In percussing the stomach it is best to use finger percussion and to practise this procedure without much force. The object of this method of examination is to determine if possible the situation of the stomach. This organ, being as a rule partly filled with air, gives a tympanitic sound on percussion. It is, however, quite difficult to ascertain its exact size, as the large intestine may be filled with gas and also give the same tympanitic sound. For this reason Piorry2 suggested filling the stomach with water before resorting to percussion. The stomach when filled in this manner gives a dull sound, which can then be more easily differentiated from the tympanitic sound of the colon. The best way to examine the patient, according to Piorry, is to let him drink large quantities of water (about one litre) and to examine him when standing. The same method was frequently used afterward by Penzoldt.1 Dehio,2 who is also a strong advocate of this method, gives the water, however, in fractional quantities. The patient first drinks one-fourth litre of water and is then examined; he now takes the same amount, after which a second examination is made, and so on until the whole litre of water has been ingested.

The area of dulness that is found on the abdominal wall is marked each time with a lead pencil. It is necessary to note whether the lower limit of this area has extended considerably farther down after the addition of each portion of water. In dilated stomachs the lower limit of this area will be found quite far down below the navel, whereas in normal stomachs the lower limit will usually be above it. According to Boas3 the Dehio method furnishes a test of the tonicity of the gastric muscle. Boas asserts that in all cases where the lower limit of the dull area descends quickly after the further addition of the water there exists a kind of weakness or atony of the stomach.

1 J. Boas: "Diagnostik und Therapie der Magenkrankheiten," i., p. 75, Leipzig, 1894.

2Piorry: "Die mittelbare Percussion," Wurzburg, 1828.

As the results obtained by the above methods of percussion are not always sufficient and clear, several other means have been introduced which permit of a better recognition of the size of the stomach. The first, and so to speak clinical method, applied for this purpose is that devised by Frericbs1 and consists in filling the stomach with carbonic-acid gas. It is done in the following way: The patient first takes 2 gm. of sodium bicarbonate in a half-glassful of water, then 2 gm. of tartaric acid also dissolved in the same quantity of water. The sodium bicarbonate coming in contact with the tartaric acid in the stomach gives rise to the development of carbonic-acid gas, which distends the organ. The contours of the stomach are now sometimes visible through the abdominal wall. If this is not the case percussion is now applied in order to map out the tympanitic area. This method can certainly be very frequently applied and will prove useful to the practitioner. It has, however, two disadvantages, one being that the quantity of gas is sometimes insufficient, and the other that it might be too large and give the patient a feeling of pressure in the stomach.

In order to overcome these difficulties, Runeberg1 first made use of a tube and a rubber bulb attachment that allowed the forcing of air into the stomach. Here the quantity of air can be easily regulated, the stomach examined in different states of distention, and afterward the air removed through the tube. This is the method of examination most commonly applied and in daily use.

1 Penzoldt: "Die Mageuerweiterung." Erlangen, 1877.

2Dehio* "Zur physikalischen Diagnostik der mechaischen In-sufficienz des Magens." Verhandl. des VII. Congresses f. innere Medicin. 1888.

3 J. Boas: hoc. cit., p. 85.

Auscultatory Percussion

Auscultation by means of the stethoscope to the sounds produced by percussion has been practised by several observers, and recently warmly recommended by W. Pepper.1 The patient holds the bulb of the stethoscope and moves it about while the physician percusses and maps out the abdominal organs. The same method can also be executed with the phonen-doscope.

1 Frerichs: Cited from H. v. Ziemssen, "Klin. Vortrage," 1883, No. 12, p. 13.

2 Runeberg: "Ueber kunstliche Aufblahung des Magens und des Dickdarms durch Einpumpen von Luft." Dentsches Archiv f. klin. Medicin, vol. 84, p. 460.