CHAPTER V.

DUODENUM.

VARIOUS writers have described symptoms of disease which they have attributed to the duodenum, whilst others have referred them to the stomach, or to the liver.

My own observations, and the facts which I adduce in the following remarks, show that there are symptoms of disease justly considered as arising from this portion of the alimentary canal; and that in some cases we may, with care, satisfactorily diagnose that this part is diseased. The peculiarities of its position and structure deserve our careful attention: extending from the pyloric extremity of the stomach to the jejunum, it is about twelve inches in length, and may be divided into three nearly equal portions:—the first is the most moveable, is more surrounded by peritoneum, and horizontal in its direction; it may be called the pyloric or stomachic portion of the duodenum, for it is associated with the diseases of the stomach. The second is vertical in direction, closely fixed near to the crura of the diaphragm, and to the vena cava; it receives the common bile and pancreatic ducts generally by a single opening. The pancreas is situated on its left side, the vena porta, the hepatic artery, and the branches of the pancreatico-duodenal artery are in relation with it. The third is horizontal in direction, having the pancreas above it, and in front the superior mesenteric vessels entering the commencement of the mesentery-it is situated upon the aorta and vena cava. The three portions of the duodenum are situated on different planes, the first portion being nearer to the anterior abdominal parietes, the third part immediately upon the spine; and this arrangement allows the contents of the canal, the chyme, mechanically to gravitate quickly into the jejunum, and assists the discharge of bile from the ducts.

The muscular layers are double, a circular, and a longitudinal coat, as in other portions of the small intestine.

The mucous coat is covered with villi, which commence at the duodenum, and soon become exceedingly numerous; so also the valvulæ conniventes are gradually developed, till we find them as large as in the jejunum. The whole of the surface is studded over with Lieberkuhn's follicles; not unfrequently, especially in young subjects, there are solitary glands, as in the jejunum and ileum. Besides, there are the glands of Brunner, peculiar to the duodenum, minute compound glands, situated beneath the substance of the mucous membrane: these commence a few lines from the pylorus, and extend about as far as the common bile duct. Their function is not definitely known, but they are believed to resemble minute salivary or pancreatic glands. It sometimes happens, that the solitary glands are so distinct, that they may very easily be mistaken for Brunner's glands; the latter are, however, situated beneath the membrane, and microscopical examination at once manifests their difference.

There is still another point in connexion with the duodenum that deserves consideration, and which indicates its close connexion with the stomach and with the liver. The pneumogastric nerves, branches of which supply the stomach, and also the liver, send filaments along the first portion of the duodenum, continued onwards from the lesser curvature of the stomach; this associates that part of the duodenum very intimately with the stomach.

The pancreatico-duodenal artery, which supplies the greater part of the duodenum, is from the hepatic, and the pyloric branch of the coronary extends into the first part of the duodenum, so that in the arterial supply we find the same association.

State of secretion.-The secretion is stated to be alkaline, and such is probably the case; the acid reaction after death probably arises from the gastric juice, which has gravitated through the pylorus. Whether a patulous feeble contractile power in the pylorus, allowing the secretions of the stomach to pass at irregular periods into the duodenum, is the cause of any of the discomforts associated with the forms of dyspepsia, we have no data on which to form an opinion. Few conditions of imperfect development have been observed in connexion with the duodenum.

Congenital malformation.-The duodenum is sometimes observed to have a double twist, firmly fixed to the spine before it joins the jejunum: this I observed in a case of intestinal obstruction, in which the cæcum was twisted over to the right side of the abdomen, and the ascending colon adherent to the sigmoid flexure. The person had been born at the seventh month, and the cæcum was preternaturally free.

In a cyclopean monster, in which the viscera of a double fœtus existed in a single peritoneal cavity, a double œsophagus was found united in a single stomach, with a large convexity extending from side to side, and giving rise to a single duodenum, placed vertically, and receiving the biliary and pancreatic ducts on either side.

Diverticula have been noticed, but are exceedingly rare as compared with those arising from the lower part of the ileum; the pouches in the duodenum consist generally of mucous membrane, and might be considered as a form of hernial protrusion of that membrane: in the museum of Guy's is one situated near the opening of the duct into the duodenum.

Some believe that the duodenum becomes distended with flatus, or with retained chyme, and that these are the result of indigestion; where there is mechanical obstruction, which we shall afterwards describe, this may be the case, in disease of the pancreas, or in cancer, or impacted gall-stone, &c. and it is possible that an enormously distended transverse colon may impede the free passage of the contents of the third portion, but such is problematical. The distension which has been supposed to arise from the duodenum, will generally be found to be from the stomach or transverse colon; the duodenum passes quickly to a lower level, and I believe its contents at once gravitate into the jejunum.

As to the strictly pathological states, we find congestion, sometimes active, more frequently passive; and ulceration, or obstruction.

To some it may appear altogether futile to speak of congestion or hyperemia of the duodenum, but observation of the appearances after death convinces me otherwise, that marked changes of this kind occur, and in some instances a careful investigation might have pointed out their existence during life.

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Great congestion of the duodenum is observed in various diseases, where the whole tract of the alimentary canal is in a similar condition, as in disease of the mitral valve, and portal obstruction in hepatic disease; but there are other cases in which we find it in an active state, or the condition of the mucous membrane evinces that congestion of some continuance has left traces of its existence. The latter may be considered as active hyperæmia of the part, and the following case illustrates the condition to which reference is made:

CASE LXX.-Inflammation of Bronchi, of Bile Ducts, or Biliary Hepatitis, &c.; Inflammatory Congestion of the Duodenum.-Thomas H-, æt. 42, was admitted into Guy's Hospital, March, 1852; he had been ill for three weeks. He was a large, stout man, who for fourteen years had been in the police service; his habits of life had been very intemperate. Four years ago he had a severe blow in his right side from a prize fighter, and for some time he had been subject to vomiting in the morning, and the bowels had at times been much relaxed. Previous to his admission jaundice came on; he had more anxiety of mind than usual, and gradually became languid and icteric. Four days before admission his legs began to swell, then his abdomen, and he became prostrate. The skin was of a dusky yellow colour; the tongue was dry, brown, and furred; respiration 44; the pulse 100, soft and compressible; the abdomen was much distended with flatus, and fluctuation could also be felt; the liver extended several inches below the ribs, and there was tenderness on pressure in that part. In the chest there were general bronchial râles; he was delirious at night, and slept but little; the motions were light in colour, the bowels relaxed, the urine contained the colouring matter of bile and lithates. Three days after admission he was more prostrate; still delirious; the pulse was very compressible; he had pain in the right hypogastric region, and on the following day he died.

On inspection there was found to be severe capillary bronchitis: the larger bronchi were also inflamed; they were somewhat congested, and contained yellow-coloured tenacious mucus. The heart was large, and had around it a considerable quantity of fat; the right ventricle was thin; the left ventricle had undergone partial fatty degeneration. The valves were healthy, with the exception of slight thickening of the mitral. Abdomen.-There were several pints of yellow serum in the peritoneum; the intestines were considerably distended with flatus, and the liver extended several inches below the ribs. The duodenum contained bloody mucus, the lining membrane was very much congested, and in some parts ecchymosed. The lower part of the small intestine contained clayey fæces. There was a considerable quantity of fat in the omentum, and in the abdominal parietes.

The liver weighed 71b., its surface smooth, and of a deep greenish-yellow colour; the acini were whitish, and some veins were seen upon the surface. The section of the liver appeared coarse along the smaller branches

of the vena porta, the capillary vessels in Glisson's capsule appeared much distended, some of them quite turgid with blood. The lining membrane of the smaller biliary vessels was congested, and contained tenacious mucus; this state of the bile ducts contrasted remarkably with the pale colour of the vein. The cells of the liver were gorged with fat, some of them quite distended with oil globules; other hepatic cells appeared ruptured, the granules and oil globules dispersed upon the field. The deep green spots did not present any cells, but homogeneous matter with granules.

The larger bile ducts appeared to be perfectly free, but the opening into the duodenum was very much congested; the gall bladder was empty; kidneys large and congested; spleen firm, and contained several fibrinous

masses.

The health of this man was much impaired by his intemperate habits; his liver was probably partially diseased for a considerable period. The affection of the chest came on subsequent to his admission into the hospital, and, consequently, after the jaundice. There was evidently inflammatory action of the smaller biliary tubes, as indicated by the congestion of Glisson's capsule, the congestion of the lining membrane of the biliary tubes, and the tenacious mucus they contained; bile appeared to have been separated from the blood, but to have been retained in the hepatic structure. The bronchitis which subsequently took place was, perhaps, the cause of the fatal termination, and tended, doubtless, to increase the congestion of the mucous membrane. The very congested state of the duodenum, near the entrance of the bile ducts, indicated an extension of disease from the duodenum to the bile ducts, or vice versá; it was much more localized than is observed in the secondary congestion of the mucous membrane in pulmonary obstruction. This did not appear to be an affection in which much benefit could be obtained from the administration of mercury, but rather salines with sedatives.

After burns the mucous membrane of the duodenum has been found greatly congested, and in several cases recorded by Mr. Curling, in the "Medico-Chirurgical Transactions," ulcerated. This has not been confirmed in the observations of Dr. Wilks, in the Guy's Reports for 1856, many of which cases I witnessed; and although in some the first part of the duodenum was hyperæmic, in none did I observe ulceration. Such a case, however, is placed in the Museum at Guy's, in which Dr. Gull