REESE UN LECTURE II. INDIGESTION, BILIOUSNESS, AND THEIR CONSEQUENCES. Delivered before the Medical Society of London, January 19th, 1885. BILIOUSNESS and indigestion are terms which we use so frequently together, and which are so intimately connected, that we do not always sufficiently distinguish between them. Yet it may be worth our while to inquire where the one begins and the other ends, and to ascertain, if we can, what the nature of their connection is. The condition which we term biliousness is, in all probability, of complex origin. Its name points to the liver as its source, while its close connection with disturbances of the stomach might lead us to ascribe a gastric origin to it. The difficulty we have in ascertaining the exact causation of biliousness is no doubt largely due to the fact that disturbance of the liver affects the stomach and intestines, and disturbance of the stomach and intestines affects the liver. Indigestion and biliousness are, therefore, so closely associated in many cases, that we can hardly say where the mischief began unless we can trace it from the commencement, although in other cases we get a clue to the primary origin of the disease by noticing whether the disturbance of function is greater in the stomach or in the liver. The close connection between the liver, on the one hand, and the stomach and intestines, on the other, is rendered inevitable by the arrangement of the blood-vessels in them. On looking at the liver, on the one hand, we see that, with the exception of a small quantity which passes through collateral branches, all the venous blood returning from the stomach and intestines must pass through the liver before it reaches the general circulation (Fig. 4). Thus, any products of imperfect digestion are likely to affect the hepatic functions, and not improbably to derange them. On looking at the stomach and intestines, on the other hand, we see that any hindrance to the flow of the portal blood through the liver will tend to cause venous congestion in them. Fig. 5.-Diagram of the veins forming part of the portal circulation. The pancreatic and splenic veins, although most important, have been omitted for the sake of clearness. On looking at the liver in a post mortem examination, it seems so hard and firm that we are apt to think that it is not capable of much dilatation and contraction in the living body. But this notion is perfectly erroneous. I have made a number of experiments on the artificial circulation of blood through the livers of rabbits, and have been quite astonished to find what an elastic organ the liver is. When the bottle containing the blood was raised two or three feet above the liver, so as to increase the Bottle containing Liver. Cannula for Outflow of Blood. Fig. 6.-Diagram to show the effect of artificial circulation of blood through the liver, under different pressures. The continuous lines indicate the size of the liver, and the arrangement of the apparatus during circulation, under a low pressure. The dotted lines indicate the increased size of the liver, and the arrangement of the apparatus, with a high pressure. pressure under which the blood flowed through it, the organ expanded almost like a sponge, and again contracted when the pressure was diminished. We do not usually notice any very great differences of size in healthy livers; but the reason of this, no doubt, is that the pressure of blood in the portal vein is very low, and not liable to great fluctuations. But there was another point which struck me greatly in my experiments. Sometimes the blood would flow very easily through the liver, would, indeed, pour out from the hepatic vein in a full stream, as if no obstacle whatever had been presented to its flow through the hepatic capillaries. At other times, however, the flow would be slow and scanty, the blood evidently meeting with great resistance in the capillaries. These two conditions were sometimes found in the same liver at different periods of the experiment, and they appeared to depend to a considerable extent upon the quality of the blood which was circulating. Bearing in mind this power of the liver to obstruct the circulation through it, we can readily see how a vicious circle may be formed: indiscretion in eating or drinking disturbs the digestive processes in the stomach and intestines; the products of imperfect digestion or of decomposition in the intestine being absorbed into the veins pass to the liver; they may there induce an obstructed flow through the hepatic capillaries; the venous blood returning from the stomach and intestines will no longer be able to find an easy passage into the general circulation, and venous congestion of the stomach and intestines will be the result. Such venous engorgement as this will interfere with gastric and intestinal digestion, and this again will react upon the liver. Here, then, is a vicious circle which it is necessary to break. It may be broken in two ways: (1) by fasting, so as to allow time for matters to right themselves; or (2) by the use of medicines, as we shall afterwards see. In order to form a clearer idea of what is actually going on in Liliousness, it may be well to take advantage of that fortunate accident by which Dr. Beaumont was enabled to examine the interior of Alexis St. Martin's stomach, and discover what was going on there. Although some authorities have denied that the state of the tongue is any index of the condition of the stomach, this is not borne out by Dr. Beaumont's observations, for he found that the state of the two corresponded pretty closely. A healthy tongue is of a pink colour, it is very slightly rough, and its surface is moist. The mucous membrane of a healthy stomach is of a pale pink colour, it has a slightly rough velvety appearance, and its surface is merely lubricated by a thin layer of mucus. When it is stimulated by the ingestion of food, the vessels dilate, the colour becomes heightened, and the gastric follicles secrete a clear transparent juice, which goes on accumulating, and trickles down the sides of the stomach. From experiments upon animals we know what changes irritation of the gastric mucous membrane will produce. A slight stimulus, as already mentioned, causes the circulation in the mucous membrane to become increased, and gastric juice to be abundantly secreted. This effect may be produced not only by the ingestion of food, but also, though to a slighter and more limited extent, by gently rubbing with a glass rod or feather. But if the stimulus be excessive, e. g. if the rod be rubbed roughly instead of gently over the mucous surface, an entirely different result occurs; the vessels, instead of dilating, contract, the stomach becomes paler, and a quantity of mucus is secreted. If irritation be carried still further, the animal shows signs of nausea, and may actually vomit. In indigestion and biliousness we find several stages upon which the experiments just mentioned throw considerable light. In the first the appetite is increased rather than diminished; in the next stage the appetite fails; and in the further stage nausea or vomiting occurs. Even in the first stage, however, it not unfrequently happens that though the appetite is craving at first, a few mouthfuls of food are sufficient to satisfy it, and sometimes the appetite disappears merely at the sight of food, and is succeeded by nausea. In this case it is evident that the increased circulation in the stomach due to the introduction into it of food, or perhaps of the saliva excited by the expectation of food, has caused the condition of the mucous membrane to pass from the stage of slight to that of violent irritation. Let us now see what conditions of the stomach correspond to these symptoms. Dr. Beaumont mentions that on one occasion St. Martin's tongue had a thin whitish fur, and the appetite was craving. On examining the stomach, several red spots and patches abraded of the mucous coat, tender and irritable, appeared spread over the surface. The digestion, too, was slower than usual, and seven hours were required for the gastric digestion of his dinner, instead of four and a half or five hours as usual. In this condition we cannot say that the liver is involved. The stomach is the only organ affected, and the disturbances of its functions are as yet but slight. Here we may say there is indigestion but not biliousness. Two days afterwards, the indigestion had advanced further and the symptoms of biliousness had become superadded. His usual appetite was gone, the tongue was covered with a thin coat, no longer whitish but yellowish, the countenance was sallow, and on the interior of the stomach there were several deep red patches. A muslin bag which had been introduced with some food in order to test the rapidity of digestion, when drawn out was covered with a coat of mucus and yellow bile. The sallowness of the face, which had now appeared, may be taken as an indication that the liver had become affected, and that biliousness as well as indigestion was now present. On the succeeding day the coats of the stomach were still unhealthy and of deeper red than naturally, with patches of a still deeper colour, and the mucous covering abraded in places. This deep colour indicates venous congestion and stagnation of blood, and is as different from the increased rosiness consequent upon the arterial dilatation and rapid circulation in healthy digestion, as the dusky hue in mitral disease is from the rosy flush of healthy exercise. This venous congestion indicates, I think, that the liver circulation is already becoming impeded, and that the impeded circulation through it is beginning to tell on the venous |