tion was nearly resultless, and was confined to the detection of gross abnormalities of size, form, location, density, and sensitiveness. More recent methods reveal the functional power, while the older methods have been made more exact and technical, and the precision and definiteness of all the diagnostic signs have been correspondingly increased. The diagnostic methods are both special and general. Some of the procedures are such as are employed in the diagnosis of all internal diseases, while others are used only in the diagnosis of the diseases of the stomach. The direct investigation of the digestive functions is a modern procedure. It has yielded a new set of signs of the very greatest value at the bedside. The stomach-tube has also enriched clinical medicine, by adding to it the bacteriological and anatomical signs of the diseases of the stomach. To the methods peculiar to the diagnosis of the diseases of the stomach should be added the more common procedures of physical diagnosis and their modifications in the examination of the digestive organs. The modified technic and special devices will receive a careful and exact description in order that the fullest information of diagnostic value may be rapidly obtained. The revealing signs and symptoms are subjective and objective, or such as are perceived and related by the patient and are detected by the physician. The one constitutes the clinical history; the other the clinical examination. The clinical history and examination give the data from which, by induction, the diagnosis is drawn. The logical process is an inductive one, but the analysis is supplemented by synthesis, or the orderly arrangement of the salient and valuable points of the clinical history, and the physical, the functional, the bacteriological, and the anatomical signs. After the clinical history and the examination are completed, the symptoms and signs are arranged in the order of their evolution and in their proper causal relations. The symptom-group is next compared with known clinical types and the disease classified according to its clinical expression. Following the thread found in the modification of function and the evolution of unhealthy variations, we arrive in a natural way at the clinical, functional, and anatomical diagnosis. The more exact and complete the data, the surer is the conclusion reached in this way. The result is dependent on the skill of the physician, the truthfulness and intelligence of the patient, and the exactness and efficiency of the methods. The constructed symptom-group rarely corresponds in every detail with a special clinical type, but may be the expression of more than one disease. By exclusion the diagnosis is made exact, and the precision essential to purposive treatment is attained. This process is commonly known as differential diagnosis, and is reached by deduction, comparison, and exclusion. The exclusion of the disease suggested by the symptom-group may be dependent on the absence of a cardinal symptom or sign. The result, though based on a negation, is none the less sure. After the symptom-group is classified and given a particular name, a comparison is then made with the typical clinical form of the malady, and an explanation is sought for the variations of type. The individual and medical constitution are thus brought prominently into view, and a complication or an associated disease may be revealed. If the situation is thus found to be complex, a further problem is the discovery of the relations of the parts, or the associated morbid entities. As a rule, one disease is the primary and predominant But the presence of a complication which may be explained as a result is not conclusive of such a mode of origin, and may lead to a false conception of the supposed causative disease. Accidental independent associations are not rare. That a disease may be explained as a complication does not exclude the possibility of its independent existence and development. Two possible explanations of a symptom-group may be equally plausible, and precision in the diagnosis may be impossible. In such cases a supposition should not be mistaken for and defended as the truth. one. A disease may have no characteristic sign or symptomgroup. The expression may be irregular, indefinite, formless. The deductive method may then be of use. This No mistake is more common than to leave out of consideration the stage of the disease. The symptom-group of an advanced disease is markedly modified by the constitutional state. The organism suppresses or modifies the expression of the disease, and the former salient features are lost. is particularly true of the final stages of a disease, when the diagnosis is more clearly revealed by the clinical history than by the present state. The death agony so changes the expression as to suggest often the possibility of an erroneous diagnosis. The mode of death is the same in many widely different diseases. The nature of a disease is revealed by its life history. Diagnosis is a logical method, proceeding by analysis, synthesis, comparison. The mode of reasoning employed has been described. Diagnosis is also a methodical procedure. In taking the clinical history and making the clinical examination, in order to avoid error and loss of time we should adhere strictly to a general plan. The clinical examination begins with the medical constitution, the strength, and the state of nutrition. Then look over the skin and visible mucous membranes and search for enlarged glands. This is to be done in every case. The next step is the examination of the organ-the stomach, for example-indicated by the clinical history as the seat of the disease. This being completed, we go on to the examination of the other organs, neglecting in no case to examine the liver, the nervous system, the heart and the blood-vessels, the lungs, and the kidneys. An examination of the blood and the urine, and of the stools, should never be neglected; and the female genital organs, if not functionating properly, should also be examined. The presence of a causative or associated disease may make the treatment of a disease of the stomach a failure. A complete diagnosis of a disease of the stomach is not a simple or an easy matter. In the clinical history are found such symptoms as point to this organ as the location of the trouble. The process of reasoning by which the nature of the disease and its clinical form are detected has just been outlined. But a complete practical diagnosis of a trouble of the stomach includes much more. In the first place, the clinical form should be recognized, when our attention is limited to the predominant characteristics revealed in the manner of the manifestations. The grand clinical character is dynamic, and is either hypersthenic or asthenic. These are the two clinical forms, and are the clinical expression of excessive or of insufficient activity. The diagnosis of the clinical form characterizes in a general manner the treatment, be it sedative, indifferent, or excitant. The physical examination yields the physical signs, or those obtained by inspection, palpation, percussion, auscultation, inflation, and electric illumination. The functional signs make clear the actual work done by the stomach, and form the basis of physiological treatment. The pathological stomach may become the breeding-place of micro-organisms which destroy the food, rob the body of its nutriment, irritate the stomach, and poison the system. The bacteriological signs possess an intense practical interest. Special therapeutic indications are given by the anatomical lesions, the determination of the nature of which is often facilitated by the anatomical signs. These signs and the clinical history combined reveal the nature and stage and probable evolution of the disease, and suggest the treatment. We shall describe them in the following order, which is the one most natural at the bedside: I. The Clinical History. 2. The Physical Signs. CHAPTER I. THE CLINICAL HISTORY. THE revelations of the modern methods of examining the stomach have so deeply engaged the attention of the medical world that the diagnostic value of the clinical history has been almost forgotten. The improved technic of physical diagnosis, the more exact and the more frequent clinical study of the functions of the stomach, the more intimate knowledge of the conditions and the effects of fermentation and putrefaction, the search for anatomical signs in the contents of the stomach, and the recent advances of pathology, have diminished the obscurity which has so long concealed the nature, the genesis, and the evolution of stomach diseases. notwithstanding the increase of knowledge, notwithstanding the great precision of modern diagnostic methods, the clinical history still maintains all its old utility. The diagnostic value of the subjective symptoms has only been enhanced by our more exact knowledge of their genesis and their evolution. But Unfortunately, many practitioners do not accept this view, but deem the time wasted which is spent in obtaining the subjective history. Many of the constitutional symptoms, it may be readily admitted, are common to all forms of gastric trouble, and are of little value in clinical investigation. Many symptoms, also, are in no fixed relation to the cause, or to the chemical pathology, or to the anatomical lesion; and the complaints of the patient may be so general as to be meaningless. The numerous and different diseases of the stomach may have a similar group of subjective symptoms. No one symptom is pathognomonic, and even the collections of symptoms, although more characteristic and more suggestive, are hardly less likely to lead to an erroneous diagnosis. Taken singly or combined, the physician may only be able to confirm the patient's statement that he is suffering from a "bad stomach"; and this does not lead very far toward a rational diagnosis or a purposive treatment. It is quite true that the bundle of sensations or perceptions is often valueless in the naked abstract; and, therefore, a thorough search must be made for the individualizing characteristics and the definitive features. To search out and keep before the mind the useful subjective symptoms is essential to the proper utilization of the clinical history. The chief importance attaches not to the gross symptom, but to its characteristics. The diseases of the stomach are not silent, and they commonly speak distinctly. Rarely, it may be otherwise. A disease of the kidneys, a compensated heart lesion, a disease of the liver, may long exist without creating a suspicion. This may also happen with a disease of the stomach, and the first revealing sign may be given by the disturbance of the function of some other organ, or the patient may be so accustomed to a "bad stomach" as to consider its existence meaningless, and may consult the physician for some other trouble-insomnia, palpitation, loss of strength, emaciation, cerebral fatigue. But in the large majority of cases the voice is more distinct, and is heard where it is produced. It is quite proper to speak of an ulcer history, a gastritis history, a cancer history, a myasthenia history, a history of neurasthenia gastrica, or a history of any of the clinically well-defined diseases of the stomach; but to be of value, the history must be compiled by the physician out of the material furnished by his purposive questioning of the patient. The interrogation of the patient demands tact and experience, and a knowledge of human nature and of the "dyspeptic." The "dyspeptic" is a poor student of himself, but a lover of criticism. Unguided, his story consists chiefly of the numerous drugs he has taken, and the many physicians whom he has consulted without benefit. Acrimonious, full of opinions, he remembers vaguely and relates unwillingly the facts concerning his digestive trouble, except in the light of a preconceived opinion. The physician, who is supposed to be familiar with the clinical pictures of the different diseases of the stomach, should, by well-chosen questions, concentrate the |