Palpation is the most important procedure available among the methods of examination in abdominal diseases. It is best performed in the recumbent position of the patient, the head being slightly raised and the abdominal muscles relaxed as much as possible. In order to effect this the room must be of a comfortable temperature and the hands of the examiner warm. If the patient is fidgety and contracts his abdominal walls, it is necessary to talk to him and to draw his attention away from the examination. I have often noticed a great relaxation of the muscles during an expiration following a deep inspiration. Whenever, therefore, it is difficult to obtain relaxation of the abdomen I tell the patient to take a deep inspiration and then make use of the following period of expiration for palpation. If all these means fail to relax the abdominal muscles, palpation may be tried in a warm tub bath, as first recommended by Chlapowski, or under chloroform narcosis. In cases of great diagnostic importance the latter method is certainly preferable. In palpating the abdomen it is advisable first to examine with the entire palm of the hand, applying very little pressure, thus determining the state and consistency of the abdomen.

The hand may thus be passed over the entire abdominal surface from one place to another. This having been done, palpation is then performed with a trifle more pressure, the finger tips being used for this purpose. The latter procedure serves for exploring a more circumscribed area. Finally, deep palpation is practised for which considerable pressure may be required.

Palpation aids us in discovering the position of some of the abdominal organs. With regard to the intestine the following portions are often accessible to this method of examination: the csecum and part of the ascending colon, the transverse colon, and the sigmoid flexure. In some instances the descending colon above the sigmoid flexure can also be palpated, especially if it is filled with hard scybala. The jejunum and ileum filling most of the lower part of the abdominal cavity (from the navel downward) cannot normally be separately outlined.

For the detection of tumors in the abdomen palpation is of great service. By means of it we gain information with regard to their size, shape, and consistency. An uneven protuberant surface is characteristic of malignant growths, while an even surface is more often found in benign neoplasms or in intussusception. A fecal tumor can be recognized by indentations made by pressure with the fingers. Sometimes after such pressure it is possible to notice for a moment, when raising the finger, a slipping off of the intestinal wall from the fecal mass. This phenomenon, first described by Gersuny 1 under the name of "Klebesymptom," I have observed quite frequently and consider of practical value.

Another important object of palpation is to ascertain whether there is tenderness or pain on pressure. While strong pressure exerted upon the intestine through the abdominal wall even normally elicits an unpleasant sensation, there is, however, no distinct pain connected with this act. Tenderness on slight pressure is often present in inflammatory conditions of the bowels and also in ulcerative processes. A circumscribed pain on pressure is present in the appendicular region (McBurney's point) in appendicitis, especially in the acute form. In chronic appendicitis the pain may be elicited only upon very strong pressure. In ulcerations of the bowel there may be also one or several circumscribed areas very painful to pressure. In pains due to a purely nervous affection of the bowel pressure may afford relief. If a mere touching of the abdomen elicits pain, it is a sign either of an extensive inflammatory process within the bowel or of peritonitis.

1 Gersuny: Wiener klinische Wochenschrift, 1896, No. 40.

Palpation in the form of tapping occasionally produces a splashing sound (clapotage) over some portions of the bowel. The splashing sound can be elicited over the colon only when it is filled with liquid or semi-liquid matter and gas. It can be discovered off and on either in the caecum and in the portion of the bowel immediately above it or in the sigmoid flexure. In the small intestine clapotage can be obtained only in the dilated portion of the gut above a stricture. Boas 1 first suggested the method of filling up the bowel with from 500 to 600 c.c. of water and then examining for the splashing sound along the colon. When the patient has been thus prepared, clapotage can be produced in the sigmoid flexure; and by having the patient turn on his right side, it can occasionally be produced in the transverse colon, and finally in the caecal region. In cases of atony of the bowel Boas was able to evoke the splashing sound even after the injection of only 200 to 300 c.c. of water. Friedenwald 1 has also practised the same method with advantage.

Whenever the splashing sound can be produced in the colon it serves the purpose of determining the situation of this organ.

Finger Cot

Fig. 13. - Finger Cot.

1 Boas:"Diagnostik und Therapie der Magenkrankheiten, " Theil i., 1897, 4te Auflage, p. 105.

The rectum is best palpated with the index finger well oiled or smeared with vaseline or encased in a rubber cot (Fig. 13) and anointed in the same way. The condition of the anus and the lower portion of the rectum can be advantageously investigated with the finger. The examination may be made either in the recumbent posture of the patient, in the side or knee-elbow position, or in the standing position. In the latter instance it is well to have the patient exert downward pressure upon the rectum. Hemorrhoids, polypi, and malignant growths can thus be occasionally discovered. In cases in which there is a suspicion of malignant growths involving portions of the colon not accessible either to palpation by the finger or inspection with the proctoscope, examination with the entire hand in chloroform narcosis can be tried as first practised by Simon.2 After dilating the anal sphincters, the entire right hand and the arm are inserted into the bowel through the anus, and thus the higher portions of the colon palpated with the fingers.

This method can be rec-ommended only in cases of extreme importance, as such an examination is liable to produce unpleasant symptoms, as, for instance, incontinence of the rectum, tearing of the mucous membrane, etc.

Cylindrical Bougies

Fig 14a. Fig. 15. Fig. 14b.

Figs. 14a and 146. - Cylindrical Bougies.

Fig. 15. - Olive-Point Bougie.

1 J. Friedenwald: Medical News, 1894.

2 Simon Verhandlungen der deutschen Gesellsch. f. Chirurgie, 1871, and Deutsche Klinik. 1872

Palpation of the rectum by means of sounds is performed whenever there is suspicion of a stricture involving portions of the bowel not accessible to examination by the finger. For this purpose either bougies (see Figs. 14 and 15)), or, still better, rectal tubes of various calibre may be employed. Kuhn 1 has recently recommended the use of tubes provided with a metal spiral. He believes that these penetrate the colon farther up without bending. His statements have, however, not as yet been corroborated.