The Clinical Pathology of the Digestive Tract

ACUTE abdominal conditions so frequently cause death, and chronic lead to so long continiued ill-health and, often, dangerous complications, that it is obvious that (liagnosis with a view to treatment should be made as sootn as possible. It is essential that the diagnosis be as certain and exact as may be, for, in the acute case, its accuracy may be a matter of paramount importance, while, in the chronic, whether the treatment resulting be medical or surgical, it is likely to entail the patient's being away from his occupation for some weeks; if he be not on the way to recovery at the endc of that tinme it will have been wiasted. In arriviing at a diagnosis, the most important help of all is a careful account of hlistory and symptoms. In a certain number of cases, especially in the acute, otne can be morally certain of the exact pathological conidition from the patient's ownl story, and a diagnosis which does not fit in wvith it should be viewedl with suspicioIl. Next comes physical examiniation. In the acute case this is often sufficient to complete a diagnosis already considered likely, but in the chronic the assistance obtained is frequently not so great. In the latter it is advisable, if at all possible, to examine the patient on two separate occasions-when symptoms are active and again when they are quiescent. When symptoms are active, the site of pain or tenderness will be readily found. It may, however, be diffuse, covering a large area and not referable to any particular organ. If this be so, it is likely to persist anid be more defined when a less active phase is present. On the other hand, if the trouble is quiescent and nIo symptoms are at the time complained of, physical examiniation may yield very scant result. WlVhen all the information possible has been gained in these ways it should be possible to arrive at a tentative diagnosis. It is then that other methods may be called in either to confirm or negative it, and the gaze turns in the direction of radiology and the laboratory. Of the investigations carried out by the clinical pathologist in (ligestive disor(lers, probably the most generally useful is the fractional test meal. Fractiotnal Test Meal.-The fractional method of investigating gastric secretion was first described in America by Rehfuss in 1914, but was not practised in this country until six years later, when the technique was introduced by Ryle. At the beginining Ryle and Bennett carried out fractional test meals on one hundred volunteer students suffering from no detectable digestive abnormality, and from the data thus obtained determined what the findings are in normal people. For this piece of work a debt of gratitude is due to them from all who are interested in the study; the limits which they placed for normal curves are generally accepted and form a standard by which aberrations may be judged. Since then a great many investigations have been carried out by gastroenterologists and a most voluminous literature has grown up. A certain amount of