The gaseous exhalations into the stomach consist of nitrogen and carburetted hydrogens, or fermentation takes place accompanied with the evolution of carbonic acid, or butyric acid is formed, or lastly, putrefactive changes arise, and sulphuretted hydrogen is produced; these several forms of fermentation arise from different causes, as we have before mentioned in speaking of distension of the stomach as a sign of gastric disease; they produce diverse symptoms, and are amenable to various forms of treatment.

We have already enumerated several sources of gaseous distension of the stomach, and shall not again enter upon their full consideration. We have stated, 1st, that gas may be swallowed; or, 2ndly, produced by the decomposition of food in the stomach; 3rdly, that it may be evolved from changes in the mucous secretions themselves; 4thly, transuded from the blood; 5thly, regurgitated from the duodenum, or from a fistulous communication with the colon, or from some adjoining abscess; 6thly, gas of an offensive kind is produced by the decomposition of a growth in the stomach, as cancerous tumour.

The first form of gaseous distension that we have to notice, is quite independent of food, or rather is frequently produced by the want of it. The gas consists of nitrogen mixed with carburetted hydrogens and some carbonic acid; it is often suddenly evolved, and is especially connected with an exhausted state of the

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nervous system; it is often peculiarly marked in hysterical patients, and in others it may be induced by mental excitement or depression, and abstinence from food is a very common cause of it.

This form of dyspepsia is of an atonic character; the want of power being due either to general loss of strength, or to deficient supply of nourishment. It is marked by a sense of sinking at the stomach, distension, and pain as that distension increases; the pain often commences in the back, and seems to pass round the body or through it to the scrobiculus cordis; headache is often present, and sometimes faintness; if the pain become severe, the pulse assumes a compressive character, the tongue is not necessarily changed; eructation takes place, and with that relief, the pain subsides; or the gas passes downwards, and the pain then moves from the stomach, and entirely ceases as the gas is evacuated. This form of dyspepsia sometimes produces extreme prostration and collapse, and the severity is so great, that perforation of intestine is simulated. At the commencement of this state, if a small quantity of nourishment can be taken, the symptoms may be checked; stimulants may be given, as wine and brandy with nourishment; but if the distension have become severe, then antispasmodics are necessary, chloric ether, ether, camphor, ammonia, and when pain has supervened, opium should be given. We have known severe collapse quickly relieved by opiates freely administered;

but, it is always very important, so to strengthen the system and regulate the diet, as to guard against these attacks.

A second form of gaseous distension arises from fermentation of the food itself, whether from its improper character, from defective gastric secretion, or from obstruction; a short time after a meal has been taken distension and pain arise, and three or four hours later, or it may be at the close of the day, several hours after food, a large quantity of fermenting substance is ejected, sour and acid in its reaction, and with a frothy surface. It might be compared to the fermentation produced by yeast in alcoholic or vinous fermentation, and carbonic acid is also evolved. It is not unfrequent, especially when associated with gastric ulcer, or with pyloric disease, to have the sarcina ventriculi of Goodsir present. These minute confervoid growths, in their bale-like quadrangles, appear to indicate some peculiarity in the fermentative process, and although often associated with organic disease, are not pathognomonic of it.

In this form of fermentative dyspepsia, pain at the stomach and in the back, flatulent distension, colic, eructation, furred tongue, are the common symptoms; the pain is often very severe, and the distress considerable.

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It would, however, be an erroneous supposition to think that the fermentation to which we have referred

is the primary disease, for it is only a symptom; and it is the consequence of previous abnormal action. The gastric juice checks fermentation, but if it be insufficient for this purpose, or if the dissolved aliment be unable to escape, either from constriction or spasmodic contraction at the pylorus, secondary changes rapidly follow.

Some forms of diet are more prone than others to produce this effect. Saccharine and starchy substances, cruciferous vegetables, and hard and indigestible products generally favour similar action.

To relieve this distressing symptom of gaseous distension from chemical change, our first object is to remove the cause, and then so to regulate the diet, as to give those articles least likely to induce this reaction; but if necessary directly to check distension, then we find the value of those reagents, which in the laboratory of the chemist stop alcoholic fermentation; the sulphites and hyposulphites powerfully absorb oxygen, and may be given with great advantage; and a still more energetic substance is creasote, and in many instances we have witnessed its efficacy. The cases, however, must be carefully selected, for in irritable conditions of the mucous membrane creasote cannot be borne, and bismuth with alkalies will be found to be more efficacious.

Charcoal may also be used, and it is certainly very valuable, in some instances, in directly absorbing

gaseous substances in the intestinal canal. Carefully prepared wood charcoal, finely triturated, may be given with simple mucilage mixture; and some patients prefer this to the charcoal biscuits. Dr. Leared strongly advocates the use of charcoal in capsules. We have many years ago seen it extremely serviceable as an enema in relieving secondary fermentative changes in the colon; and given by the mouth, we have found it of greater value in intestinal than in gastric distension, for the latter we could obviate by more agreeable treatment.

Another form of fermentative dyspepsia results in the production of butyric acid. This organic acid is closely allied to lactic acid, and it is that which gives the peculiar sourness to the vomited matters in dyspepsia. Fatty matters, milk, cheese, especially when these are partaken of in disordered conditions of the digestive apparatus, lead to this chemical change, and butyric acid is formed.

The symptoms are severe heartburn, regurgitation of food into the throat, pain at the scrobiculus cordis and in the back, foul tongue, disordered state of the liver, the urine often high coloured, and the bowels irregular. This state may arise in occasional attacks from indiscretion in diet, or it may become persistent and most trying to the patient; almost everything that is taken becoming, as the sufferer says, "sour" on the stomach.

The most powerful means of relieving this condition