ymptoms. 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 66 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

After years of freedom,

ymptoms entirely subside. hey may return, but again yield to judicious treatment. The condition we have just described is one in which he strictest attention to hygienic rules and to a restricted dietary is essential to restoration.

The diet should be of a bland unirritating character. Sufficient time should elapse between the meals, and stimulants should be avoided if possible, especially ardent spirit and malt liquors. Physical rest, in a recumbent position, is also important; for exertion of a violent kind, even horse exercise, tends greatly to increase the pain and susceptibility.

If these means can be used thoroughly and continuously, medicine may be almost or entirely disregarded; if the bowels be confined, mild saline aperients should he used, as Karlsbad salts, Rochelle salts, or the carbonate of magnesia with hydrocyanic acid.

The nitrate of bismuth with carbonate of soda, in ten or fifteen grain doses, and if the pain be severe, with small doses of morphia, are extremely useful in some instances; or minute doses of opium may be given; but the great disadvantage of opium is soon felt, that it confines the bowels, and interferes with free secretion.

Acute inflammation of the duodenum is sometimes found after the administration of poisons; and after severe burns, the mucous membrane of this part of the alimentary tract becomes in some cases greatly congested; and, as first remarked by Mr. Curling, ulceration may

supervene. He describes diarrhoea, and the discharge of blood, as having arisen from this condition of the duodenum, and sometimes severe hæmatemesis and prostration. In some instances of severe burns, death has taken place as the consequence of perforation of the duodenum causing peritonitis. And after such severe injury to the skin, which, as we have before remarked, always evinces the closest sympathy with the mucous membranes of the stomach and intestines, it is not surprising to find, in connection with the general disturbance of the circulation, that congestion of this part occurs. In some instances, the free use of stimulants may have conduced to this inflammatory disease of the duodenum.

Grey discoloration of the mucous membrane of the duodenum is produced by long-continued congestion. It is of a uniform or punctate character, and it arises from the deposition of pigmental grains in the substance of the mucous membrane, or in the coats of the capillaries.

This chronic hyperæmia is observed in connection with pulmonary and hepatic congestion, in fact in any disease which leads to distension of the vena portæ ; and we also find a less general condition of vascular repletion of the first part of the duodenum in disease of the pylorus, whether it be simple fibroid degeneration and hypertrophy, or true cancerous disease. The mucous membrane becomes thickened, its vessels con

gested, and its glands enlarged; sometimes, indeed, so much so, that the glands might easily be mistaken for minute cancerous tubercles; the continued irritation having led to hypertrophy of the glands of the mucous membrane, as we find in other similar structures.

This state of chronic engorgement is best relieved by diminishing portal and hepatic congestion, and by stimulating the abdominal excretory organs to increased action, as we have described in speaking of congestive dyspepsia.

There is, however, a state of acute hyperæmia of an interesting kind described by Sir H. Marsh and by Dr. Stokes. It is induced by exposure to cold, by great mental anxiety, and sometimes by irregularity in diet and by stimulants. There is sallowness of the complexion, often followed by jaundice, with febrile excitement and headache. Vomiting is a very troublesome and distressing symptom, and induces a sense of great exhaustion, with faintness and pallor of the countenance. After intemperance there is the same violent bilious vomiting, but with a furred state of the tongue; loss of appetite and loathing of food, diarrhoea, tenderness of the right hypochondriac region, being followed by jaundice.

The inflammatory hyperæmia probably commences in the duodenum, and extends into the biliary ducts, and along the course of Glisson's capsule; the ducts become obstructed by the changed secretion, and

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