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 HEALTH SCIENCES 
 
 HX64131700 
 RC826 .AL5 The nature andcause 
 
 THE NATURE AND CAUSES OF 
 
 DUODENAL INDIGESTION 
 
 BEING THE 
 
 BRADSHAW LECTURE 
 
 DELIVERED BEFORE 
 
 e "glo^aC goCCege of ^{^stctcuts 
 
 BY 
 
 W. H. ALLCHIN, M.B.Lond. 
 
 Fellow of the College. 
 
 Physician and Joint Lecturer on the Principles and Practice of 
 
 Medicine to the Westminster Hospital, Examiner in Medicine to 
 
 the Examining Board for England, 
 
 On NOVEMBER 26, 1891. 
 
 Xondon 
 
 JOHN BALE & SONS 
 
 87-89, GREAT TITCHFIELD STREET, OXFORD STREET, W. 
 
 1892 
 
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THE NATURE AND CAUSES OF 
 DUODENAL INDIGESTION. 
 
THE NATURE AND CAUSES OF 
 
 DUODENAL INDIGESTION 
 
 BEING THE 
 
 BRADSHAW LECTURE 
 
 DELIVERED BEFORE 
 
 §6e ^lo^ctC gotTege of "g^stctcms 
 
 BY 
 
 W. H. ALLCHIN, M.B. 
 
 Fellow of the College. 
 
 Physician and Joint Lecturer on the Principles and Practice of 
 
 Medicine to the Westminster Hospital, Examiner in Medicine to 
 
 the Examining Board for England, 
 
 On NOVEMBER 26, 1891. 
 
 Hon&on 
 
 JOHN BALE & SONS 
 87-89, GREAT TITCHFIELD STREET, OXFORD STREET, \V. 
 
 1892 
 

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 THE NATURE AND CAUSES OF 
 
 DUODENAL INDIGESTION 
 
 Mr. President, Fellows of the Royal 
 College of Physicians, and Gentlemen, — 
 The series of lectures of which I am about 
 to deliver to you the eleventh owes its name 
 and origin to a bequest to this College made 
 in the year 1880 by the late Mrs. Bradshaw 
 in honour of the memory of her deceased 
 husband, Dr. William Woode Bradshaw, 
 some time extra-licentiate and member of 
 this College, who died at Reading on August 
 1 8th, 1866. The testator stipulated that the 
 income of the bequest should be "yearly 
 expended in establishing and permanently 
 maintaining an annual lecture to be de- 
 
DUODENAL INDIGESTION. 
 
 livered in connection with this College by a 
 lecturer to be chosen by the President on 
 some subject connected with physic." A 
 similar bequest with a like object was made 
 to the Royal College of Surgeons of England. 
 It was further enjoined that the lecture should 
 be delivered on August 18th, the anniversary 
 of Dr. Bradshaw's death. So far as this Col- 
 lege is concerned this condition has been 
 faithfully observed during the past ten years ; 
 but the serious inconvenience attached 
 thereto, together with the great probability 
 that the primary object of the testator would 
 thereby be considerably defeated, have in- 
 duced the College to apply to the Charity 
 Commissioners for permission to leave the 
 selection of the date in the hands of the 
 President. The consent of the Commis- 
 sioners having been obtained, an alteration, 
 more, it is hoped, in accordance with the 
 convenience of the Fellows, is made for the 
 first time this year. I think it altogether 
 fitting that my first words should be devoted 
 
DUODENAL INDIGESTION. 
 
 to the commemoration of our benefactor, 
 alike in honour of his memory and the en- 
 couragement of others similarly to benefit our 
 College for the good of our profession and 
 the increase of our common knowledge ; and 
 this I do with peculiar pleasure inasmuch as 
 Dr. Bradshaw received his medical education 
 in part at the medical school with which I 
 have the honour to be connected. 
 
 In proceeding to determine in what way I 
 could most profitably employ the opportunity 
 offered to me, I was obliged to consider what 
 subject I could best treat with any degree of 
 completeness within the limits of my allotted 
 time, and also what I might best pretend to 
 speak on, I will not say with authority, but 
 perhaps with some more intimate knowledge 
 due to a familiarity with the questions involved. 
 The one I have selected has long possessed 
 for me exceptional interest, and towards it I 
 have for some time especially directed my 
 attention. Yet no one is more fully conscious 
 than myself of the risk of failure that I court ; 
 
8 DUODENAL INDIGESTION. 
 
 for apart from great inherent difficulties in the 
 subject itself — difficulties which our present 
 want of physiological knowledge renders in- 
 superable — there remains the chance, if not 
 the certainty, that much of what I may say, 
 and perhaps in my own mind venture to claim 
 credit for, may be well known to many in this 
 learned company. I must rest content, there- 
 fore, if I should succeed in placing before you, 
 in a manner that is comprehensive and yet sug- 
 gestive of fresh inquiry and thought, a subject 
 well deserving of your consideration. 
 
 The nature and causes of duodenal indiges- 
 tion have not, so far as I have been able to 
 ascertain, received at the hands of authors 
 any very special attention. As a phase of 
 the general processes of dyspepsia, it doubt- 
 less has found a place ; but whilst various 
 remedies have been suggested to relieve 
 assumed imperfections in the performance of 
 the function, I can find no detailed descrip- 
 tion of the symptoms referable to this dis- 
 order, or of the causes leading thereto, still 
 
DUODENAL INDIGESTION. 9 
 
 less any account of the grounds upon which 
 its diagnosis may be based. I will even go 
 further, and express a belief that there 
 exists a general vagueness of thought and 
 expression in respect to this subject far 
 beyond what our present unavoidable ignor- 
 ance would justify. The whole subject of 
 indigestion, moreover, has, I venture to say, 
 been far from being always considered in a 
 scientific manner — in a manner, that is, based 
 on physiological grounds. Perversions of 
 other functions of the body have been of 
 recent years studied with far greater regard 
 to proved physiological data than have 
 imperfections of digestion, which have 
 furnished a happy hunting-ground for the 
 impostor and the quack. One has only to 
 read even in the works of those who are 
 accounted among leaders to recognise a sort 
 of accepted hopelessness in dealing with the 
 problems of indigestion. The multiplicity 
 and frequent remoteness of the symptoms 
 are considered a reproach, and, except for 
 
io DUODENAL INDIGESTION. 
 
 being occasionally treated of separately, are 
 but seldom regarded from the point of view 
 of the organs and functions primarily in- 
 volved. The great frequency of dyspeptic 
 troubles, and the general familiarity of the 
 profession no less than the laity with certain 
 symptoms thereof, have not engendered a 
 corresponding accuracy in their study or 
 rational basis of treatment. On the contrary, 
 there are few groups of diseases which can 
 show a more reckless empiricism in this 
 latter respect. I fully believe that not a 
 little of the obscurity attaching to the subject 
 and the general vagueness of idea concerning 
 it have a very distinct connection with a 
 want of precision in the use of the terms 
 employed, and with a lack of definition of 
 the limits of the question, as well as a failure 
 to recognise the exact relationship that the 
 function of digestion bears to the entire 
 economy of the organism. I find it need- 
 ful therefore to preface my remarks on 
 the proper subject of my lecture with some 
 
DUODENAL INDIGESTION. n 
 
 preliminary observations of a general char- 
 acter. 
 
 Indigestion, or its synonym, dyspepsia, 
 should be taken to signify some imperfection 
 in the performance of the function of digestion, 
 and should not, I hold, be made to include 
 disorders of other functions clearly distinct 
 from digestion, as is too often the case. The 
 process of digestion is strictly concerned with 
 the conversion of the solid and fluid ingesta 
 into a fluid and diffusible form ; it is essentially 
 of a physico-chemical character, capable to a 
 great extent of being imitated in our test-tubes 
 and laboratories. It is, I think, most un- 
 desirable to extend the meaning of the term 
 so as to include the process of absorption, 
 still less those subsequent metabolic changes 
 which tend to fit the digesta for their subse- 
 quent use in the nutrition of the tissues. 
 These latter functions are wholly different 
 from the acts comprised in digestion, and 
 though equally if not more important for the 
 well-being of the individual, are nevertheless 
 performed by entirely different structures, and 
 
12 DUODENAL INDIGESTION. 
 
 depend on entirely different conditions. It 
 may be urged, no doubt, that as digestion is 
 a necessary preliminary to absorption, as this 
 is in turn to assimilation, that for practical 
 purposes they may be considered as one, 
 especially as it is quite possible that some 
 molecular changes in the ingesta are effected 
 during digestion which are steps in the process 
 of metabolism, apart from those alterations 
 distinctly tending to the diffusibility of the 
 materials. But I entirely demur to this. 
 These three phases of the entire function of 
 nutrition, whilst intimately associated and 
 consequential, are, nevertheless, in the main 
 distinct in the character of the tissues con- 
 cerned no less than in the nature of the very 
 acts themselves, and for an investigation of 
 one or other of these functions when performed 
 abnormally, for recognising the distinctive 
 symptoms of each, the causes which lead 
 thereto, and for proposing rational remedies, 
 no limitation, I believe, can be too defined at 
 first, fully appreciating, of course, the inter- 
 
DUODENAL INDIGESTION. 13 
 
 dependence of these functions among them- 
 selves and with all other functions of the body. 
 If from among what have been designated 
 the protean symptoms of indigestion we are 
 enabled to discriminate those which owe their 
 origin essentially to a flaw in the physico- 
 chemical changes in the food from those 
 which depend on a failure in the due absorption 
 of the digested products, and still more from 
 those caused by subsequent mal-assimilation, 
 an important step has been made ; and there 
 is no more reason why such distinction should 
 not be drawn than there is for not making a 
 differential diagnosis of the disorders of other 
 functions. The expression ''digestion by the 
 tissues or interstitial digestion " merely 
 denotes the anabolic processes of the tissues, 
 and such extension of terms leads to no 
 practical good, since the digestion by the 
 tissues is doubtfully comparable to the 
 processes carried on in the alimentary canal, 
 and is wholly different in the conditions under 
 which it is performed. It is worth while also 
 
i 4 DUODENAL INDIGESTION. 
 
 to remember that the real significance of 
 the phrase " disorders of digestion " is very 
 different from that of " diseases of the 
 digestive organs." The greater number of 
 the maladies which engage our attention are 
 named and primarily regarded from an 
 anatomical standpoint ; the recognisable 
 modification in structure, whether gross or 
 minute, is made the basis of enquiry, and 
 even when the disease is studied clinically 
 it is with a more or less expressed reference 
 to the associated or causative structural 
 perversions. The nomenclature of our di- 
 seases is also mainly anatomical ; and whilst 
 I regard it as all-important to make anatomy 
 the foundation of pathology, such a view 
 does not meet all the requirements of the 
 practical physician, nor completely satisfy 
 our conceptions as to the real nature of 
 morbid phenomena. 
 
 Whilst, therefore, by "diseases of the 
 digestive organs " is signified those structural 
 changes in the tissues of the organs expressed 
 
DUODENAL INDIGESTION. 15 
 
 by such terms as inflammation, degeneration, 
 new growths, &c., and specifically denoted by 
 such words as gastritis, enteritis, cancer of 
 the liver, &c, comparable to similar diseases 
 of the heart, lungs, or nervous system 
 (endocarditis, pneumonia, cerebral abscess, 
 &c), the phrase " disorders of digestion " 
 denotes imperfection in the functional per- 
 formances of the digestive organs, with less 
 implied reference to structural changes of 
 those organs than is the case with disorders 
 of other parts of the body. How seldom 
 comparatively speaking, do we hear of cases 
 of gastritis, or enteritis, of gastric cirrhosis or 
 atrophy of the intestine, and how often of 
 indigestion or dyspepsia, w r hich are none the 
 less immediately due, in the majority of cases, 
 to structural perversions in the organs con- 
 cerned. The fact is that in regard to 
 digestive disorders we are far more in the 
 habit of regarding the functions apart from 
 the organs than we are in the case of any 
 other regions of the body, and, as a con- 
 
16 DUODENAL INDIGESTION. 
 
 sequence, to place the disturbance of the 
 function of digestion on a somewhat differ- 
 ent platform to what we do disorders of other 
 parts. In other words, the structural diseases 
 of the alimentary tract and appendages are 
 described and regarded apart from their 
 relation to the digestive function. The 
 symptoms of a gastritis or hepatic cirrhosis 
 overshadow the true indigestion effects to 
 which they give rise, and as a consequence 
 we find ourselves insensibly separating 
 tangible diseases of the alimentary organs 
 from the symptomatic perversions of the 
 digestive process. That such should not 
 tend to elucidation, or to a clear conception 
 of indigestion, must, I think, be admitted. 
 It introduces an element of confusion fatal 
 to a proper appreciation of what indigestion 
 is, still more to the differential diagnosis 
 of the various forms of the malady. I 
 believe this to be in great part attributable 
 to the fact that the function of digestion 
 bears a somewhat different relation to the 
 
DUODENAL INDIGESTION. 17 
 
 whole organism than do the other functions 
 of the body. I have described it as being 
 essentially physico-chemical ; that is to say, 
 the preparation of the food for absorption, 
 irrespective of its nutritive value and only 
 conditioned by its digestibility, is affected 
 by certain movements which bring about 
 a finer subdivision of the food and a due 
 mixing with certain solvent juices which 
 convert the ingesta into a soluble and 
 diffusible state. To a great extent these 
 processes are but continuations of what is 
 accomplished by the ordinary preparation 
 of our food for the table. It is true that 
 the movements of mastication, deglutition, 
 and peristalsis are effected by a character- 
 istically living tissue-muscle, but the results 
 obtained are in no way different from what 
 a mincing machine and a mixer can perform. 
 The changes which are brought about by 
 the various alimentary secretions, saliva, 
 gastric and pancreatic juices, and bile, can 
 be very closely imitated out of the body. 
 
DUODENAL INDIGESTION. 
 
 and their sole peculiarity is the presence 
 in some of them of peculiar ferment bodies 
 which depend for their formation on living 
 protoplasm ; and with their action digestion 
 proper ends, whilst the subsequent absorption 
 and metabolism are intimately dependent, 
 more especially the latter, on vital activity. 
 Moreover, the process of digestion is to all 
 intents and purposes carried on outside the 
 body on an epithelial surface, the lining of 
 a canal which is open to the exterior at each 
 end, and is in no sense within the body 
 proper. It is only after the food has been 
 digested that it actually gains entrance into 
 the tissues by absorption. The relationship 
 of the food during digestion to the tissue 
 elements is therefore most remote ; the 
 various digestive secretions formed by certain 
 specialised epithelia are thrown out by the 
 cells upon a free surface, where they exert 
 their characteristic effects upon the food 
 constituents. A very considerable re-absorp- 
 tion doubtless takes place of the juices, but 
 this would seem to be a matter of economy. 
 
DUODENAL INDIGESTION. 19 
 
 So long as the various stages of the 
 digestive process are performed according 
 to the standard which we assume as normal, 
 unaccompanied by pain, and, indeed, for 
 the most part without sensation, except, 
 perhaps, of a mildly pleasurable kind, the 
 function is to be regarded as healthy, what- 
 ever failure may occur in the absorption of 
 the digesta and in their subsequent assimi- 
 lation. Doubtless it will be urged that 
 should either of these functions be imper- 
 fectly performed, the process of digestion 
 itself will suffer ; that delay in absorption 
 of the digesta is a definite cause of 
 dyspepsia, and mal-assimilation leads to a 
 general mal-nutrition, in which digestion 
 fails, along with other functions. True, of 
 course ; but I am contending that if we are 
 to form a clear conception of what indiges- 
 tion is as a preliminary to diagnosing what 
 phase of digestion is imperfect, we must 
 commence by having a clear notion of what 
 digestion is strictly concerned with. 
 
20 DUODENAL INDIGESTION. 
 
 There is another characteristic of the 
 function of digestion which requires con- 
 sideration in view of the special subject of 
 my remarks, and that is what may be 
 termed its progressive character. Owing to 
 the different nature of the alimentary prin- 
 ciples and the corresponding different nature 
 of the means for digesting them, they are 
 not all reduced to a fluid and absorbable 
 state at once, but at successive stages and 
 in successive parts of the canal. Thus we 
 have buccal, gastric, and intestinal indiges- 
 tion ; and an important question arises : To 
 what extent is the process, as carried out 
 in later stages, influenced by or dependent 
 on those which have preceded them ? 
 Looking to the three groups of alimentary 
 principles which require digestion — proteids, 
 carbo-hydrates, and fats — the others being 
 diffusible without change, the first-mentioned, 
 and in one sense most important, element 
 of food requires the greatest amount of 
 digestion, and occupies by far the longest 
 
DUODENAL INDIGESTION. 21 
 
 time in so doing. The sequence in the 
 digestion of these substances is also notice- 
 able. Thus, commencing with the mouth, 
 a considerable amount of the starch food is 
 converted by saliva during mastication into 
 soluble maltose, and for a short period this 
 conversion is continued after the food reaches 
 the stomach. In the stomach the proteids 
 are mostly converted into diffusible peptones, 
 a process which occupies a relatively long 
 period. Up to the passage of the chyme 
 into the duodenum the fats have been 
 untouched, and are not unfrequently a 
 hindrance to the due digestion of the other 
 materials. First the carbo-hydrates alone, 
 then the proteids alone, are acted upon, and 
 there is little doubt but that some of the 
 digesta are absorbed from the stomach as 
 dextrose, peptones, and salts, whilst the 
 greater bulk, which constitutes the chyme, 
 passes on through the pylorus into the 
 intestine for subsequent treatment, where 
 the facilities for absorption are much 
 
22 DUODENAL INDIGESTION. 
 
 greater. The chyme, then, as it leaves the 
 stomach, being emitted through the relaxed 
 pyloric orifice at intervals during gastric 
 digestion, appears as a grey grumous fluid 
 of strongly acid reaction, and consists of 
 such proteids and carbo-hydrates as may 
 have escaped any treatment by the gastric 
 juice and saliva respectively, products of the 
 digestion of these substances not absorbed 
 — namely, albumoses and peptones, dextrine 
 and maltose, fats which have as yet received 
 no treatment, unabsorbed salts and water, 
 such indigestible substances as may happen 
 to be present, and remnants of saliva with 
 a variable quantity of the gastric juice. 
 The passage of this material over the 
 common orifice of the bile and pancreatic 
 ducts excites a flow of these fluids, which 
 arrest the action of the pepsin and finally 
 destroy it, and, in virtue of their strong 
 alkalinity, very quickly neutralise the acidity 
 of the chyme, which in the lower part of 
 the duodenum and throughout the greater 
 
DUODENAL INDIGESTION. 23 
 
 part of the small intestine remains alkaline. 
 Briefly stated, the changes effected in the 
 constituents of the chyme to further fit them 
 for absorption by the villi depend upon the 
 maintenance of a temperature of ioo° F., 
 or thereabouts, which, so long as life exists, 
 may be said to be provided, and any known 
 variations in which are not recognised as 
 modifying the digestive process in any way ; 
 and, secondly, upon a sufficient supply of 
 the bile and pancreatic juice, disregarding 
 the succus entericus, concerning the action 
 of which much uncertainty prevails. Prac- 
 tically what is for shortness termed "duodenal 
 digestion " is the digestion of the chyme by 
 these two fluids, which takes place through- 
 out an unknown and probably variable length 
 of the jejunum, and consists in a special 
 preparation of fats for absorption, and in a 
 supplementary treatment of carbo-hydrates 
 and proteids which have each received 
 individual digestion in the mouth and 
 stomach. At the outset, then, intestinal 
 
24 DUODENAL INDIGESTION. 
 
 digestion, and more particularly that which 
 may be denominated duodenal, is in marked 
 contrast to the buccal and gastric, inasmuch 
 as here for the first time all three alimentary 
 principles are submitted to simultaneous 
 digestion, and the opportunities for mal- 
 performance would appear to be propor- 
 tionately increased. 
 
 As a digestive agent — i.e., as a solvent 
 fluid — the bile is of little account, since it is 
 very doubtful whether it exerts any effect by 
 itself upon the proteids or carbo-hydrates, and 
 as an emulsioniser of fats it is far inferior to 
 the pancreatic juice, to which it appears to be 
 distinctly accessory in its digestive action. 
 But whilst occupying this secondary position 
 as regards the conversion of the ingesta to a 
 diffusible state, it has a very special value in 
 two other directions, one of which especially 
 concerns us here. First, it undoubtedly 
 facilitates the absorption of fats, rendering 
 the mucous surface more permeable ; and 
 secondly, it exerts a very definite action upon 
 
DUODENAL INDIGESTION. 25 
 
 the chyme, which appears to be a desirable 
 preliminary to the pancreatic digestion. The 
 proteids of the chyme, as already said, con- 
 sist of those which have escaped peptic 
 digestion, together with peptones and inter- 
 mediate bodies known as acid albumen and 
 albumoses. The peptones, which are both 
 soluble and diffusible, are untouched, but the 
 undigested proteids in solution and the acid 
 albumens and albumoses, as well as the 
 pepsin, are precipitated in a flocculent and 
 granular form by the alkalies and salts of the 
 bile. The exact object of this is not very 
 apparent, but it is upon these substances that 
 the trypsin ferment of the pancreatic juice 
 exerts its action, with the result of converting 
 them into diffusible peptones, similar if not 
 identical with the products of peptic digestion, 
 and through similar intermediary stages. The 
 pancreatic digestion of proteids is, however, 
 carried further in the disintegration of the 
 molecules than the gastric digestion is, since 
 the hemi-peptones of tryptic fermentation 
 
26 DUODENAL INDIGESTION. 
 
 may be converted into leucin and tyrosin, 
 preliminary stages to the excretion of the 
 nitrogenous excess as urea. How far this 
 actually takes place in the intestine probably 
 depends in great part upon the amount of 
 proteids present. The conversion of the un- 
 digested starches of the chyme by the 
 amylotic ferment of the pancreatic juice is 
 exactly comparable to the action of the 
 ptyalin of the saliva, perhaps aided therein by 
 the bile, and the fats are chiefly emulsionised, 
 and to a slight degree saponified. The salts 
 and other diffusible elements of the chyme 
 are absorbed from the intestine without 
 further treatment. 
 
 Over and above the changes exerted by 
 the digestive juices upon the intestinal con- 
 tents, another agent has to be considered. 
 How far it is effective in normal digestion is 
 doubtful, but it very readily asserts itself, and 
 becomes responsible for many indigestion 
 results. I refer to the action of micro- 
 organisms, various species of which normally 
 
DUODENAL INDIGESTION. 27 
 
 inhabit different regions of the alimentary 
 canal, the mouth, stomach, and different 
 parts of the intestine. Under ordinary cir- 
 cumstances they take no part in buccal 
 digestion, and to only a very slight extent in 
 the acid medium of the stomach ; but in the 
 alkaline contents of the intestine they find a 
 most suitable field for their activities and de- 
 velopment. In normal conditions the changes 
 which these bodies produce, in the small in- 
 testine at least, are scarcely, if at all, of a 
 putrefactive character, and are probably in 
 great part limited to a lactic and butyric acid 
 fermentation of carbo-hydrates, a fat-splitting 
 action comparable to that exerted by the 
 steapsin of the pancreatic juice and a slight 
 peptonising action on proteids. But it most 
 certainly appears that none of these actions 
 are essential, and so far as is at present 
 known, the entire process of digestion would 
 equally well be carried out in the complete 
 absence of these organisms by the sole 
 agency of the various juices. Their presence, 
 
28 DUODENAL INDIGESTION. 
 
 moreover, is to be regarded as a risk, since it 
 would seem that the normal limits within 
 which their action is kept, perhaps by the 
 bile, is easily overstepped, with the result of 
 giving rise to putrefactive decomposition of 
 a serious nature, which, under ordinary cir- 
 cumstances, only occurs to a very slight ex- 
 tent in the large intestine and lower end of 
 the ileum — that is to say, beyond the limits of 
 action of the pancreatic juice, where it is 
 believed that the intestinal contents, having 
 lost their nutritive constituents by absorption, 
 consist only of indigestible residue. In this 
 connection I would quote from Professor 
 Halliburton's recent valuable work on 
 " Physiological Chemistry," the following sug- 
 gestive remarks: — "A useful function ful- 
 filled by the organisms appears to be the 
 destruction of poisonous substances, such as 
 cholin, the alkaloid derived from lecithin. It 
 is possible that, if other alkaloids (leuco- 
 maines) are formed by the processes occur- 
 ring in the intestines, these also are destroyed, 
 for they are absent in the normal excretions." 
 
DUODENAL INDIGESTION. 29 
 
 Very briefly, but as necessarily preliminary 
 to my subject proper, have I sketched the 
 main features of intestinal digestion, or at 
 least that part of it which may be con- 
 veniently denominated duodenal. I would 
 specially emphasise what I have termed the 
 progressive character of the process. The 
 various alimentary principles are dealt with 
 seriatim and then simultaneously, and it 
 behoves us to try to ascertain how far the 
 earlier steps in the process are essential to 
 the proper performance of the later ones ; 
 whether, that is to say, buccal and gastric 
 digestion, apart from the direct conversion 
 they effect in certain food elements, are 
 necessary to the subsequent satisfactory 
 action of the duodenal secretions. In the 
 experimental inquiries upon which much of 
 our knowledge of intestinal digestion is based, 
 I cannot help thinking this has not been 
 sufficiently taken into consideration, and that 
 untouched food stuffs have been submitted 
 to the action of the pancreatic juice under 
 
3 o DUODENAL INDIGESTION. 
 
 suitable conditions, but without any attempt 
 to imitate the preliminary gastric treatment of 
 them. I had myself partially devised some 
 experiments keeping this object in view, and 
 much regret that I have been unable to carry 
 them out up to the present time, but hope to 
 do so very shortly with the facilities offered 
 by our laboratories on the Embankment. It 
 is true that in animals the introduction of the 
 crude foods through duodenal fistulse has 
 been followed by a complete digestion of 
 them, the effect of the stomach being thus 
 eliminated ; but I am not disposed myself to 
 regard the results as conclusive nor as fairly 
 comparable to what takes place in the human 
 subject. So far as I am aware, the only case 
 in man that offers opportunity for observa- 
 tion on this point occurred at Guy's Hospital 
 in the practice of Mr. Golding-Bird, and was 
 reported by him in the nineteenth volume 
 of the Clinical Society's Transactions. In a 
 patient whose jejunum had been opened about 
 four inches below the duodenum — exactly, that 
 
DUODENAL INDIGESTION. 31 
 
 is, where the biliary and pancreatic digestion 
 is in progress — it was noticed that certain indi- 
 gestion symptoms followed the introduction, 
 through the fistula of such food as beef-tea, 
 milk, bread, and corn-flour — i.e., food which 
 had not received previous buccal or gastric 
 treatment. The case serves to illustrate 
 another point, and I shall refer to it again, but 
 so far as it goes it confirms what I am in- 
 sisting on, viz., the all-importance of salivary 
 and peptic digestion of the food before the 
 bile and pancreatic juice are called upon to 
 exercise their activity. 
 
 So much for the normal process of intes- 
 tinal digestion. Now let us turn to consider 
 in what way this may be imperfectly per- 
 formed, and by what symptoms, if any, such 
 imperfection may be recognised ; the evi- 
 dences, that is, of the chyme not being so 
 treated as to fit its constituents for absorption, 
 at which point the digestive process proper 
 ends. For clearness of description the con- 
 ditions leading to such indigestion may be 
 
32 DUODENAL INDIGESTION. 
 
 summarised thus: — i. Some impropriety in 
 quantity or composition of the chyme, in- 
 cluding initial errors in diet. 2. Some per- 
 version in the quantity or quality of the bile 
 and pancreatic juice, more particularly the 
 latter. 3. Some accessory fermentation pro- 
 cess or processes of an abnormal character. 
 4. Exaggerated or deficient peristalsis. 5. 
 Defective absorption of the digesta. Any 
 form of duodenal dyspepsia must be directly 
 referable to one or other of these causes. Is it 
 possible to discriminate or to recognise any 
 symptoms which may be clearly traceable to 
 either of these states ? It will be well, in any 
 attempt to answer this question, to consider 
 these groups of causal conditions somewhat in 
 detail. A clear idea of the possible circum- 
 stances which may lead to imperfect digestion 
 in the intestine should be helpful towards 
 making the diagnosis. 
 
 First, as to the character of the chyme, the 
 material to be digested and rendered absorb- 
 able/ Obviously the perfectness of its di- 
 
DUODENAL INDIGESTION. 33 
 
 gestion may be as dependent upon its intrin- 
 sic nature as upon the efficacy of the agents 
 by which it is to be acted upon. If the con- 
 stituents of the chyme be impossible of 
 digestion by the pancreatic juice and bile, the 
 digestive result will be proportionately small. 
 All our food of course contains a certain pro- 
 portion of such material, which, passing along 
 unchanged, contributes to the formation of the 
 faeces. Cases where the great bulk of the 
 food consists of such indigestible material are 
 so exceptional and so easily corrected that 
 further consideration of them need not detain 
 us. In another class of diets there are few 
 or many substances which are noxious, 
 though perfectly digestible — digestible, that 
 is, though not nutritious, a distinction not 
 always sufficiently observed — the former is 
 strictly what may be made in the alimentary 
 canal diffusible ; the latter is only what is of 
 value in tissue metabolism, subsequent to ab- 
 sorption from the canal. In the greater 
 number of cases it will be found, I believe, 
 3 
 
34 DUODENAL INDIGESTION. 
 
 that such substances receive fitting treatment 
 in the stomach, whether by causing vomiting 
 and so removal, or are rendered innocuous by 
 the action of the gastric juice, and cannot be 
 recognised as causing difficulty in the in- 
 testine. Exceptions of course do occur, and 
 the toxic bodies, passing on into the bowel, 
 there set up effects directed to their removal, 
 by causing diarrhoea, often with pain and 
 other symptoms. Such ingredients of the 
 food are, however, accidental, and their pre- 
 sence, except for completeness of our subject, 
 scarce require mention as a cause of intestinal 
 dyspepsia. The conclusions arrived at by- 
 Sir Wm. Roberts respecting the effect of food 
 accessories — such as alcoholic drinks, tea, 
 coffee, beef-tea, and whey — upon salivary, 
 gastric, and pancreatic digestion, are of ex- 
 ceeding interest, especially in reference to my 
 present point. He found their general ten- 
 dency was to retard digestion in the mouth 
 and stomach in proportion to their strength, 
 but that with regard to pancreatic digestion 
 their effects were practically nil. 
 
DUODENAL INDIGESTION. 35 
 
 Very different, however, is it with those 
 modifications of diet which consist in excesses 
 or deficiences of those constituents which in 
 themselves, and in proper quantity, are re- 
 quisite, viz., proteids, fats, and carbo-hydrates, 
 and, to a much less degree, salts and water. 
 Insufficiency of the amount of any of the 
 required alimentary principles, it may be said 
 at once, shows itself rather in remote nutri- 
 tive disturbances than in immediate digestive 
 trouble, but excess in the quantity of one or 
 more of these substances distinctly does, in 
 the great majority of cases, directly bring 
 about a dyspepsia more or less considerable. 
 Doubtless here, as in so many other cases, 
 habit does much, and the person who can 
 digest anything can also usually digest any 
 quantity which his appetite allows of his con- 
 suming. Excess of proteid ingesta, so far as 
 it affects the quality of the chyme and the 
 consequent duodenal digestion, will likely lead 
 to a larger amount escaping gastric treatment 
 than is normally the case, and the greater 
 
36 DUODENAL INDIGESTION. 
 
 demand, therefore, for treatment by the pan- 
 creatic juice. Here, again, in the majority of 
 persons, the excess over what is actually 
 required is probably met by an advanced 
 stage of disintegration, with the production of 
 large quantities of leucin and tyrosin, later, 
 no doubt, converted into urea and its allies, 
 and thus may become responsible for dis- 
 orders primarily of metabolism or excretion, 
 the work of digestion, so far as they are con- 
 cerned, being properly performed, and there 
 being no dyspepsia, at least of a primary 
 character. Again, chyme containing a large 
 excess of proteid matter, in various forms — 
 more, we may fairly suppose, than the pan- 
 creatic juice can satisfactorily deal with — 
 gives at once the opportunity for increased 
 activity and development of those intestinal 
 micro-organisms which are ever ready to 
 assert their powers, and with this grave dis- 
 advantage, that whilst the trypsin fermenta- 
 tion ceases with the production of such com- 
 paratively harmless bodies as leucin and 
 
DUODENAL INDIGESTION. 37 
 
 tyrosin, the decomposition effected by the 
 living germs becomes more and more putre- 
 factive in character, and leads to the produc- 
 tion of many toxic substances, leuco- 
 maines, &c, which, becoming absorbed, are 
 largely responsible for the remote symptoms 
 of dyspepsia to be afterwards considered. In 
 the sense, then, of permitting excessive 
 micro-organism activity, with its attendant 
 risks, an overplus of proteid food becomes a 
 cause, and one that is to be regarded as fre- 
 quent, of duodenal indigestion. 
 
 The excessive ingestion of carbo-hydrate 
 food, whether as starch or in the form of 
 sugar, is liable seriously to modify the pro- 
 gress of digestion in the stomach, and thus 
 to affect the character of the chyme. There 
 is good reason to believe that in the earliest 
 stage of normal gastric digestion the prevail- 
 ing acid in the process is lactic, derived 
 mainly from the carbo-hydrate food. Gra- 
 dually this is replaced by hydrochloric acid, 
 which alone is found after the middle of the 
 
38 DUODENAL INDIGESTION. 
 
 period occupied by the digestion of an or- 
 dinary meal. Should the source of the lactic 
 acid be unduly excessive, the predominance 
 of the hydrochloric acid is likely to be de- 
 layed, and perhaps not attained, with the 
 result of very considerably interfering with 
 the proper digestion of the proteids in the 
 stomach, and their consequent appearance in 
 the chyme, ill prepared for tryptic digestion. 
 Moreover, when lactic acid is formed in the 
 stomach to any considerable extent, as it is 
 likely to be when there is very much sugar 
 present, further organic fermentations are set 
 up, with the production of various acids, 
 especially butyric, which escape in the chyme, 
 and are probably a further source of dis- 
 arrangement of the intestinal digestion. 
 Somewhat in contrast to the previously men- 
 tioned condition — viz., excessive proteid food, 
 where the ill effects, so far as digestion is 
 concerned, are produced in the intestine — 
 here, where carbo-hydrates are in excess, the 
 dyspeptic results are gastric in situation, or at 
 least are so primarily. 
 
DUODENAL INDIGESTION. 39 
 
 Lastly, an excess of fat in the diet. This 
 to a great extent exerts an ill effect by its 
 mechanical distribution in the food. If it be 
 in separate portions there is no reason that I 
 am aware of to attribute to it any harm ; but 
 if it be presented as an oily coating to par- 
 ticles of proteid or carbo-hydrate, it protects 
 these latter from the solvent action of the 
 saliva and gastric juice until their escape in 
 the chyme to the intestine, where the fat first 
 receives treatment by the bile and pancreatic 
 juice. Inasmuch as the various fats of food, 
 in whatever form taken, are melted in the 
 stomach, a large quantity might tend to pre- 
 vent in this merely mechanical manner the 
 due digestion of the other food constituents, 
 and thus to determine a gastric, if not a sub- 
 sequent duodenal indigestion of these sub- 
 stances. 
 
 I have so far spoken of dietetic errors in 
 the main groups of alimentary principles as 
 they may occur singly, but it is, of course, 
 often the case that two or more of these im- 
 
4 o DUODENAL INDIGESTION. 
 
 proprieties coexist, with, it may be presumed, 
 a corresponding complexity in dyspeptic re- 
 sults. The interactions, if any, which take 
 place among — or, at least, the influences ex- 
 erted on each other by — the different food 
 stuffs in the progress of their digestion are 
 but little known in health, and still less in the 
 course of disease. 
 
 The chief imperfections in the chyme, then, 
 that we can fairly assume to exist, exclusive 
 of noxious substances occurring in the food, 
 are a large excess of proteids very partially 
 and deficiently treated by the gastric juice, 
 and a very considerable excess of lactic, 
 butyric, and other acids, the results of carbo- 
 hydrate decomposition. Both derangements 
 may occur together, and the former certainly 
 in the way shown, and possibly also the latter 
 may be the cause of mal-digestion in the 
 intestines. 
 
 Supposing, however, the diet be all that is 
 satisfactory so far as it conforms to what is 
 required in digestibility and composition — 
 
DUODENAL INDIGESTION. 41 
 
 and how often are the most careful and 
 regular in their feeding severe sufferers from 
 indigestion — there yet may be a very im- 
 perfect gastric digestion due to improper 
 quantity or quality of the gastric secretion, or 
 to some deficiency in the movements of the 
 stomach, whereby the contents are not pro- 
 perly mixed or are not ejected into the duode- 
 num as they should be, the whole process being 
 thereby delayed, and giving rise to organic 
 fermentations of the contents, as may be seen 
 in an aggravated form in the ordinary state of 
 gastroectasis. It is apart from my subject to 
 discuss thecauses of gastric indigestion ; suffice 
 it to say that, whatever they may be, the re- 
 sulting chyme which is submitted to duodenal 
 digestion is impaired as regards the changes 
 in its proteid elements, and may contain large 
 amounts of lactic and butyric acids and other 
 products of carbo-hydrate fermentation — 
 similar results, that is, to those which may 
 attend an excessive ingestion of either of 
 these alimentary principles. Should both the 
 
42 DUODENAL INDIGESTION. 
 
 diet be improper and the gastric juice be 
 deficient, it is reasonable to suppose a still 
 further defect of the chyme in the absence of 
 any compensations or adjustments which are 
 at present quite unknown to exist. In these 
 various directions, then, may we conceive of 
 the chyme being abnormal, and as such the 
 cause of duodenal indigestion. 
 
 Another cause for the same is to be found 
 in the deteriorated quality of the duodenal 
 secretions, or a deficiency in their quantity, 
 which may happen with either a perfectly 
 normal or a seriously vitiated chyme. Prac- 
 tically, as we have seen, the pancreatic juice 
 is alone to be taken account of as a digestive 
 agent, the bile being only accessory thereto. 
 As regards the composition of the juice, we 
 have only an uncertain knowledge, though 
 occasionally opportunities have offered to ob- 
 tain it from the main duct, and we certainly 
 have no definite indications as to any modifi- 
 cations it may undergo in disease, such as we 
 possess in respect to the amounts of the acid 
 
DUODENAL INDIGESTION. 43 
 
 and pepsine of the gastric juice ; but its 
 efficiency may be suspected to be impaired in 
 general states of mal-nutrition, such as fever, 
 anaemia, and the like. But if we know 
 nothing of alterations in the composition we 
 are not infrequently able to detect deficiencies 
 or, indeed entire absence, of one or both of 
 these secretions from the intestine. Occlu- 
 sion of the main ducts by calculi or pressure 
 of tumours will lead to this condition, and 
 afford opportunity for the study of intestinal 
 digestion in their absence. Deficiency or 
 absence of these fluids signifies, of course, in- 
 complete digestion of the chyme, and apart 
 from the direct dyspepsia which such may 
 cause, indirect effects may be induced by non- 
 arrest of the peptic digestion which should 
 normally take place, although this may be a 
 beneficial compensation, by permitting a con- 
 tinuance of the proteid changes and peptone 
 formation by the gastric juice, which other- 
 wise the pancreatic fluid should have accom- 
 plished. In exclusion of these secretions 
 
44 DUODENAL INDIGESTION. 
 
 from the duodenum the precipitation of the 
 albumoses above described can hardly be 
 supposed to take place, perhaps again ad- 
 vantageous in the absence of the trypsin 
 ferment. Sir William Roberts has shown, 
 in contradiction to views that had been main- 
 tained, that the activity of the pancreatic 
 juice is arrested by the acids of the stomach, 
 and it is not improbable that in those condi- 
 tions already described, where the chyme 
 contains a large excess of the gastric acids, 
 the power of the pancreatic juice is dimin- 
 ished or even temporarily destroyed. 
 
 A third group of conditions which are 
 undoubted causes of intestinal indigestion, are 
 those abnormal or excessive organic fermen- 
 tations which have already been referred to 
 as liable to follow a defect in the quality of 
 the chyme. The bile is usually regarded as 
 specially concerned in the prevention of these 
 fermentations, or, at least, those of a putre- 
 factive character, and entire absence of bile 
 ought to be followed by considerable changes 
 
DUODENAL INDIGESTION. 45 
 
 of this nature in the intestinal contents. Yet 
 my own experience would lead me to very 
 much question the great power of the bile in 
 this respect. At all events, it is no uncom- 
 mon thing to find the stools absolutely free 
 from bile, and yet with no specially putrid 
 characteristics ; whilst, on the other hand, 
 those which may contain fully the normal 
 quantity, so far as can be estimated by colour, 
 may be remarkably offensive. I believe my- 
 self the putrefactive changes are mainly 
 effected low down in the canal, and are not 
 much influenced by the bile, and I am quite 
 unaware of any control being exercised by 
 this fluid over those toxic substances which 
 may be formed in the intestine from the de- 
 composition of the proteids. 
 
 Lastly, as causes of intestinal indigestion 
 may be mentioned deficient or exaggerated 
 peristalsis and insufficient absorption into the 
 vessels of the villi, with consequent retention 
 of the digesta in the canal. Perversions of 
 peristalsis may be induced by the irritating 
 
46 DUODENAL INDIGESTION. 
 
 character of the chyme, causing diarrhoea, 
 with mal-digestion and imperfect absorption ; 
 or the movements may be hindered by oedema 
 of the muscular coat from congestion, by de- 
 generation, by excessive distension or dis- 
 turbed innervation. The delav in the onward 
 progress of the chyme favours the activity of 
 the micro-organisms present with the results 
 already indicated, whilst deficient peristalsis 
 means insufficient mixing of the food with the 
 secretion, and also lessens the secretion itself, 
 as well as hindering absorption, both of which 
 the movements of the canal very considerably 
 stimulate. But there is a special disorder 
 of the movements of the stomach to which 
 I am of opinion not a little indigestion is 
 due — viz., an exaggeration of the normal 
 propulsive movements, with undue relaxa- 
 tion of the pylorus, thereby facilitating 
 exit of the gastric contents, especially the 
 larger solid portions, before the peptic action 
 is sufficiently advanced, and so, in the ways 
 already referred to, interfering with pan- 
 
DUODENAL INDIGESTION. 47 
 
 creatic digestion. The opposite condition 
 — namely, deficient gastric movements, with 
 consequent retention of food in the stomach 
 — has also to be mentioned, as causing 
 an abnormal chyme and subsequent liability 
 to duodenal dyspepsia. There is good 
 reason to believe that if the diffusible pro- 
 ducts of digestion be not absorbed as they 
 are formed, the continuance of digestion is 
 unfavourably interfered with, whether in 
 stomach or intestine, owing to putrefaction 
 taking place in the substances retained ; and 
 it would further seem that the due secretion 
 of the various juices — certainly the gastric — 
 is very directly dependent, among other 
 things, upon the regular absorption of 
 material from the canal. 
 
 To recapitulate the conditions which are 
 immediately provocative of an indigestion in 
 the upper part of the intestine, they are (1) 
 Initial errors in diet ; (2) defects in the pre- 
 paratory buccal and gastric changes ; (3) 
 perversion of biliary or pancreatic digestion ; 
 
48 DUODENAL INDIGESTION. 
 
 (4) excessive and abnormal micro-organism 
 activity ; (5) exaggerated or deficient peris- 
 talsis ; and (6) imperfect absorption of the 
 already digested materials. It is probably rare 
 that one of these causal conditions occurs 
 alone ; more commonly several contribute to 
 the existent dyspepsia. It is to be understood 
 that I speak here of immediate causes only. 
 The circumstances which lead to them time 
 does not allow me to touch upon, but it is of 
 course implied that these conditions, in their 
 turn, are the expressions of structural changes 
 in the organs involved, whether these be as 
 obvious as a gastritis, or as impossible of de- 
 tection as a disturbed innervation. But it 
 should not be forgotten that among the ante- 
 cedent circumstances of these immediate 
 causes is often to be reckoned dyspepsia 
 itself, since the imperfect tissue changes 
 thereby determined lead to an impaired 
 structural condition of the digestive organs, 
 with deteriorated functions and vitiated 
 secretion of juices, thus maintaining a vicious 
 
DUODENAL INDIGESTION. 49 
 
 circle which intensifies itself. The depend- 
 ence of indigestion also upon disorders of 
 metabolism or on mal-excretion of tissue 
 waste — errors of nutrition leading to the cir- 
 culation of a vitiated blood, with consequent 
 deterioration of glandular secretion — is too 
 obvious to require more than mention. 
 
 Looking at the subject in the way I have 
 done, the following questions suggest them- 
 selves, and though not capable of solution 
 at present, are, I think, worth stating as 
 helping to define the limits of our knowledge 
 and to indicate the direction of future in- 
 quiry. Given a case of gastric dyspepsia, 
 from whatever cause, with its special symp- 
 toms, must the resulting abnormal chyme de- 
 termine a further duodenal dyspepsia with 
 fresh symptoms, though other conditions in 
 the bowel may be taken as satisfactory ? 
 Or may the duodenal process correct and 
 compensate the stomach failure, with the 
 result that the indigestion is restricted to 
 the latter region ? Or, again, in a case in 
 4 
 
50 DUODENAL INDIGESTION. 
 
 which there is no evidence of gastric indiges- 
 tion, can a true duodenal dyspepsia arise 
 From any local causes — deficiency of secre- 
 tions, micro-organisms, &c. — producing symp- 
 toms, if not of a distinctive character, at 
 least primarily attributable to it ? Admitting 
 that gastric indigestion may cause pancreatic 
 indigestion, the two coexisting, may each 
 occur independently and alone ? 
 
 Passing now to the symptoms, are we 
 able to discriminate any which especially 
 betoken mal-digestion in the intestine as 
 there are those which may be regarded as 
 diagnostic of gastric dyspepsia ? To answer 
 this it will be requisite very briefly to con- 
 sider the various symptoms referable to 
 disordered digestion in general before pro- 
 ceeding to group them in respect to their 
 immediate causation. For convenience of 
 description of such numerous and varied 
 phenomena, it is almost necessary to attempt 
 some sort of classification, and the first and 
 most obvious division is into those which 
 
DUODENAL INDIGESTION. 51 
 
 are clearly connected with the alimentary 
 viscera — i.e., local symptoms — and those 
 which are remote and manifested through 
 other than the digestive organs ; an artificial 
 distinction, I admit, and not capable of 
 being rigidly drawn. Among the former or 
 local symptoms will be included — 1. Pain 
 and all other sensory perversions, varying 
 from a mere sense of weight at the epigas- 
 trium to acute, griping colic, or sensations 
 of a peculiar character, such as heartburn. 
 2. Evidences of perverted peristalsis, such 
 as diarrhoea, constipation, vomiting, with all 
 varieties of ejecta from unaltered food to 
 blood, bile, clear acid fluid, or yeasty 
 fermenting material. 3. Signs of undue 
 distension of parts of the canal, flatulence 
 and meteorism, causing general abdominal 
 fulness. 4. State of the tongue and mouth ; 
 salivation. 5. Character of the evacuations. 
 The remote symptoms of dyspepsia almost 
 defy arrangement, and complete enumera- 
 tion would occupy too long. Again pain 
 
52 DUODENAL INDIGESTION. 
 
 heads the list, in shoulders, back, or limbs ; 
 and, above all, headache, frontal, occipital, 
 or vertex ; as well as various neuralgias. 
 The muscular system manifests a general 
 weakness, lassitude, and distaste for exercise, 
 which is badly borne ; or there may be 
 cramps, specially in the muscles of the calf. 
 Affections of the circulation are of extreme 
 frequency — such as flushings after food, cold 
 extremities, palpitation, cardiac irregularity, 
 fainting, and angina. The respiratory 
 function exhibits such perversions as cough, 
 dyspnoea, and hiccough ; whilst vertigo, 
 muscae volitantes, subjective sensations of 
 hearing or smell, all degrees of mental 
 perversion, from a passing irritability to 
 a lasting hypochondriasis, or apathy, drow- 
 siness, or insomnia, and impaired appe- 
 tite, may be conveniently set down as 
 nervous manifestations, as well as pain 
 already mentioned. Characteristic among 
 the remote symptoms are skin eruptions, 
 mainly of the erythematous type. And 
 
DUODENAL INDIGESTION. 53 
 
 finally may be mentioned abnormalities of 
 the urine. It is not, of course, claimed 
 that this list is complete or precise in 
 arrangement, any more than it is suggested 
 that those symptoms mentioned are all of 
 equal frequency of occurrence. The extreme 
 variety of combination is scarcely less 
 remarkable than the multiplicity of the 
 phenomena. Is it possible to select from 
 among them any which may serve to 
 localise the primary, or, may be, sole seat 
 of the digestive failure ? I fear only very 
 partially, at least, so far as the duodenal 
 digestion is concerned. The complexity of 
 causation of most of these phenomena 
 renders the unravelling of the problem well- 
 nigh hopeless ; but it is none the less desirable 
 to set forth what may be affirmed with 
 approximate certainty, remembering that at 
 this point occurs the risk of confounding 
 symptoms which are clearly due to defective 
 tissue metabolism, with those which are 
 purely dyspeptic. Attempts have been made 
 
54 DUODENAL INDIGESTION. 
 
 to refer dyspeptic phenomena to stomach 
 or intestine, based on an observance of the 
 time of their occurrence in respect to the 
 taking of food. But a circumstance which 
 goes far to vitiate the results is that both 
 gastric and duodenal digestion progress to 
 a great extent simultaneously ; for very soon 
 after the food enters the stomach the. 
 propulsive movements of the viscus begin 
 with the object of propelling the fluid 
 portions into the duodenum, there to be 
 submitted to the action of the bile and 
 pancreatic juice ; and hence symptoms which 
 may arise within three or four hours after 
 taking an ordinary meal cannot with 
 certainty, on the ground of time of their 
 occurrence, be attributed to stomach or 
 intestine. Nor could any greater probability 
 be well asserted for symptoms occurring 
 later, since many such are dependent upon 
 long-delayed gastric digestion with deferred 
 propulsion into the duodenum. 
 
 Certainly, I do not think we can find 
 
DUODENAL INDIGESTION. 55 
 
 among the local symptoms many that may 
 be termed diagnostic of situation, however 
 suggestive some may be ; and the fact that 
 not a few are equally associated with 
 structural diseases of the canal itself, as well, 
 as with assumed imperfections of the diges- 
 tive process taking place therein, adds much, 
 to the difficulty, more especially if both 
 abnormalities coexist. The sense of weight 
 and sinking at the epigastrium so often 
 complained of, so far as we know its 
 explanation, will equally be referable to the 
 stomach or upper part of the intestine ; but 
 the time of its occurrence in relation to 
 meals would usually suggest its greater 
 frequency while most of the food is still in 
 the stomach, and that it really does depend 
 upon mere bulk of substance, with impaired 
 movements of the ororan. Mr. Goldinoo 
 Bird's case of jejunostomy already referred 
 to bears this out ; for on introducing from fif- 
 teen to twenty ounces of food into the jeju- 
 num the patient immediately experienced a 
 
56 DUODENAL INDIGESTION. 
 
 feeling of sinking, or as he said, " faintness," 
 with flushing of face, rapid pulse, and extreme 
 discomfort. These symptoms were invariably 
 repeated so long as the bulk of the meal 
 remained as stated, but did not appear when 
 the quantity of food given was much reduced ; 
 and from this circumstance Mr. Golding Bird 
 suggested that these symptoms may be some- 
 times due in patients to a too rapid passage 
 of the contents of the stomach through an 
 unduly relaxed pylorus. But I think it would 
 be difficult to discriminate between such, if 
 such cases there be, and those where the 
 same symptoms are apparently caused by 
 too great a bulk of food in the stomach, 
 and disappear on vomiting — too great, that 
 is, for that particular stomach at that par- 
 ticular time, though not necessarily greater 
 than may be taken at other times with im- 
 punity. Actual pain that may occur in the 
 course of digestion is extremely obscure in 
 cause, if we exclude irritating ingesta of all 
 kinds and pain due to lesions of the canal, 
 
DUODENAL INDIGESTION. 57 
 
 which then becomes a symptom of definite 
 disease of the organ, such as ulcer, and is 
 not an evidence of disordered digestion 
 proper. It is of course possible that during 
 a faulty digestion acrid substances may be 
 developed and produce pain as surely as 
 similar materials do when swallowed in the 
 food, and it is also probable that, if such do 
 occur, they are formed during pancreatic di- 
 gestion. But it is also probable that many 
 cases of intestinal colic are of a spasmodic 
 origin, expressions of some w T ant of harmo- 
 nious action between the nerves and muscles 
 of the bowel, perhaps induced by the character 
 of the contents ; or, on the contrary, may be 
 centric in origin. It has been asserted that 
 pain in the region of the right scapula is 
 indicative of duodenal disturbance, but I 
 am not aware of any clinical evidence in sup- 
 port of the statement, and if it be true it is to 
 be compared to a similar pain occurring in 
 hepatic affections, and is referable to actual 
 structural changes in the organ, rather than 
 
58 DUODENAL INDIGESTION. 
 
 to imperfect physico-chemical changes in the 
 bowel contents. Nor can such irregularities 
 as constipation or diarrhoea be made a ground 
 upon which to determine the existence of a 
 gastric rather than a duodenal indigestion, 
 since it would be easy to show that failures 
 in either situation might determine either of 
 these conditions, just as in a large number of 
 cases both depend on states of the lower part 
 of the intestine beyond where the influence 
 of the pancreatic juice may be supposed to 
 extend, and therefore on conditions beyond 
 the limits of my subject. 
 
 Some of the local symptoms I have enu- 
 merated are more or less significant of gastric 
 disturbance, and gastric disturbance only, find- 
 ing no explanation in intestinal states. Such 
 are especially acidity, heartburn and pyrosis, 
 all due to the presence, whether in excess or 
 not is doubtful, of gastric acids, hydrochloric, 
 lactic, or butyric, with possibly some hyper- 
 esthesia of the mucous membrane. The 
 occurrence of these symptoms, whilst un- 
 
DUODENAL INDIGESTION. 59 
 
 doubtedly pointing to stomach indigestion, 
 does not of necessity exclude a coexistent 
 duodenal failure. Somewhat less positive 
 gastric symptoms are nausea and vomiting. 
 Both may be due to causes quite remote 
 from the digestive organs, and I have had 
 reason sometimes to think that the former, if 
 not both, have been the result of absorption 
 of toxic intestinal digesta. But nevertheless, 
 in the great majority of cases, these two 
 symptoms are referable to stomach rather 
 than bowel. 
 
 My experience so far has not led me to 
 recognise any appearance of the tongue which 
 can in any way be considered diagnostic of 
 intestinal indigestion, even if there be any 
 positively indicative of true gastric dyspepsia. 
 General states, such as pyrexia or local con- 
 ditions of the mouth and salivary flow, are, 
 as Dr. Dickinson has shown, far more potent 
 causes of morbid states of the tongue than 
 disturbances in the functional performance of 
 digestion lower down. 
 
60 DUODENAL INDIGESTION. 
 
 Setting aside, then, those phenomena 
 which are either distinctly or mainly gastric 
 in nature, or are indifferently evidence of 
 stomach or intestinal disorder, there only 
 remain to us for diagnostic purposes, among 
 the local symptoms, flatulence and the cha- 
 racter of the stools. Without doubt the for- 
 mer is, with certain reservations, to be regarded 
 as a valuable diagnostic sign. But it is need- 
 ful to eliminate those cases in which the 
 excessive formation of gas is strictly limited 
 to the stomach. Such cases are usually easy 
 to detect ; physical examination suffices to 
 demonstrate them ; but apart from the fact 
 that the gastric distension may not always 
 exceed normal limits, the excess of gas being 
 eructated or passed on into the bowel, there 
 still remain a number of cases in which there 
 is reason to suppose that there is a regurgita- 
 tion of carbonic acid from the duodenum into 
 the stomach, as Sir William Roberts supposed, 
 and it is probable that most gas of an ill- 
 smelling character which is eructated originally 
 
DUODENAL INDIGESTION. 61 
 
 comes from the intestine. Speaking generally, 
 however, over-distension of the bowels with 
 flatus, especially if accompanied with much 
 voidance per anum, is to be accounted as 
 evidence of mal-digestion in the intestine, 
 though even then it cannot be always set 
 down to mal-performance within the scope 
 of the duodenal processes, since fermentation 
 changes, accompanied by formation of much 
 gas, does also occur in the colon without any 
 reason to suspect failure higher up. Sul- 
 phuretted hydrogen and marsh gas may be 
 looked upon as exclusively developed in the 
 intestine, but the latter may certainly origin- 
 ate in the large bowel as a decomposition 
 product of its contents. But it is not all 
 cases of true flatulence of the small intestine 
 that are the results of an indigestion. There 
 undoubtedly take place throughout the canal 
 extensive gaseous interchanges between the 
 blood in its vessels and the air it contains, 
 and interference with this interchange may 
 readily determine accumulations of gases in 
 
62 DUODENAL INDIGESTION. 
 
 the bowel independently of any defect in 
 digestion. Otherwise, making due allowance 
 in the directions I have indicated, intestinal 
 flatulence is probably the most reliable local 
 sign of duodenal dyspepsia, owing its origin 
 to excessive ferment action of micro-or- 
 ganisms. 
 
 Neither the appearances presented by the 
 stools nor their chemical investigation are as 
 reliable as evidences of indigestion as they 
 might reasonably be supposed to be, or as 
 we may hope, with more extended knowledge, 
 they will be. An excessively hurried passage 
 of the ingesta along the canal may lead to 
 much of it appearing in the evacuations un- 
 changed, or almost so ; but though such a 
 condition would de facto indicate both gastric 
 and intestinal indigestion, there would be 
 nothing to show that the secretions were in 
 any way at fault, and that it was anything 
 beyond a much-increased peristalsis. Ex- 
 cepting such cases and the particles of food 
 which have accidentally escaped digestion and 
 
DUODENAL INDIGESTION. 63 
 
 are always found in the faeces, the only ali- 
 ment which passes unchanged and unabsorbed 
 in any quantity, is fat — that is, the one which 
 receives no treatment until it has escaped 
 from the stomach. When the bile and pan- 
 creatic juice are excluded from the duodenum, 
 this substance appears both unaltered and as 
 crystals of fatty acids with soda, lime, and 
 magnesia. Such motions as these often con- 
 tain also a large quantity of peptones which 
 are wanting in health. But this latter con- 
 dition may be as much a sign of defective 
 absorption as it is of imperfect digestion, 
 though, so far as it goes, it, like the presence 
 of fats, suggests the probability of improper 
 duodenal changes. Of such bodies as pto- 
 maines and other products of abnormal micro- 
 organism activity, we know too little to allow 
 of their occasional presence in the evacua- 
 tions being useful for diagnostic purposes. 
 
 Before any attempt can be made to select 
 from among the numerous and varied distal 
 symptoms of indigestion those which may 
 
64 DUODENAL INDIGESTION. 
 
 serve to indicate duodenal failure, it is almost 
 necessary to seek what explanation there 
 may be for their occurrence. Their diver- 
 sity, their interchangeability, their frequent 
 rapid appearance and disappearance, no less 
 than the intrinsic character of many of them, 
 irresistibly suggest that in some way or other 
 the nervous system is concerned. Some 
 such, as pain, paresthesia and subjective 
 disorders of the senses, are clearly to be so 
 explained ; whilst others are obviously vaso- 
 motor disturbances, as others are expres- 
 sions of perverted trophic influence. Such 
 phrases, I admit, do not carry us very far, 
 but they represent our present way of 
 thinking. There is also the question, How 
 are these disordered nerve influences them- 
 selves originated ? Are they reflex, deter- 
 mined by gastro-intestinal peripheral stimula- 
 tion ; or are they centric, induced by toxic 
 agents absorbed from the canal and conveyed 
 by the blood to the cortical " nervous 
 arrangements," from which, in consequence, 
 
DUODENAL INDIGESTION. 65 
 
 they emanate and come to be expressed by 
 the symptoms we speak of as dyspeptic ? 
 These are questions easier asked than 
 answered, but they are framed entirely in 
 accordance with our present conceptions. 
 
 Many of these symptoms may be caused 
 by drugs taken into the stomach or injected 
 subcutaneously, so that we have warrant for 
 the suggestion of their poisonous origin, and 
 certainly most of the vascular phenomena, 
 if not others as well, are capable of being 
 artificially produced reflexly by peripheral 
 stimulation. It is not easy to suppose any 
 other method of action from the gastro- 
 intestinal tract than by the blood to the 
 nerve centres, or by nervous irritation, but 
 the supposition does not help very much to 
 distinguish between gastric and upper intes- 
 tinal situation ; the blood channels are the 
 same, and the nerve paths take the same 
 course. If it could be shown that these 
 remote symptoms are wholly reflex in origin, 
 I do not see how we could suggest any 
 5 
 
66 DUODENAL INDIGESTION. 
 
 grounds for referring any given symptom 
 to stomach rather than to duodenum, or 
 vice versa ; but if the phenomena be toxic 
 in cause, then probability would lead us to 
 refer them to the intestine rather than higher 
 up, since in that situation poisons are more 
 likely to be developed. But, as I have 
 more than once said, the responsibility for 
 many of these symptoms must not be thrown 
 on the digestive process. The assimila- 
 tive power of the tissues themselves may 
 be at fault, or between the actual results 
 of the digestion and their final presentation 
 to the tissue elements abnormal changes may 
 take place in the pabulum in connection 
 with the many protoplasmic influences which 
 intervene. 
 
 Certain products of digestion, peptones 
 and albumoses, as well as further results 
 of proteid decomposition, such as indican, 
 are of frequent occurrence in the urine. 
 But the presence of the first-named is by 
 no means associated with dyspepsia ; and 
 
DUODENAL INDIGESTION. 67 
 
 indeed, since the object of digestion is the 
 formation of these bodies, their existence 
 rather proves the excellence of the digestive 
 powers, and their occurrence in the urine 
 when derived from the alimentary canal 
 would be due to some errors in their 
 destination after digestion and absorption, 
 much as glycosuria is. As regards indican 
 and its allies of the ether-sulphuric acid series, 
 it is probable that they may ultimately become 
 valuable aids to the detection of abnormal 
 splitting up of proteids in the alimentary 
 canal under the influence of micro-organisms. 
 From this survey of the symptoms of 
 indigestion the conclusion, I think, would 
 be warranted that those which are capable 
 of being specially referred for their causation 
 to imperfect digestion in the upper part of 
 the intestine, and that may be considered 
 in any way diagnostic of such imperfection, 
 are attributable to excessive, if not perverted, 
 micro-organism activity — a condition which 
 we have good reason to believe is quite a 
 
68 DUODENAL INDIGESTION. 
 
 superfluous accessory to the normal biliary 
 and pancreatic changes, and one liable to 
 be attended with much risk. A clinical 
 point which to my mind has much signi- 
 ficance in this connection is that in those 
 not infrequent cases where the bile and 
 pancreatic secretions are entirely excluded 
 from the intestine, and when therefore a 
 normal duodenal digestion is impossible, 
 symptoms ordinarily described as dyspeptic 
 are noticeably absent. Symptoms depen- 
 dent on the structural disease causing the 
 obstruction to the entrance of these fluids 
 may of course exist, but few, if any, directly 
 due to improper treatment of the ingesta. 
 The patient will probably emaciate, and 
 fat will occur in the stools, the digestive 
 agents for that special alimentary principle 
 being absent. But we look in vain, as a 
 rule, for headache, palpitation, flushing, or 
 even flatulence — that is, for those pheno- 
 mena which perverted germ activity would 
 produce. I am inclined to explain this by 
 
DUODENAL INDIGESTION. 69 
 
 the chyme from the stomach meeting with 
 no neutralising fluids ; the acids of the 
 gastric juice pass on into the intestine and 
 destroy the organisms which might other- 
 wise have given rise to noxious fermenta- 
 tions. But be that as it may, the point I 
 would urge is that complete absence of 
 proper duodenal digestion may be unattended 
 with dyspeptic symptoms, which goes far to 
 support my contention that such symptoms are 
 in the main due to imperfections of gastric 
 action giving rise to primary phenomena of 
 stomach indigestion; and secondarily, by provi- 
 ding a chyme that is vitiated, determining addi- 
 tional symptoms originating in the intestine, 
 and mainly due to the action of micro-organ- 
 isms which in normal circumstances would not 
 have taken place. 
 
 Let me conclude with a few words by 
 way of summary. In view of the object of 
 my remarks — viz., the nature, causation, and 
 diagnosis of duodenal dyspepsia — I have 
 insisted on the necessity, for the proper 
 
70 DUODENAL INDIGESTION. 
 
 study of the subject, that a strict under- 
 standing should be come to on what is 
 exactly the scope of digestion, since many 
 symptoms referred to mal-performance of it 
 are in reality due to perversions of functions 
 — absorption and tissue metabolism — which 
 do not commence until digestion has finished, 
 and are wholly different in nature and con- 
 ditions of exercise to the physico-chemical 
 processes which take place in the alimentary 
 canal. Also that the character of the suc- 
 cessive digestive changes is such that inter- 
 ference with one is liable to seriously modify 
 those which follow, and that this especially 
 holds good in respect to the gastric diges- 
 tion, which is a necessary preliminary to the 
 duodenal, the normal performance of which 
 is intimately dependent on a healthy chyme 
 — far more, in fact, than upon the action 
 of its own proper secretions. Further, that the 
 most important factor of duodenal dyspepsia 
 is its dependence on abnormal fermentations, 
 caused by micro-organisms introduced ab 
 
DUODENAL INDIGESTION. 71 
 
 extra, which in healthy conditions do not 
 assert themselves, and are wholly superfluous 
 adjuncts to digestion. And, lastly, that any 
 symptoms which may at all serve to localise 
 the imperfect performance in the intestine 
 are the results of these organic activities. 
 
 I do not pretend to have treated my subject 
 exhaustively ; it were impossible in the time 
 at my command. The entire question of 
 treatment I have not been able to touch 
 upon, though I will affirm my belief that 
 most benefit is to be done in this direc- 
 tion by such diet or drugs as will correct 
 gastric deficiencies, but I have attempted 
 to map out the outlines and broad features 
 and to lay down a course for the further 
 study of an obscure and important subject 
 in accordance with present physiological 
 knowledge and the prevailing conceptions 
 of pathology. It may be objected that in 
 so doing I have, unnecessarily, if not unwar- 
 rantably, restricted the scope of the question, 
 and have regarded digestion and its faults 
 
72 DUODENAL INDIGESTION. 
 
 too much apart from the influences of other 
 functions, and that no such limitation as I 
 have drawn can occur. But I feel sure that 
 to ' obtain correct notions of the problems 
 presented no limitation can be too definite 
 at first ; when they are acquired we may 
 more profitably enter on the subject of other 
 influences. 
 
 It only remains for me to express to you, 
 Sir, my very deep appreciation of the honour 
 you have done me in selecting me to address 
 you to-day, and my warmest thanks to the 
 Fellows in College assembled who approved 
 your choice, and to hope that neither you, 
 Sir, nor they have felt reason to regret the 
 manner in which I have fulfilled the trust. 
 
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 The nature and causes of duo-