ABDOMINAL PALPATION.
First described by Mercurius Scipio in 1•01, then by Dionis, Roederer, Smellie, and Baudelocque, abdominal palpation was not considered of much use to the obstetrician, when Wigand, in 1813, attempted to show its importance and to fix its rules. After him Joerg, Schmidt, Hohl, Velpeau, Devilliers, Chailly, and Hubert de Louvain, described this mode of exploration; but it was Mattei who first developed all its details and showed its importance, not only in the diagnosis of pregnancy, but also for the diagnosis of presentation and position, and for version by external manipulation. Unfortunately his researches were not received by ob stetricians with the attention that they deserved, and it is only during the past few years, in France at least, that palpation has been really studied and practised.
Tarnier first returned to it in 1865; he then resumed his researches at la Maternite, and Pinard continued them under his direction (1868). It is only since then that palpation has been practised in ordinary obstetrical routine in France; and it is really to Tarnier and his pupils Pinard, Chantreuil, and Budin that we owe our appreciation of the advantages of palpation and the precise indications which it furnishes.
Palpation permits us not only to appreciate the development of the uterus, and to prove the presence of the foetus in the uterine cavity, but it enables us to recognize the number, presentation and position of the foetus, in such a manner that abnormalities can be remedied, and the woman have a normal and physiological delivery, instead of a difficult one. Let us study the rules that are necessary for its practice.
The woman should lie upon her back, with legs and thighs stretched out, and with her arms extended along the sides of the body. In some cases it is advisable to flex the thighs upon the pelvis, and thus relax the muscles of the abdominal walls. [Careful abdominal palpation can only be made with the thighs flexed on the pelvis, in order to obtain as complete relaxation of the abdominal walls as is possible.—Ed.] It is not necessary, however, in most instances. The bladder and rectum should be empty.
The woman should only have her chemise on, and the decubitus should be as horizontal as possible. Pinard protests against the elevation
of the thighs—but we ourselves believe that it is of advantage in certain cases. The chemise is then drawn up to the epigastrium, and the rest of the clothes down to the symphysis—so that the abdomen is completely exposed without offending the patient's sense of modesty. The physician places himself on the patient's left side, at the level of the umbilicus.
He then lays one of his hands, which must not be cold, flat on the hypogastric region of the patient, and holds it there for a few minutes so as to get used to the first phenomenon, the contraction of the abdominal muscles on contact with the hand. At the end of a few seconds, their resistance gives way, and the hand can freely explore and outline the shape of the uterus.
In fact, the entire first exploration should be devoted to examining the presence and size of the womb. Beginning at the pubes, the hand is slowly carried upwards, and easily determines the height to which the uterus is elevated. Over the uterus the hand encounters a more or less marked resistance, according to the thickness of the abdominal walls; but this resistance ceases at the level of the fundus, and, by plunging the hand deeply into the wall of the abdomen, we can grasp the fundus itself. When the uterus is far developed this first exploration often permits us to appreciate the presence of more or less mobile solid parts contained in a liquid.
If then the two hands be placed flatly upon the sides of the tumor, there can often be felt an alternate displacement of the solid body from side to side as alternating pressure is made. The displaced body strikes the opposite wall with a kind of shock. This is known as abdominal ballottement. Sometimes these shocks occur of themselves, the hands remaining motionless, and are due to movements of the foetus; they may be due to movements of the whole body, or of only parts of it, and con stitute what Pajot calls the foetal shock, which is also appreciable, as we shall see, by auscultation. Thus, by the simple application of the halide, we have been able to appreciate the volume of the uterus, and the presence of a living foetus.