1. Leading Questions, Concerning

II. Occasional Questions, Concerning

III. General Observations, Upon Physical Character

1. Bulk and Stature. 2. Particular Conformation.

3. Complexion and Physiognomy. 4. Mobility and Irritability.

IV. Collateral Circumstances

1. Season of the Year. 2. Nature of Prevailinq; Epidemics.

3. Weather ..

a. Moisture and Dryness.

b. Prevailing Winds.

c. Abundance and Quality of Fruits.

Commentary Upon The Preceding Table

322. In order to illustrate the relative importance of the several subjects which are embraced in the preceding tabular scheme, as well as to direct the practitioner into the more direct path of pathological inquiry, let us suppose a person labouring under some one of the forms of dyspepsia, to present himself for examination. We first learn, from bis own report, the general nature of the symptoms by which he is distressed; and we then proceed to make such further inquiries as may enable us to form an opinion respecting their origin and mode of cure.

323. The intensity of the symptoms cannot be always inferred from the patient's own report, but must be deduced from our experience in such cases. The dyspeptic is too apt to depict his feelings in extravagant language, and to become unnecessarily anxious and apprehensive. An inquiry into the duration of his complaints is of much importance; for it has been already stated that the intervals of comfort are abridged as the disease progresses, until at length he becomes harassed by an uninterrupted series of sufferings. It is, however, from the locality of the symptoms that we are to form our opinion with respect to their seat and origin; and for ascertaining this fact we must be particular in our inquiry, and minute in our examination. Is the stomach affected? If a sense of weight or burning after the ingestion of food, acid, or putrescent eructations be present, we may conclude such to be the case. If there exist any uneasiness or fulness in the epigastric and right hypochondric regions, produced or increased by pressure, we may infer that there exists some diseased condition of the liver, duodenum, or, perhaps, of the stomach; and that we may be enabled, under such circumstances, to form a diagnosis, the patient must be submitted to a manual examination.

For this purpose, every ligature must be removed from the abdomen, and he must be placed on a sofa, reclining on his back, with his legs drawn up, so as to throw the abdominal muscles into a state of relaxation. Where the fulness and tenderness arise from a distended state of the duodenum, the sensation given to the hand is very different from that which is produced by organic disease of the liver; the tumour in the former case is more diffused and less defined. It also deserves particular notice, that, by pressure, on the region of the liver, no uneasiness will be complained of, but if the pressure be made with the edge of the open hand under the ribs, with the palm of it flat upon the abdomen, considerable uneasiness will be felt up towards the liver, and down towards the right kidney; a soreness is likewise felt an inch or two to the right, just above the navel. In such cases, also, the anatomical accuracy with which the patient will trace the course of the duodenum with his finger, from the stomach to the loins on the right side, and back again across the abdomen to the umbilicus, will greatly assist the diagnosis. There are, besides, other symptoms to be hereafter enumerated, which will enable us to arrive at a still more positive conclusion.

It is of the greatest importance to distinguish between a morbid state of the duodenum and that of the liver: I have frequently, in the course of my own practice, seen patients who have undergone salivation, from a belief in the existence of hepatic disease, but who were merely suffering under duodenal irritation. On the other hand, I am equally satisfied that chronic inflammation of the liver has been repeatedly mistaken for a dyspeptic state of the stomach. Dr. Saunders says, that he has seen many cases of this kind, which have been supposed to arise from indigestion. The patient generally complains of pain, which he falsely attributes to the stomach; but its continuance is so snort, and the degree of it frequently so inconsiderable, that no alarm respecting the future health of the patient is produced. The relief obtained by eructation and discharge of air tends to confirm the opinion that the seat of the disease is in the stomach; but this relief may be explained on the principle of removing the distension of the stomach, and so taking off the pressure of this organ from that which is the seat of the complaint.

324. Where the tenderness in the epigastrium is extremely circumscribed, not occupying a space larger than a shilling, Dr. Philip infers the presence of an inflammatory affection, or a state approaching to it, of the pylorus, excited by the passage of the irritating-contents of the stomach; I cannot, however, conceive such a state of pylorus, as to occasion pain on pressure, to be unattended with vomiting.

325. The accession, concourse, and order of succession of the different symptoms, are calculated to throw considerable light upon the nature of a dyspeptic disease; indeed, in protracted cases, it is only by a careful examination of these circumstances that we shall be able to separate primary from secondary affections. The stomach cannot long err without communicating its vice to the other chylopoietic organs; the liver may become affected from mere irritation, and every part of the body, from sympathetic influence, may put on the appearance of disease. How are we, then, except by a careful examination into the history of the case, to ascertain the organ in which the mischief originated?

326. Whether the symptoms are mitigated, or increased by any particular posture or motion. This is an important question. Where the disease is confined to the stomach, the patient appears capable of lying with equal ease on either side; but if the duodenum or liver be affected, he will experience some uneasiness on lying on the left side. Where the disease has become compli-cated, lying on either side is irksome, and the easiest position is found to be that of lying on the back, with the shoulders a little raised, and inclined to the right side. The muscles of the chest are, on such occasions, not unfrequently sore, and the patient finds it difficult to turn even in his bed without pain.

327. Assignable Causes

It will be always right to inquire of the patient whether he can account for the accession of his disease. He will tell you whether he has exposed himself to the operation of any of those causes which are known to be active in producing it. His previous state of health should also be investigated, for we may be thus enabled to explain the occurrence of symptoms, and to connect them with the derangements of distant organs. An affection of the stomach may, for instance, be traced to some sympathetic action, which might otherwise be mistaken for a primary disease.