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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 X V.

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 of the pain 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 symptoms. Some have regarded the oesophagus as the source of this pyrotic fluid; it is generally referred to the stomach, and the question naturally arises, can the pancreas be the origin of it? However it may be produced, pyrosis or water brash is a distressing symptom to the patient, and is often associated with a state of general dyspepsia. We have previously referred to it as a symptom of gastric disease.

There are two forms of duodenal dyspepsia that require especial consideration; the one arising from excessive irritability of the mucous membrane, the second from inflammatory congestion.

Great credit is justly due to M. Corvisart for the investigation he has carried out in reference to the function of the pancreas, and its connection with duodenal dyspepsia; and doubtless this large gland, situated at the commencement of the small intestine, has important relation to the functional activity of the ileum and jejunum. Without entering upon the consideration as to the agency of the secretion in promoting the solution of nitrogenous products, there can be no doubt that its function is as important and probably analogous to that of the salivary glands; and that with the function of the pancreas the minute duodenal glands, Brunner's glands, are closely connected.

The first condition to which we have referred, abnormal irritability, is probably of a functional rather than of an organic kind; but, in some instances, the symptoms are so severe, that we have feared superficial ulceration. Such patients are generally in a weak and enfeebled state, the mind is restless, and the countenance anxious. There is tenderness to the right of the scrobiculus cordis, and the statement generally made is, that all goes on very well for about two to three hours after a meal; then, that soreness is felt, and a trying sense of pain with faintness is induced, the pain is sometimes described as a feeling of “tightness,” “grasping;” at other times as if there was “a raw surface,” which was disturbed when the food was made to pass over it. Other portions of the mucous membrane may be irritable, and vomiting is not very unfrequent. The tongue is irregularly congested or patchy, the bowels may be in a normal or irritable condition, the pulse is compressible, but the most distressing symptom is the general feeling of malaise and exhaustion. It may be, that these symptoms are due to an unusual sensibility of the pyloric valve; and we believe that this state does sometimes exist. It is, however, difficult precisely to localize these symptoms, for both stomach and duodenum are supplied with branches from the pneumogastric nerve, and the first part of the duodenum is closely allied in function with the stomach.

That this state may precede one of organic change, and be followed by ulceration of a serious kind, is doubtless the case; but with care, we have known the

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