes. In such cases we shall gene- rally find, after a short time, that the muscles relax gradually of their own accord, particularly if the patient's attention is diverted from our pro- ceedings ; or we succeed in our object by causing the individual to take a deep inspiration, to cough, or speak; by which means the state of tonic tension of the muscles is destroyed. Sometimes, however, we find it impossible to obtain a com- plete relaxation ; and this circumstance is of itself an important sign, and taken in conjunction with others is well deserving the attention of the prac- titioner. The patient, in these cases, seems in- stinctively to keep the muscles in a state of tension, in order to ward off the pressure from the parts beneath, some of which are inflamed, and there- fore morbidly sensible. This state of the muscles is often found in inflammation of the intestinal mucous membrane. It is of the more consequence to ensure the complete relaxation of the muscles, because their tension not merely prevents the accurate examina- tion of the parts beneath, but even occasions the muscles themselves to be mistaken for enlarge- ment or induration of the viscera. This remark applies more particularly to the recti muscles, the prominent bellies of which sometimes simulate pretty accurately the inferior border of an enlarged liver. We have often seen this mistake com- mitted at the first moment of exploration ; and, although generally, it has not always been cor- rected by further examination. The chief objects we have in view, in exploring the abdomen, are the following :—To ascertain, 1, its form and size; 2, its degree of tension or solidity ; 3, its temperature ; 4, its sensibility; 5, the presence or absence of tumours of the viscera, or new growths within the cavity ; 6,. the presence of fluids in the peritoneal sac ; 7, the nature and extent of the intestinal contents, &c. Some of these require much more attention than others. We shall only notice, with any degree of minuteness, such of them as are of most im- portance. The form, size, degree of temperature, tension and superficial sensibility of the abdomen, are ascertained by the simple application of the hand to the different parts of it in succession, or, at most, by the gentlest pressure. Some precautions, however, and some further attention, are requisite, in order to enable us to ascertain the true degree of temperature and sensibility of the parts. Owing to the singular infidelity of our sensa- tions as a measure of temperature, the greatest care is necessary to prevent our being misled in judging of the degree of heat from the testimony of our hands alone. Every body knows that our perceptions of warmth have relation as much to the preceding as to the actual sensation. We are apt to consider a body as warm, solely because it is of superior temperature to one previously touched ; and we may almost immediately be induced to reckon the very same substance cold after touching one that is of a temperature greatly