On the Investigation of Dyspeptics: A British Medical Association Lecture
Authors: J. Ryle
Journal: BMJ (1923)

THz group of diseases embracing the various classes of dyspeptic is prevalent, and, in civilized communities, I think one may say increasingly prevalent.Its mortality rate is comparatively low, but it is responsible for much misery, inefficiency, and sick-wastage, and is by no means a trial only to its victims.From.thie diagnostic and thera- peutic points of view it will be generally conceded that it is a difficult and unsatisfactory group; and yet if we consider and correlate the work conducted in recent years by physio- logists, physicians, radiologists, surgeons, and biochemists, we must admit that great advances in our understanding of digestion and its errors have been made.It has been my good fortune during the past three years to have opportunities of studying, both from experimental and clinical points of view, the behaviour of the stomach in health and disease, and it is my hope that I may be able to crystallize for you in some useful form the present state of our knowledge of the methods used in the investigation of dyspeptics, together with some thoughts on their relative value which I lhave gathered by tlle way.In approaching the study of the dyspepsias we are at once confronted with a serious lack of ordered teaching and clear classification.Few of us will recollect in our student days any attempt at a scientific grouping of the dyspepsias, and many textbooks even in recent years have been content -after a discussion of ulcer, carcinoma, and gastritis- briefly to compound the remaining dyspepsias under some such vague heading as "chronic indigestion."Attempts to classify according to symptoms have been made, and we are familiar with such designations as "flatulent dyspepsia," "acid dyspepsia," "fermentative dyspepsia," "atonic dys- pepsia," and so on-all valueless and misleading titles on the whole.Even in a recent edition of a very excellent textbook of medicine we find clhronic indigestion baldly summarized as follows:"Indigestion, apart from organic lesions, is due either to irritating properties of the food or to deficiency of secretion or motility of the stomach; and these conditions may be met."The most satisfactory classifications of disease are those based on causal pathology.As a preliminary, therefore, to the subject under review I have drawn up a rough working classification of dyspepsias according to cause, which I have come to employ for my own purposes.There is, however, one important conception to consider even before the question of classification.It is the simple conception, now much more widely accepted than formerly, but still not sufficiently applied, that the majority of dyspepsias are not dependent on any gastric disease.The work of Cannon with animals on the gastric responses to emotional states, such as fear and anger, and to pain, has buttressed the much older recognition in our own bodies that strong emotions, such as fear, anxiety, worry, falling in love, and depression, may upset the normal functions of the Btomach.Further, if not in our own persons, at any rate in our clinical observations we are familiar with the digestive disturbances accompanying or following fatigue and infection, or reflexl'y induced by lesions distant from the stomach.In Prief, just as with other viscera, so with the Stomach it is important to realize that disturbed function as well as, and more frequently than, altered structure may produce physical symptoms.The cause8 which produce such disturbance of function are for the most part situated outside the viscusThe following is a suggested classification of dyspepsias according to cause:Classification of Dyspepsias.A. Dyspepsias due to organic disease of the stomach (including pylorus and duodenum)-for example, ulcer, carcinoma, gastritis, and the end-results of operations.B. Reflex dyspepsias due to organic disease elsewhere in the Flimentary tract-for example, gall stones, appendicitis, etc.-and * A general statement of the physiological and therapeutic effects of insulin, by