Auscultatory Percussion and Allied Methods 
oi Physical Diagnosis. 
A. L. BENEDICT, A.M., M.D., 
BUFFALO, N. Y. Auscultatory Percussion and Allied Methods 
ol Physical Diagnosis. 
A. L. BENEDICT, A.M., M.D., 
BUFFALO, N. V. [Reprinted from The Medical and Surgical Reporter, April 27 and June 1,1895.] 
AUSCULATORY PERCUSSION AND ALLIED METHODS 
OF PHYSICAL DIAGNOSIS.* 
A. L. BENEDICT, A.M., M.D., BUFFALO, N. Y. 
The value of acoustics in the investiga- 
tion of the viscera is such that the term 
"Physical Diagnosis" without qualifica- 
tion, is usually understood to refer to 
methods in which, by the senses of touch 
and hearing, cognizance is taken of the 
vibrations of the various internal organs. 
It is important to note that we have to 
deal with sounds produced in at least three 
different ways: 
1. Localized vibrations due to the fric- 
tion of a fluid. 
2. Localized vibrations produced by the 
mutual friction of solid tissues. 
3. Resonant vibrations, by the thrill of 
some anatomical or pathological unit. 
Under the first head, may be considered 
the auscultation of breath-sounds, of the 
circulatory organs (including the heart, 
both foetal and adult, the umbilical, uter- 
ine and other large arteries, the cervical 
and other veins, the thyroid body, aneur- 
ysms, the cerebral pulse), of the gastro- 
intestinal tract (with special reference to 
direct and regurgitant murmurs at the 
cardia), and, theoretically, at least, of the 
superficial urinary organs. It is possible 
that urethral stricture might be located by 
the stethoscope and that, in certain lesions 
of the renal pelvis when the relative flow 
of pus or urine through the ureters is of 
diagnostic importance, a special instru- 
ment for vaginal auscultation may prove 
to have a practical value. 
Frictions of the second class occur nor- 
mally only from the movements of the 
foetus in utero. They are heard under 
more or less abnormal conditions in joints, 
at the line of fracture of bones, sometimes 
in tendon- sheathes-a case might be cited 
in which the long tendon or the biceps 
was involved-and in the true serous sacs, 
especially the pericardium and the pleurae. 
Widely different in principle from these 
local frictions, is the resonant thrill of an 
organ. The so-called muscular quality of 
the heart-sounds is due to such a vibra- 
tion but, manifestly, it cannot be separated 
in practice from the tap of the valve-leaf- 
lets. Three methods are commonly used 
in the investigation of resonance; auscul- 
tation of voice sounds, in which we judge 
of the condition of the lung and pleura by 
the conduction of vibrations to the sur- 
face, percussion and palpation, by which 
last we seek to appreciate acoustic vibra- 
tions vicariously by the sense of touch. 
In ordinary percussion, also, tactile sensa- 
tion is, with many persons, an aid to the 
appeciation of resonance. While the tyro 
or the clinician in his demonstrations 
to a class, aims merely to produce a sound 
and may prefer an artificial plexor and 
pleximeter, an experienced diagnostician, 
making an examination for his own bene- 
fit, almost invariably uses his fingers and 
depends largely on tactile perception of 
the vibrations produced. Much may be 
learned in this way from a perfectly silent 
percussion. 
It has been implied that sounds pro- 
duced by throwing an organ into vibration 
are heard over the whole organ. This is 
true providing all parts of the organ have 
the same consistency, as in health but, in 
disease, some part of an organ may be- 
come so altered as to vibrate quite differ- 
ently from the normal structures. Thus, 
in lobar pneumonia there is commonly, 
dullness amounting sometimes to flatness,' 
in the lower lobe of the right lung. The 
writer remembers a case of moderately 
severe catarrhal pneumonia, in which a 
zone of infiltration in the middle of the 
left lung posteriorly, was so sharply de- 
fined from resonant lung above and below 
as to suggest the possibility of a trilobate 
division. The significance of the words 
"anatomical or pathological unit" is now 
apparent. Except in the case of the 
lungs, disease rarely affects an organ in 
such a way as to cause one portion to vi- 
brate differently from another; hence in 
the investigation of the heart, liver, spleen, 
stomach, intestine and bladder we expect 
* Being the Merritt H. Cash Prize Essay of the 
Medical Society of the State of New York, 1895. 3 
to gain only such information as depends 
on the question of size-or, in the case of 
the hollow organs, fullness. A solid 
tumor of the stomach or bowel affords a 
marked contrast to the normal tympany, 
but only when of such size and location 
as to be quite readily palpable. 
The ordinary observer, in the use of 
percussion, recognizes two degrees of res- 
onance-pulmonary and gastro-intestinal 
or tympanitic; and two degrees of flatness, 
absolute flatness and dullness. Nicer dis- 
crimination may be made by an acute ear, 
as in the diagnosis of pulmonary cavities. 
The gastric tympany is usually about a 
semitone lower in pitch than that of the 
colon, while the tympany of the small in- 
testine is still higher; pitch in general 
varying inversely as the calibre of the re- 
sonant body. 
By ordinary percussion, no distinction 
can be made between the resonance of the 
two lungs; hepatic, splenic and cardiac 
dullness are alike and, practically, it is 
usually impossible to mark the exact 
boundaries of the heart and the liver where 
they approach. Moreover, the overlap- 
ping of organs obscures diagnosis and, in 
particular, the right border of the heart 
cannot be defined by percussion except by 
an expert; while distended intestine may 
lead to the erroneous conclusion that the 
liver is contracted and splenic dullness 
may be altogether concealed. 
The object of this paper is to call atten- 
tion to methods of physical examination 
with which the majority of the profession 
are unfamiliar and, for part of which, 
some originality is claimed. These meth- 
ods all depend upon the same principle- 
the setting up of vibrations in an organ 
and, by excluding indirect conduction of 
sound, locating the boundaries of the or- 
gan by auscultation of its resonance. Per- 
haps a homely comparison will enable us 
better to appreciate the problem and the 
means of solution. Suppose one wishes to 
trace a system of pipes through a building. 
If the pipes are of different sizes or if they 
convey different fluids, for instance gas 
and water, ordinary percussion will elicit 
notes of so different quality that the mat- 
ter is easy. If, however, the pipes are of 
the same size and filled with gas, no 
amount of percussion will afford an idea of 
their continuity unless we listen first at 
one pipe and then at another and note 
that, in one case, the sound of tapping is 
conducted directly to the ear while in an- 
other only a diffuse noise is heard. 
In the case of structures so close to- 
gether as the viscera, we must limit the 
conductivity by some form of aural trans- 
mitter-of which the stethoscope is the 
commonest example-and it is this aid to 
percussion that has given rise to the term 
auscultatory percussion. The term is ob- 
jectionable since auscultatory by no means 
implies the use of an instrument. Stetho- 
scopic percussion would be a preferable 
term, although the language critic might 
object that a stethoscope is literally a 
chest-looker, while its use is not confined 
to the chest and it is only metaphorically 
a looker. Not to quibble over a question 
of nomenclature, it must be recognized 
that auscultatory or stethoscopic percus- 
sion is not merely ordinary percussion 
aided by an instrument. Ordinary per- 
cussion seeks to elicit a characteristic note 
whose pitch and quality shall enable us to 
distinguish one anatomical or pathologi- 
cal unit from another of different struct- 
ure. In auscultatory percussion, on the 
other hand, almost no attention is paid 
either to pitch or quality. We simply 
endeavor to locate the boundaries of an 
organ by noting when the sound of per- 
cussion becomes suddenly feeble. So long 
as both plexor and stethoscope are over the 
same organ, the sound conveyed to the 
ear is peculiarly sharp and penetrating. 
As soon as either passes the limits of the 
organ, the sound becomes dull and dif- 
fused. It makes no difference in tracing 
the pipes through a house, whether the 
listener is in the attic and the percussor 
in the cellar or vice-versa. Analogously, 
it matters not whether the stethoscope is 
moved or the tapping finger, except that, 
for the sake of convenience, the instru- 
ment is usually held stationary at about 
the center of the area to be defined. The 
exact point of application is not impor- 
tant, except that it should be somewhere 
within the area in which the organ to be 
investigated is in contact with the body- 
wall. These areas are easily found by or- 
dinary percussion and they are described 
or illustrated in most anatomies and works 
on physical diagnosis. The best example 
of the radical difference between ordi- 
nary and auscultatory percussion is to 
be found in the examination of the 
lungs. The former method reveals no 
partition into two organs, except where 4 
the mediastinum widens out; the latter 
method draws the line as closely as nature 
herself. 
The demonstrable (not the anatomical) 
cardiac area, as usually taught, is limited 
by the third rib, the nipple line and the 
right border of the sternum. The lower 
portion of the right boundary is obtained 
by drawing an imaginary line to the pal- 
pable apex. The examination to obtain 
these limits involves almost painfully hard 
percussion in order to strike below the 
superficial pulmonary resonance; it is, 
moreover, tedious and many physicians are 
unable to find the right limit of the heart. 
By auscultatory percussion almost the 
whole cardiac area may be mapped out, 
and it is nearly as easy to diagnose disten- 
sion of the right side as outward enlarge- 
ment of the left ventricle. 
A graphic representation is not so im- 
portant in the case of the thoracic organs 
as in that of the stomach and liver, since 
changes in the former are easily located by 
bony land-marks. Moreover, the diag- 
nosis of pulmonary and cardiac disease 
does not depend so largely upon the de- 
termination of areas as it does in the case 
of the stomach and liver. 
The spleen varies in size, even physio- 
logically and temporarily. Some go so far 
as to say that the normal spleen is not 
percussible; others, while admitting that 
it has a definite area of dullness, confess 
that in many instances they can not locate 
it. From its position at the side 
of the body where the ribs have their 
greatest convexity and from its lack of 
definite shape, the graphic representation 
of the spleen on a plane surface is not es- 
pecially important, yet an approximate 
estimation of its size is often of the high- 
est value. Malaria, leucocythasmia, ma- 
lignant lymphoma (Hodgkin's disease), 
carcinoma, almost all septic conditions of 
the intestine, various interferences with 
the portal circulation, infectious fevers, 
even without intestinal lesion, are among 
the causes of splenic enlargement. While 
in many such cases the finding of a large 
spleen is simply a verification of a diagno- 
sis already well established, in other cases 
the condition of the spleen is of great im- 
portance. Those cases of hepatic cirrho- 
sis without demonstrable change in the 
liver itself, are among the most puzzling 
which confront the physician, and the fact 
of splenic enlargement, not otherwise ex- 
plained, throws light on the hepatic con- 
dition. Again, a case of deep tumor in 
the region of the left kidney may be cited. 
With splenic enlargement, some implica- 
tion of the intestine or, possibly, carcino- 
ma would be thought of. The spleen be- 
ing of normal size, both these conditions 
were excluded and the probable diagnosis 
was made of renal sarcoma which is not 
prone to anastomosis. The diagnosis was 
confirmed by haematuria. Such cases il- 
lustrate the benefit of ausculatory percus- 
sion as a far more delicate means of inves- 
tigation than ordinary percussion or pal- 
pation. 
It is rather difficult to state exactly 
what the area of the stomach should be. 
It varies greatly within normal limits ac- 
cording to the time after eating and the 
amount of gas produced during digestion, 
while authorities differ as to its location 
when distended. Moreover, we can not 
expect to map out the most deeply seated 
parts of the organ, any more than to lo- 
cate the summit of the dome of the liver, 
which rises at least a rib higher than even 
the heaviest percussion indicates. The 
usual limits of the area of gastric reso- 
nance may be assigned as follows. A ver- 
tical line extending for an inch or more 
about the mid-point between the xiphoid 
and the umbilicus marks the right limit, 
although the organ itself extends further 
and a slight transgression of the resonant 
area is not sufficient to establish the diag- 
nosis of dilatation. The lowest point of 
the stomach is about an inch, or an inch 
and a half above the level of the umbili- 
cus and about half way between the medi- 
an and the axillary line. The left curve 
varies greatly according to the degree of 
distension. The anatomies usually pict- 
ure a thoroughly distended stomach 
whose extreme left limit is at the level of 
the seventh rib, touching the thoracic 
wall laterally, while the highest point of 
the curve is just inside the nipple in the 
fourth intercostal space. On percussion, 
these limits are seldom or never reached. 
Usually, in a stomach distended as much 
as possible without spontaneous relief of 
pressure through the oesophagus, the 
highest and extreme left points coincide, 
falling on the sixth or seventh rib and as 
far to the left as the thickness of the thor- 
acic wall will allow. From this point, 
there is a sag downward and to the right. 
One would get the impression from the 5 
percussion area, that the cardiac opening 
of the stomach was at the highest left 
point; on the contrary, it is located pos- 
teriorly and only slightly to the left of the 
median line. The sag from the highest 
point, therefore, corresponds not only to 
the anatomical lesser curvature, but also 
to the upper part of the greater curva- 
ture. Owing to the different degrees of 
distention of the stomach, to the manner 
in which it touches the abdominal wall, to 
the weighing down of the lower part with 
food or liquid, and to the muscular tone 
which naturally tends to keep the organ 
somewhat contracted, the percussion area 
varies very greatly and it may be consid- 
ered normal if it falls within the extreme 
limits mentioned. 
The direction of the axis of the stomach 
is a matter of some dispute. Quain's an- 
atomy represen ts a d istended stomach whose 
axis is about 55° from horizontal. Luschka 
figures a stomach inclined at about 45° 
and passing an inch or more to the right 
of the median line. At autopsies a marked 
variation is seen. Since the term gas- 
troptosis was first used, some controversy 
has arisen as to the normal direction of 
the stomach, some claiming that the axis 
of the organ is nearly horizontal, others 
that it deviates only 20° or 30° from the 
vertical. Speaking with a limited experi- 
ence, the writer believes that, in short 
persons, the axis of the area of gastric re- 
sonance is considerably less than 45° from 
the horizontal, while tall, long-chested 
persons have a gastric axis with an inclina- 
tion of 45° or more. This statement 
applies to clinical appearances and not to 
the findings at autopsies. It is uncom- 
mon to find a stomach that reaches more 
than a quarter of an inch to the right of 
the median line, while, without any 
rparked dilatation, the greater curvature 
may sag as low as the umbilicus. This is 
especially true of flabby, atonic women 
who compress the waist with corsets. The 
whole question reminds one of the con- 
troversy among gynaecologists as to the 
normal position of the uterus. Certainly, 
the physiological deviations of a soft or- 
gan like the stomach are much greater than 
those of the small and rigid uterus. 
The writer would like to call attention 
to a fact to which most text-books do not 
allude, namely, that the greater curvature 
of the stomach, as mapped out by percus- 
sion, is, in most instances, not a simple 
convexity, there being usually a slight 
concavity in the middle of the curve, 
marking a tendency to the division of the 
organ into two digestive compartments. 
The area of liver dullness begins, on 
deep percussion, at the fourth rib. The 
nipple is usually at this level but, not very 
rarely, it varies on one or both sides, even 
in men. In women with pendulous breasts 
it has no value as a land-mark. As the 
lung substance intervening between the 
liver and the chest-wall becomes thinner, 
dullness increases, until at the sixth rib in 
the nipple line, there is almost absolute 
flatness. The liver extends to the costal 
arch. Palpation usually reveals the left 
lobe of the liver in the epigastrium, but 
ordinary percussion and palpation afford 
only the vaguest notion of the contour of 
the organ. By auscultatory percussion, on 
the other hand, it is possible, in most 
cases, to map out practically the whole 
liver, and overlapping intestine does not 
materially obscure the findings, whereas 
with ordinary percussion, it may lead to a 
diagnosis of Contracted liver. 
When we remember that the physical 
diagnosis of liver troubles depends almost 
entirely upon the determination of "back 
pressure " of blood, lymph and bile, and 
of the size of the organ, the value of even 
the slightest increase in our means of ex- 
amination becomes apparent. The writer 
recalls a patient who had no ascites nor 
oedema, no haemorrhoids nor other promi- 
nent veins, no jaundice and, for the time 
being, no disturbance of digestion, yet 
his liver was scarcely two inches in verti- 
cal diameter. Much doubt was felt as to 
whether the apparent contraction of the 
liver was not due, at least in part, to dis- 
tended intestine in the right hypochon- 
drium. Auscultatory percussion would 
have settled the question at one examina- 
tion ; without it, a positive diagnosis was 
not made except after several examina- 
tions and after securing some significant 
history. 
By auscultatory percussion, the colon 
can be quite accurately distinguished from 
stomach and small intestine. The ex- 
treme length and complicated coiling of 
the small intestine prevent its resounding 
as an anatomical unit, so that ausculta- 
tory percussion is, in this case, of little 
value. 
The examination of the pregnant uterus 
and of various large tumors of the pelvic 6 
pleximeter is necessary; thus the physician, 
holding the stethoscope in one hand and 
tapping with a finger of the other, needs 
no assistant. The writer uses for all pur- 
poses a Camman chest-piece to which are 
fitted flexible rubber tubes terminating in 
hard rubber ear-pieces. This instrument 
has only two advantages over the ordinary 
Camman stethoscope; it is portable and, 
since the ear-pieces must be made to fit 
tightly into the meatus, it cannot usually 
be of service to any but the owner, so that 
the transmission of cerumen from one 
person to another is avoided. It is a 
physiological fact that a person accus- 
tomed to listening with both ears refers 
sounds heard with only one ear to the ear 
itself and thus, there being no distraction 
of attention to note the direction of the 
sound, its pitch is a little more sharply 
defined. Accordingly, the writer has de- 
vised a flexible monaural stethoscope which 
answers the purpose well if the opposite 
ear is stopped. 
The writer would also report the fol- 
lowing original methods of investigating 
visceral resonance. All are used in con- 
BINAURAL STETHESCOPE AND TUNING-FORK. Page 585. 
organs is greatly facilitated by ausculta- 
tory percussion. It would seem that one 
with a gynaecological practice, might so 
perfect the art of external diagnosis that 
cceliotomies would not reveal so many 
totally unexpected conditions of the pelvic 
interior. 
Under ordinary circcmstances, it would 
seem presumptuous to present an essay 
dealing largely with the general principles 
of a branch of medical art publicly re- 
ported more than half a century ago. 
Yet, unless recently, the majority of 
graduates in medicine have left college 
totally uninstructed in auscultatory per- 
cussion, and comparatively few physicians 
make practical use of it. Thus, one who 
wishes to become expert must, as a rule, 
depend upon his own exertions, aided 
only by general directions to be found in a 
few text-books and some articles on this 
neglected method buried in files of medi- 
cal magazines. Under these circumstan- 
ces, some explicit details of the technique 
of auscultatory percussion may be allow- 
able. While the early authorities recom- 
mended a hard-wood monaural stetho- 
scope, the writer believes that any form 
may be used, and that the binaural in- 
strument is preferable, since it shuts out 
more completely extraneous sounds. No 
MONAURAL STETHESCOPE WITH COIL VIBRATOR. Page 585. 7 
nection with a stethoscope and no new 
principles are involved. All are solutions, 
more or less perfect, of the problem to 
substitute for percussion a more conveni- 
ent method of exciting visceral vibra- 
tions: 
1. Instead of tapping, friction may be 
used to originate vibrations. The rubber 
tip of a pencil answers well, or even the 
end of a dermograph. The choice between 
friction and percussion depends largely on 
the sensations of the patient. 
2. A tuning fork fitted into a hard rub- 
ber handle, is set into vibration and closely 
applied to the body wall. This method 
causes neither tenderness nor tickling, as 
percussion and friction, respectively, some- 
times do, while it is even more delicate as 
a test. (See Chart 4). 
3. The tuning fork has the disadvantage 
of vibrating only for a short time and the 
repeated snapping of the tines is rather 
tedious. Inorder to obtain a continuance 
of the vibration, a portable Faradic coil 
has been prepared, the hollow core serv- 
ing to conduct the vibrations of sound to 
the body. Within certain limits, it is 
possible to guage the pitch of the hum- 
ming note and, thus, to set up vibrations 
best adapted to the transmission of each 
particular organ. It will be understood 
that the coil is not used as an electrical 
instrument, the secondary wires being cut 
short. 
On account of the trouble of carrying a 
battery and of keeping one in order, the 
writer has found the finger and the tuning 
fork to be the most convenient means of 
instituting resonant vibrations. 
Contrary to what might be expected, 
the nature of the body-wall has very little 
influence on the conduction of vibrations. 
Thus, in moving the source of vibration 
-percussing finger, pencil, tuning fork 
or coil-along a rib, the sound diminishes 
when the limits of the organ are passed 
quite as suddenly as if the examination 
were made over the soft abdominal wall. 
So too, in passing from rib to intercostal 
space, the conductivity of the underlying 
organ is not affected. Although the 
deepest portions of organs can not be out- 
lined, parts may be mapped that are cer- 
tainly overlain to a moderate depth by 
other viscera. 
It is usually advisable to mark the lim- 
its of an organ with a dermograph. 
Tracings may then be made to preserve a 
record of the case. Photography would 
naturally suggest itself as a means of re- 
producing the outlines in their relation to 
superficial landmarks, but it is impractic- 
able to have the necessary apparatus and 
assistants always at hand; many patients 
would object: the expense must be consid- 
ered; and, most important of all, the 
lateral regions of the body would appear 
so foreshortened in a photograph as to give 
false notions of the actual areas, and it 
would be difficult to focus either to a life- 
size or to a uniform scale of reduction. 
The accompanying photograph* is prac- 
tically, a failure. The patients were boys 
about twelve years old, presenting symp- 
toms of cardiac hypertrophy. Ausculta- 
tory percussion demonstrated that the con- 
dition was a neurosis, the cardiac area not 
being in the least enlarged. 
*Not reproduced here. 8 
EXPLANATION OF THE CHARTS. 
The writer regrets that he could not 
have had the assistance of someone ac- 
customed to draughting, but it seemed bet- 
ter to sacrifice the aesthetic appearance 
rather than to allow technical inaccuracies 
zontal line but, for the purpose of com- 
parison, we must allow for the distension 
of the lesser curvature. The gastric area, 
though absolutely one of the largest in the 
series, does not indicate the degree of di- 
latation and ptosis seen in Nos. 3,5, 7 and 
9, since it does not pass to the right of the 
median line nor within an inch and a-half 
of the level of the umbilicus. 
\Tip cfXiphoid 
II. This chart represents the contours 
of the stomach on two occasions, eleven 
days apart. The dotted lines indicate the 
NippleLine 
Median Line 
Axis ofStomach 
Umbilicus 
Median .Line 
FIG. I. 
to detract from the value of diagrams pre- 
pared by one unfamiliar with medical 
science. The charts were prepared by plac- 
ing the original tracings on card-board, 
following the lines with a style and mark- 
ing the depressions with ink.* 
I. The patient was a large, flabby, 
middle-aged woman with chronic diffuse 
nephritis. She was subject to so much 
gastro-intestinal fermentation that her ab- 
domen always suggested ascites, which was 
never found. The chart was made one 
hour P.O., when the stomach was dis- 
tended nearly to its maximum capacity. 
The axis appears to be almost in the hori- 
Umbilicus 
FIG. II. 
result of the first examination, three hours 
P.O. For some reason, the upper part of 
the organ was not found. The second ex- 
amination (marked in wavey lines) was made 
two hours P.O., when the stomach was 
*They are here reduced to a scale of about one- 
fourth, varying with the different figures. 9 
more distended. The patient was a re- 
markably long-chested individual,although 
only 5 feet 10| inches tall. It will be 
seen that the distance from xiphoid to 
umbilicus was nearly two inches greater 
than in the first patient. The gastric 
tinal distension. The stomach, though 
not sufficiently distended to inflate the 
lesser curvature, passed to the right of the 
median line and descended to the umbili- 
cus, suggesting a very moderate and prob- 
ably temporary dilatation. It is ques- 
tionable which of the two axes drawn in 
the diagram represents more fairly the 
general direction of the stomach. The 
patient, though five feet eleven inches 
tall, was not " long-chested," and we 
should expect simply the average inclina- 
tion of the stomach. 
IV. This represents the stomach of a 
short and naturally broad-chested woman, 
though at present emaciated on account of 
fibroid phthisis. She is subject to oc- 
casional attacks of fermentation due to 
subacid dyspepsia. Although the stomach 
reaches farther to the right than is gener- 
ally demonstrable, its area is not abnor- 
mal. The diagram is introduced, partly 
to illustrate the inclination of the axis, 
but more particularly to show the differ- 
ence between the area as mapped out by 
auscultatory percussion and by ausculta- 
tion of the tuning-fork vibrations. The 
dotted lines represent the area as deter- 
mined by the latter method which seems 
• Left Nipple on 
LeffAty/rte cn eb/iib 
Umbilicus 
fig. in. 
axis, also, was nearly 20° farther from the 
horizontal. In each diagram, especially 
the first, is seen a tendency to the forma- 
tion of two gastric compartments. Some 
have asserted that, by auscultatory percus- 
sion, the beginning of the duodenum can 
be located. The writer has frequently 
found a narrow projection from the right 
border of the gastric area, which, appar- 
ently, marked the duodenum. In this 
case, there seems to be a downward dila- 
tation of the lower compartment of the 
stomach, since the duodenal projection, if 
such it be, usually appears not much above 
the lowest part of the greater curvature. 
III. The patient had suffered for four or 
five days during a voyage, with gastro- 
enteritis. The symptoms had largely sub- 
sided without medical aid, though there 
was still tenderness over the abdomen, 
belching of gas and general gastro intes- 
Umbilicus 
FIG. IV. 
to be slightly more delicate. Where the 
dotted lines are absent, the two areas co- 
incided. 
V. This was a case of subacute gastritis, 
which, from its occurrence during an epi- 10 
demic of typhoid fever and, on account of 
diarrhoea and a rise of temperature to 
102.2°, occasioned considerable anxiety. 
The patient was a young man of average 
ward dilatation of the lower compartment. 
The chart was made in the morning, 
twelve hours after a meal. 
VI. This map, made two hours after eat- 
£,eUtJVipple cn ,Aflib 
Left Nipple cn 
CostalArc/i 
i) Umbilicus'' 
FIG. VII. 
Umbilicus 
fig. v. 
ing, represents the stomach of a nurse, 
aged forty, who suffered greatly from sub- 
acid and fermentative dyspepsia, appar- 
height, rather stockily built. The in- 
clination of the axis of the stomach is a 
little greater than in a person of average 
build. Like that of Case IL, this map in- 
Le/tjVipple on ■J'"'/?ib 
Umbilicus 
FIG. VIII. 
FIG. VI. 
ently induced by fatigue. She was of 
large frame and broad-chested. The be- 
ginning of the duodenum appears in the 
usual location. The tuning-fork was used 
in making this map. 
dicates a partial constriction of the stomach 
into two compartments, the duodenum 
being apparently high as if from a down- 11 
VII. This represents the stomach of a 
young man in the first week of typhoid 
fever. Although no food had been taken 
for sixteen hours (this was at the first 
visit) the organ was greatly distended with 
gas. It will be seen, however, that there 
was no essential dilatation. During the 
course of the examination, a gurgling was 
heard at the pylorus and it was found that 
the superior convexity of the stomach had 
descended as indicated by the dotted line. 
although care was taken to have the arms 
symmetrically disposed, so as to prevent 
stretching of the skin. 
X. This was an extremely interesting 
case of hepatic carcinoma. Not having 
seen the patient during life, an excellent 
opportunity was afforded for testing the 
reliability of auscultatory percussion. 
Long pins were driven through the tis- 
sues at the limits of the area of resonance. 
(It will be noted that the word resonance 
LieLfAdpple on 
•Llip/rfAVpplein space 
Lower Aorder 
LTmMict/s' 
FIG. IX. 
VIII. This was a case of dilatation seen 
in consultation. The map was made three 
hours and a half P. 0. and, although cor- 
roborative of dilatation, it would not suf- 
fice to establish the diagnosis without con- 
firmatory evidence. 
IX. The case was one of pyloric cancer 
complicated with hepatic cirrhosis. The 
patient had been some hours without food, 
so that the stomach was relatively con- 
tracted, yet it was evident that secondary 
dilatation had occurred. The condition 
is plain from the diagram. It will be no- 
ticed that the nipples are not on a level, 
has not the same sense as when used of 
ordinary percussion.) A piece of paper 
was then applied to the body, being punc- 
tured by the heads of the pins. The out- 
er limit of the left lobe, falling over the 
6th rib, could not be marked by a pin but 
it was verified by the section. The right 
lobe was correctly outlined, the left ex- 
tended a little higher than the pin-marks 
(marked by x's on the chart). Depend- 
ing from the liver was a cancerous 
mass which had been overlooked. On 
account of rigor mortis and gaseous dis- 
tension of the stomach and bowels, it was 12 
neither palpable nor percussible. So far 
from indicating a failure of auscultatory 
percussion, this test simply illustrates its 
physical limitations, since it shows that 
vibrations imparted to an organ are prac- 
tically limited to tissues of the same kind. 
In other words, the cancerous mass, though 
growing from the liver, was a separate 
"pathological unit." 
At another autopsy, the attempt to lo- 
cate the liver was a failure. The subject 
had been dead four days and decomposi- 
tion had engendered an enormous amount 
of gas. Being unable to trace the liver 
corresponded to the lower margin of the 
lungs. In moving the stethoscope one of 
the rules of auscultatory percussion had 
been infringed, for it had been transferred 
from the area in which the liver was su- 
perficial to the area of the inflated stom- 
ach, which had exceeded its normal 
bounds. The failure, therefore, in spite 
of the unfavorable circumstances, was at- 
tributable not to the method but to a 
blunder in carrying it into execution. It 
is difficult to learn the lesson that, in phys- 
ical examinations, we must trust blindly 
to our senses, not to previously formed 
AfetfianZine 
RipMMppie on -/"'/iiA 
* 5th space 
'> Left border by 
]Auscultatory Percussion 
' correct 
& (f space X 
FIG. X. 
beyond the median line by auscultatory 
percussion, the stethoscope was moved to 
the left. What was supposed to be the 
upper margin of the left lobe was then 
marked, but on account of the inflation of 
the stomach, the lower margin could not 
be found. The section showed that the 
right lobe had been fairly well located, the 
left lobe was almost wanting, the liver be- 
ing extremely contracted. The line 
marked as the upper margin of the liver 
conceptions nor to the probabilities of the 
case. Afterward, any discrepancies are to 
be carefully weighed and the decision 
made accordingly. The writer, in the 
present instance, was really making an ac- 
curate map of the liver when he thought 
himself failing, and by following the no- 
tion that the left lobe was present to a 
demonstrable extent, the error was made 
of mapping out part of the stomach under 
the delusion that it was part of the liver.