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are thoroughly to unload the portal system, to exclude as much as possible substances capable of butyric acid fermentation, and to strengthen the mucous membrane of the stomach by vegetable tonics.

During the severity of an acute attack, salines of potash, soda and magnesia most effectually relieve the pain and heartburn.

The last condition of fermentative change to which we have to allude is that in which sulphuretted hydrogen is formed; a putrefactive action, in which the patient complains of the offensive character of the eructation or of the unpleasant odour of the breath, or of the taste in the mouth. It would seem that some varieties of food containing sulphur, more readily than others, thus become decomposed. With some the sulphur present in egg is at once the cause of this offensive gaseous formation.

The sources of fallacy upon which we have previously dwelt must be borne in mind, that the gaseous taint may exist in the mouth, in the tonsil, the nares, and the throat, or be produced in the respiratory passages. And again, regurgitation may take place from the duodenum, or from a fistulous communication with the colon, but here we have a focal odour conjoined. Sloughing in the stomach itself, as of a cancerous or other tumour, decomposing blood, and the communication with an adjoining abscess, are other sources of fetid gaseous formations in the stomach.

When it is truly gastric in its character and arising from dyspepsia, beside the more prominent and distressing symptom of the taste of rotten eggs, the secretions are vitiated, and we find other symptoms are conjoined: sallowness of the complexion, headache, sense of weakness, a furred tongue, and an irregular condition of the bowels, the evacuations are dark and offensive, and often loose in character; a sense of malaise or of general inability for exertion is also present. We do not find the same amount of pain as in the last-mentioned form of dyspepsia, but an atonic state exists, the bolus of food is not properly dissolved, it soon putrefies, or if dissolved, before it passes from the stomach decomposition commences. The gastric juice itself checks putrefaction, so also does the admixture of bile; but in these cases the action of the first is insufficient. It is probable that to some extent symptoms resembling those produced by the inhalation of sulphuretted hydrogen accompany this form of dyspepsia, and that the blood becomes contaminated by the absorption of this gas from the stomach; we refer especially to the sense of exhaustion that is induced, and the irregular action of the bowels.

The diet must be carefully regulated; and when no obstruction exists, it is well to administer warm saline. aperients, as the sulphate of soda or tartrate of potash, with the aromatic spirit of ammonia and the bitter vegetable infusions of orange peel, calumba, cascarilla or

gentian. The old formula of Guy's rhubarb, soda and calumba may be advantageously tried; but creasote, whilst it checks the decomposition, is not so effective in these, as in the cases previously described.

CHAPTER XV.

DUODENAL DYSPEPSIA.

THE duodenum, as the commencement of the small intestine, may be divided into three parts: its 1st and horizontal portion, its 2nd and vertical, and its 3rd again horizontal, as it joins the jejunum. The 1st part is intimately connected with the stomach, in its physiological as well as in its pathological relations; the 2nd with the liver and the pancreas; and the 3rd with the intestines.

The pyloric valve separates the stomach from the duodenum; this valve receives nervous supply from the pneumogastric, and so also does the first part of the duodenum, and consequently diseases affecting the mucous membrane of this part of the intestine, immediately beyond the valve, closely simulate the same disease of the stomach; thus, we find congestive conditions, altered enervation, superficial and chronic ulceration, sudden perforation, and cancerous diseases, which are with difficulty diagnosed from disease on the gastric side of the valve. But it will be generally found that the position and tenderness, and

the duration of time after the food has been taken before the attack comes on, will enable us to form a correct opinion as to the nature of the disease. Three or four hours after food, that is, at the close of the digestive process, the pain commences. But there are instances, in which the rapid passage of fluids from the stomach induces pain in the region of the duodenum almost at once.

The pancreatic duct opens into the duodenum close to, and frequently in common with, the bile duct; and, as the bile is known to regurgitate into the stomach, it is probable that the pancreatic secretion may in a similar manner pass backwards and be vomited. In irritable conditions of the stomach large quantities of mucus are often brought up in conjunction with bile; and it may be that the pancreatic fluid alone is rejected through the stomach. The symptom to which the term pyrosis has been applied has been variously explained : it consists in the regurgitation of a watery fluid, sometimes saline in its taste, sometimes tasteless; it is accompanied with some pain at the scrobiculus cordis, and with burning pain at the back of the mouth, or in the gullet, usually designated heartburn. The fluid is ejected at irregular intervals; the mouth may be filled with this fluid almost without warning, or it may be expelled soon after a meal, or even in the middle of the night. Other symptoms of gastric disorder may be present, but it is often unaccompanied by any of these

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