THE DIAGNOSIS OF CHANGES IN THE SIZE, 
POSITION, AND MOTILITY OF THE STOM- 
ACH IN CASES WHERE INTRAGASTRIC 
INSTRUMENTS CANNOT BE USED. 
BY 
BOARDMAN REED, M.D., 
OF ATLANTIC CITY. N. J. 
FROM 
THE MEDICAL NEWS, 
January 18, 1896. [Reprinted from The Medical News, January 18, 1896.] 
THE DIAGNOSIS OF CHANGES IN THE SIZE, 
POSITION, AND MOTILITY OF THE 
STOMACH IN CASES WHERE 
I NT R AG AST RI C INSTRU- 
MENTS CANNOT 
BE USED. 
By BOARDMAN REED, M.D., 
OF ATLANTIC CITY.-rt'Tj; 
It was only twenty years ago, in 1875, that Ewald1 
by accident discovered that a soft, flexible tube could 
be introduced into the stomach without a stylet. 
Since then the use of this instrument has been very 
widely extended. When in 1885 the writer took 
his first lessons in lavage under Oser, in Vienna, it 
seemed almost a novelty there, and was very rarely 
employed in the United States; but it has been 
more and more popularized, until now in some 
quarters it has possibly come to be abused, especially 
by patients who have learned to wash out their own 
stomachs. 
There are many cases of gastric disease in which, 
for one reason or another, we cannot employ even 
the soft tube, and still less the sound, or any of its 
ingenious modifications and amplifications, such as 
Einhorn's gastrodiaphane or Turck's gyromele. The 
contraindications are given by the leading authori- 
ties, and include especially all cases of acute illness, 
recent hemorrhages from any part, gastric ulcer as 2 
a rule, most serious diseases in their last stages, con- 
gestion of the brain, and advanced age. It needs 
to be remembered, however, that age for this pur- 
pose should be reckoned by the condition of the 
heart and bloodvessels, rather than by years. I have 
had patients eighty years of age who took the tube 
with less inconvenience than many do at forty. 
Then, besides the contraindications, we are 
obliged to take into account the foolish dread which 
many nervous patients have of this trifling proce- 
dure, amounting sometimes to an insuperable ob- 
stacle. In my long experience with chronic invalids 
in Atlantic City, the most frequented health-resort 
in America, I have found that only a small propor- 
tion of patients of the better class who need special 
treatment will consent to the use of a stomach-tube, 
at least until their diseases have progressed to a 
serious stage. 
Therefore, in order to reach as accurate a diagno- 
sis as possible in such cases, I have been obliged to 
make the most of the various methods which do not 
include the employment of any instrument inside 
the stomach. Trusting that the mode of systema- 
tizing such methods which has proved useful in my 
own work may be helpful to others, I venture to 
submit a description of it. 
In thus pointing out what can be done when neces- 
sary without the tube, there is no thought of under- 
estimating the enormous advantages which that little 
instrument affords in the diagnosis and treatment of 
gastric disease. In studying the chemical functions 
of the stomach the tube is virtually indispensable, 
though occasionally accidental vomiting at the right 3 
time gives an opportunity for making the necessary 
chemical tests ; and the Einhorn bucket may some- 
times serve us a good turn. 
It would require too much space to go into a dis- 
cussion of symptomatology and the now somewhat 
promising results of the chemical and microscopical 
examination of the urine and blood. That these 
latter researches are capable of throwing much light 
upon the affections of the stomach as well as of 
those of the intestines there is no longer any ques- 
tion. 
We come then at once to the examination of the 
abdomen externally. Not stopping here to consider 
what can be learned from inspection and palpation, 
as to the usefulness and great value of which no 
question has ever been raised, we pass on to a study 
of clapotement and percussion. It is to the value 
of the combined employment of these two proce- 
dures, according to a certain order, that I desire to 
call attention especially. Both are separately well 
described in the works of Ewald,2 Boas,3 and 
other standard treatises on diseases of the stomach, 
and during recent years there have been numerous 
contributions to current medical literature on ab- 
dominal percussion. The most notable of these is 
a paper by Dehio,4 in which he gives directions for 
percussing with the patient lying on the back, as 
well as standing, after drinking various portions of 
water. He states that the normal empty stomach 
is entirely within the thorax, and not accessible 
to percussion, but that the drinking of one-quarter 
of a litre of water produces in the erect position a 
dull area, which extends cm. below the lower 4 
end of the corpus sterni; then by drinking the 
same quantity a second time, the dulness is extended 
2.7 cm. further downward, and so on until after the 
person has taken a whole litre he finds in the ma- 
jority of cases the lower border of stomach-dulness 
a few centimetres above the level of the umbilicus. 
He points out also that from the different degrees 
of distensibility thus indicated we may infer much 
as to the motility of the stomach. 
On the other hand, Jaschtschenko,5 at about the 
same time, took quite the opposite view of the matter. 
He sharply criticises Traube, whose conclusions were 
similar to those of Dehio above cited, and declares 
that the empty stomach is percussible, and that fill- 
ing it gradually with water causes an extension of 
the dulness upward but not downward. Neither of 
these two writers makes any mention of clapotement. 
Obrastrow,® of Kiel, writing on this subject in 
1888 an elaborate and valuable paper which I had 
not seen till the present article had been nearly 
finished, gave a full exposition of clapotement, but 
had not at that time as much faith in the accuracy 
of the information to be obtained by a delicate 
percussion as he has evidently since acquired, judg- 
ing by an able contribution which has just appeared 
from his pen.7 
Rose,8 an American physician, has also recently 
written on the subject of the splash. 
Certain it is that even the normally small healthy 
stomach under usual conditions, when empty as 
well as full, presents a portion of its anterior sur- 
face in contact with the front wall of the thorax, 
and to a small extent with the front wall of the 5 
abdomen; and except in conditions of marked 
obesity it is not generally very difficult to determine 
both the upper and lower borders of that portion 
in contact. But stomachs which are thus almost 
entirely covered by the ribs are rare, at least in 
civilized communities, and physicians are seldom 
called upon to prescribe for them. 
Physicians are most interested in abnormal 
stomachs, which nearly always extend far enough 
below the ribs to afford us the opportunity of test- 
ing their condition by all the usual methods of 
physical exploration. 
My own experience has convinced me that 
stomachs, like noses, may vary considerably in size, 
and yet be within normal limits, but that when they 
extend, in the empty condition, much lower than 
a point midway between the sternum and umbili- 
cus, they are generally pathological. That experi- 
ence includes the examination of about 300 per- 
sons by the methods now under consideration. 
Two hundred and twenty-five of these were exam- 
ined in the course of my practice in Atlantic City 
and the remainder in the Polyclinic of the Augusta 
Hospital in Berlin during the present winter, 
through the courtesy of Professor Ewald and his 
chief assistant, Dr. L. Kuttner. By the kindness 
also of Dr. Oesterreicher, pathologist at the same 
hospital, I have been permitted to witness numerous 
autopsies in the cases of persons who had had vari- 
ous forms of gastric disease as well as a few whose 
stomachs were normal as to their size and position. 
At some future time I may summarize the results 
of these observations and of others yet to be made 6 
in a more general way, and deduce from them some 
of the lessons which they teach; but it is sufficient 
for the object of this article to show that they con- 
firm the value of clapotement and percussion. 
In a number of the cases in Ewald's clinic in 
which, by external examination, I had diagnosticated 
and designated by chalk-lines on the abdomen, gross 
departures from the normal in the way of displace- 
ment, dilatation, or both, the stomach was afterward 
inflated by air, and in some instances illuminated 
by the electric lamp from within, with a substantial 
verification of the results previously obtained. In 
two noteworthy instances while by percussion the 
boundaries were correctly determined, the splash 
obtained by clapotement told an entirely different 
story, and thus led at first to some doubt. But as 
exceptions are said to " prove the rule," so these 
two exceptional cases have been unusually instruct- 
ive. Both were cases of downward displacement 
and dilatation. In one of them the entire stomach 
had fallen until the fundus rested firmly upon the 
pelvic organs; in the other the pyloric end, greatly 
dilated, occupied the same position, while the car- 
diac portion was still in its normal place. Percus- 
sion in various positions with the stomach first 
empty and afterward partly filled, gave the above 
results, and distending the organ with air was 
fully confirmatory; but the splash, even after one 
or two glasses of water had been drunk, could not 
be heard at any point below the navel in either 
case. Usually with the patient lying on the back 
the splash is heard at the nethermost part of the 
stomach when obtainable at all. 7 
The practical inference to be drawn from this 
observation is, that if in any case clapotement and 
percussion do not agree in their testimony, we 
should be guided by the latter rather than the 
former, as being less likely to deceive, though until 
this recent experience I was inclined to the con- 
trary view. When clapotement and the results of 
intelligent, careful percussion agree, we need have 
no doubt. When, as rarely happens, they disagree 
and the case is important, it will be well to inflate 
either the stomach or colon to settle the point. Ex- 
periments were made by me in a series of six cases of 
gastrectasia in Ewald's clinic with a view to ascer- 
tain whether by clapotement and percussion to- 
gether it is possible to determine positively when 
the stomach has emptied itself. The patients 
reported in the morning fasting. In each of these 
cases when the splash was obtainable and percussion 
in the erect position demonstrated dulness in the 
lower segment of the stomach, I was able afterward 
by means of the tube to bring up a considerable 
quantity of the undigested remnants of a previous 
meal. Then after carefully emptying the stomach 
by aspiration the former tests were again employed, 
and this time with negative results. 
In a number of other (doubtful) cases that were 
required to present themselves in the morning fast- 
ing the presence of fluid in the stomach was sus- 
pected, and to determine the question I practised 
clapotement and percussion, but failed to obtain a 
splash, or to detect dulness over the lower part of 
the gastric area in the erect position. The tube 
was then used, but nothing obtained, except three 8 
or four grammes of a pale, thin solution, consisting 
mostly of saliva. 
In this simple manner, therefore, we may test the 
motility of any given stomach frequently, at various 
intervals after various kinds of meals, with very little 
difficulty or inconvenience to the patient, especially 
after the boundaries have once been accurately 
determined. 
Numerous experiments have also been made by 
me to determine whether the stomach fills upward 
or sinks lower after the taking of food or drink in 
successive portions. The results have been somewhat 
various, as might be expected, according to the mus- 
cular energy of the stomach tested. In the cases of 
gastrectasia and all cases of weak motility, there has 
been a depression of the lower border after each 
glass of water, except when it was already at the 
lowest point attainable, and then there was a 
demonstrable widening of the organ on either side. 
Since beginning this particular investigation I have 
unfortunately not been able to find many normal 
stomachs, but the few presumably healthy ones ex- 
amined filled upward without the lower border as a 
rule showing any noticeable depression after drink- 
ing several successive glasses of water, thus confirm- 
ing the observation of Jaschtschenko rather than 
those of Dehio and Taube. In some cases, how- 
ever, in which there were no other signs of weak- 
ness, the area of dulness increased both upward and 
downward after drinking. 
It is best to examine the patient at a time when 
the stomach should be entirely empty-that is, in 
the morning fasting or six hours at least after the 9 
last meal. But this is not always practicable, 
and after a light breakfast or a very moderate 
lunch a healthy stomach will usually be found 
by the tests of clapotement and percussion to have 
voided its contents into the intestine at the end of 
two hours. Even when these tests show that gastric 
digestion is still incomplete, we may in many cases 
nevertheless satisfy ourselves with sufficient accuracy 
as to the size, position, and motility of the organ ; 
but in cases of difficulty or obscurity it is safest to 
examine a second time under the best possible 
conditions. 
If upon examining a patient six hours at least 
after his last meal we obtain the splash by clapote- 
ment, we can infer deficient motility. Noting at 
the same time the lowest point where the splash 
can be distinctly heard, we may infer as a rule 
that the lower boundary extends to about that 
level. 
We should then percuss the abdomen with the 
patient in various positions to verify the results of 
clapotement and map out the boundaries. 
If no splash should be obtained, before proceed- 
ing to administer water it is well to percuss with 
the patient first recumbent, and afterward in the 
erect posture, to determine the apparent stomach- 
boundaries while the viscus is still empty. Note 
these mentally or mark them on the body. 
Then have the patient drink to litre of 
water, and try again to obtain the splash. If it is 
obtained distinctly after the smaller amount of 
water mentioned, it raises a question as to the 
motility, and will also show where to percuss with 
especial care and delicacy for the lower border. 10 
For the adept in percussion the fingers may suf- 
fice to bring out the finer differences in tone, but 
with a good percussor and pleximeter the task is 
greatly simplified. 
The cut of a new pleximeter devised by myself 
will be found below. It is wholly made of rubber 
of medium hardness and is very easily carried in 
the pocket. The smaller end serves ordinarily as 
the handle, but in mapping out spaces very accu- 
rately or in percussing in narrow spaces, as between 
the ribs or over the clavicle, especially in children, 
it is better to reverse the ends and percuss over the 
smaller part. 
Any one of the rubber-tipped percussors usually 
found in the instrument-stores can be used satisfac- 
torily with this pleximeter.* 
Having already made out the apparent boundaries 
with the stomach empty, we percuss again with it 
partly filled while the patient stands, or, in the case 
of persons who are in bed or very weak, sitting up- 
right will usually suffice to bring the fluid contents 
in contact with the front wall of the abdomen and 
thus develop a zone of dulness. In going over a 
new case in this way it is best to give one glass of 
water at a time, when, if the stomach is atonic, the 
* The above cut was published in The Medical News of 
July 13, 1895, with a few lines descriptive of it, but is reproduced 
here because of its importance in connection with the subject- 
matter of this paper.-B. R. 11 
area of dulness usually extends downward with each 
successive glass; but if entirely strong, it extends 
upward only or mainly. 
One can begin either above or below, and should 
then percuss carefully in the median, left para- 
sternal, and mammillary lines from the level of the 
nipple to the pubes in any doubtful case. Having 
determined the highest and lowest points of the 
anterior thoracic and abdominal surface with which 
the stomach is in contact, we should percuss perpen- 
dicularly across the oblique curved line joining these 
points and forming the left lateral boundary of this 
epigastric area. Then the right lateral boundary 
separating the stomach from the ascending colon 
should be made out in like manner. With the 
patient erect and the stomach well filled, this is 
usually a simple matter, the ascending and descend- 
ing colons and their flexures nearly always emitting 
a more or less tympanitic note, even when partly 
filled. If the precaution has been taken to have 
the colon previously emptied, the contrast with the 
dull note over the full stomach will be, of course, 
still more marked. Having the patient lie first on 
one side and then on the other during the percus- 
sion may help to clear up a doubtful question. 
Filling the colon with air by the double-bulb rubber 
syringe in the usual manner will emphasize strongly 
the contrast with the dull stomach-area in the erect 
position, and filling the colon with tepid water while 
the patient is recumbent reverses the contrast in a 
very striking manner, though this is not a feasible 
undertaking with all patients, since some cannot 
retain the liquid long enough. 12 
The determination of the upper border or stom- 
ach-lung boundary is the most difficult part of the 
procedure. Usually, however, by trying alternately 
light and strong percussion, there will be obtained 
a marked difference in the two qualities of the reso- 
nant tone, that over the stomach being more tym- 
panitic. Still it requires much practice to make 
this out quickly and positively. Occasionally in 
exceptional cases where the stomach contains very 
little gas, we may fail at one examination and suc- 
ceed readily at a second one. This line is some- 
times more easily determined after a meal, since then 
such gases as are present are forced to the upper 
part and produce more tympany. One needs to 
bear in mind such possible disturbing factors as a 
greatly enlarged spleen or enlarged left lobe of the 
liver; also left-sided pleurisy filling up the half- 
moon-shaped space of Traube with exudation. 
However, there is only one condition at all fre- 
quent which is likely to prevent us entirely from 
determining the boundaries of the stomach by the 
combination of procedures we have been describing, 
and that is extreme obesity with great thickening of 
the anterior abdominal wall. Fortunately, however, 
this is a condition which does not often coexist with 
any serious form of gastric disease. 
To recapitulate, the following nine different kinds 
of stomachs can usually be differentiated by this 
combination of methods: 
1. Stomach of normal size, in normal position, 
and having sufficient motor power. 
2. Stomach normal as to size and position, but 
weak in motility. Gastric atony. 13 
3. Stomach enlarged, but motor power strong. 
Megalogastrie of Ewald.9 
4. Stomach enlarged and motility weak. Dila- 
tation or gastrectasia. 
5. Stomach wholly displaced downward, but 
otherwise normal. Not enlarged. Gastroptosis of 
Glenard. 
6. Stomach both enlarged and displaced down- 
ward as a whole, but not dilated. Motility good. 
Megal ogastrie with gastroptosis. 
7. Stomach wholly displaced downward and 
dilated. Weak motility. Gastroptosis with gas- 
trectasia. 
8. Pyloric end of the stomach displaced down- 
ward and swung around to the left, but without dila- 
tation. Often the pylorus is carried down almost, if 
not quite, into the long axis of the fundus, producing 
what has been called by Meinert10, Kellogg,11 and 
others the vertical or subvertical stomach, according 
to the degree of the displacement. This form may 
be appropriately called pyloroptosis. 
9. Pyloric end of the stomach displaced as in 
No. 8, and also dilated. Pyloroptosis with dilata- 
tion. 
These several varieties of stomachs may be re- 
cognized as follows: 
1. Normal stomach. If empty, no splash will be 
obtainable until after the viscus has been partly 
filled, and then either none or a feeble one heard, 
not lower, as a rule, than midway between the 
lower end of the sternum and the umbilicus-ex- 
ceptionally to within three cm. of the umbili- 
cus. Percussion, especially with the patient stand- 14 
ing after drinking water, will demonstrate the 
boundaries in normal place. 
2. Atonic stomach. The findings will be the 
same, except that a splash may possibly be heard 
four to six hours or longer after a full meal, or, if 
not, the drinking of a very small quantity of water 
will develop it decidedly. Percussion will show 
delayed emptying of the organ. 
3. Megalogastrie. Upper border will be found 
in the normal situation. Lower border may be at 
the level of the umbilicus or even below, but mo- 
tility good. No splash obtainable six hours or 
longer after a full meal. 
4. Gastrectasia. Splash usually obtainable six 
hours or longer after a meal and in bad cases at 
any time during the twenty-four hours. Percus- 
sion shows enlargement of the organ and delay in 
emptying itself. 
5. Gastroptosis. Splash usually rather more 
easily obtainable than in the normal condition and 
at a lower level, often at the navel or even consid- 
erably below it. Percussion shows descent of both 
upper and lower boundaries, but no enlargement. 
6. Megalogastrie with gastroptosis. Same as in 
No. 5, except that percussion shows the upper 
boundary not so much displaced, or if so, then the 
lower border still further below its normal line. 
Percussion shows enlargement. 
7. Gastroptosis with gastrectasia. Same as No. 
6, except that the splash is obtainable too long 
after taking food or drink. Clapotement and per- 
cussion show abnormal delay also in emptying the 
stomach. 15 
8. Pyloroptosis. Splash obtained usually far 
below the level of the normal lower border. Per- 
cussion reveals the peculiar outlines of the vertical 
stomach with the pyloric end low in the abdominal 
cavity. 
9. Pyloroptosis with dilatation. Same as in No. 
8, except that the splash is usually more pronounced 
and may be found too long after food or drink. 
Percussion shows also a widening of the pyloric 
end of the stomach. 
In any of the foregoing cases it may be neces- 
sary to inflate the stomach with carbonic acid gas, 
supposing it to be impracticable to use the tube, or 
to inflate the colon with air from below. 
Bibliography. 
1. Diseases of the Stomach, by Professor C. A. Ewald, M.D., 
New York, 1893. 
2. Ibid. 
3. Diagnostik u. Ther. der Magenkrankheiten, by Dr. I. Boas, 
1894. 
4. Zur Physikalischen Diagnostik der Mechanischen Insuffi- 
cienz des Magens, by Dr. Dehio. Separat Abdruck aus den 
Verhandlungen des Congresses f. Innere Medicin. 
5. Die Grenzen des Magens und des Darmcanals, by Dr. P. 
Jaschtschenko. St. Petersburger med. Woch., 1888, No. 29. 
6. Zur phys. Untersuchung des Magens und Darms, von Dr. 
Obrastzow. Deutsches Archiv. f. klinische Medicin, December 
7, 1888. 
7. Ueber die phys. Untersuchung des Darms, von Dr. Obrast- 
zow. Archiv. f. Verdauung's Krankheiten, 1895, B. i. Heft 3. 
8. What is the Significance of the Splashing Sound of the 
Stomach? by Dr. A. Rose. New York Medical Journal, June 
15. 1895. 
9. Ewald, loc. cit. 
10. Zur Aetiologie der Chlorose, von Dr. E. Meinert, Wies- 
baden, 1894. 
11. The Relation of Static Disturbances of the Abdominal 
Viscera to Displacements of the Pelvic Organs, by Dr. J. H. 
Kellogg. Modern Med. Pub. Co., Battle Creek, Mich., 1894. The Medical News. 
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