of bile into the cavity of the viscus. After having been subject for some time to a frequent recurrence of the sensation of heartburn, and with it thus fresh before me, I was struck at perceiving the same burning sensation at the pit of the stomach that belongs to it come on during the occurrence of vomiting efforts, the result of sea-sickness, after all the food had been some time previously discharged from the stomach. The rejection following the arrival of this burning sensation was strongly tinged with bile, whilst no appearance of bile had been noticed before.

The treatment that is usually successful for heartburn consists of the administration of alkaline agents conjoined with a proper regulation of the quantity and quality of the food, A combination of the carbonate of soda or ammonia with rhubarb and magnesia, or with rhubarb and a mild bitter, as the calumba, may be advantageously given; or sometimes the liquor potassæ in a bitter infusion. As alkaline agents, the seltzer, Vichy, and Vals waters form agreeable and useful remedies. Heartburn which is habitual or of long standing is often more effectually relieved by acids than alkalies, and the nitric acid is the best for the purpose.

WATER-BRASH (PYROSIS).

This constitutes an affection attended with pain, and the eructation of fluid in considerable quantity from the stomach. Dr. Cullen, whose experience of the complaint was large, his field of observation being in Scotland, where it is much more prevalent than in England, has left a faithful description of its phenomena. Its paroxysms, he says, "usually come on in the morning and forenoon, when the stomach is empty. The first symptom of it is a pain at the pit of the stomach, with a sense of constriction, as if the stomach were drawn towards the back. The pain is increased by raising the body into an erect posture, and therefore the body is bended forward. The pain is often very severe; and, after continuing for some time, it brings on an eructation of a thin watery fluid in considerable quantity."

The fluid discharged is usually almost tasteless, but sometimes more or less acid or sour. Patients often complain that it feels cold as it rises into the mouth, notwithstanding that the pain at the epigastrium which has preceded its eructation is of a burning character. The eructation is repeated several times without at first affording relief to the pain; ultimately, however, the pain ceases, and the paroxysm is at an end. The paroxysms vary considerably in duration in different individuals, and likewise the different paroxysms in the same individual. Their period of recurrence is

also uncertain. Sometimes, for instance, there may be a paroxysm every day for some time; whilst at other times the paroxysms occur irregularly at more distant periods. They are unaccompanied with any nausea, retching, or febrile excitement.

Pyrosis is an affection especially belonging to the middle period of life. It is seldom encountered in children, and rarely in advanced age. Women are more subject to it than men, and unmarried women than the married. After it has once occurred it is

very apt to return.

amongst the poor

From its being more common than the rich, the extensive use of farinaceous food has been assigned as one of its exciting causes. In Scotland, and some other northern countries—as Norway, Sweden, and Lapland-it constitutes a very common complaint-infinitely more so than in England. This is thought to be attributable to the rye, barley, or oatmeal food that is consumed in the place of bread. Nearly half the men and women living near the mountains in Lapland were, according to Linnæus, in his time, the subjects of pyrosis.

The precise nature of the fluid discharged in pyrosis and its source have not been as yet satisfactorily ascertained.

Frerichs, from his examination of vomited fluids, has ascertained that in some disorders of the stomach the fluid rejected consists of saliva. The salivary glands, being sympathetically irritated, secrete an abundance of saliva, which is swallowed and subsequently rejected. The fluid has been found to present all the characters of saliva in these cases. In reaction it has been generally alkaline, but often neutral, rarely acid. It has contained a large quantity of the sulphocyanides, and

under the requisite conditions has rapidly converted starch into sugar.

Montegre, who possessed the faculty of discharging the contents of his stomach at will by eructation, sometimes ejected half a tumblerful of liquid before anything had been taken in the morning. This he looked upon as gastric juice; but it is evident from the properties he described it as possessing, and from what is now known concerning the action of the secreting follicles of the stomach, that it was not such. He remarked

that the rejected fluid differed in reaction at different times, acidity being a character that by no means invariably belonged to it; and that it resembled-in fact seemed identical with, saliva. It evidently consisted of saliva which had been swallowed, and had accumulated in the stomach; and such is doubtless often the source of the fluid matter rejected from the stomach when in an empty state as regards food.

The characters of the fluid raised in pyrosis are not those of gastric juice; but fluid, other than gastric juice, it may be inferred, can be poured out under certain circumstances from the walls of the stomach.

In some cases of uræmia belonging to Bright's disease, large quantities of fluid are thrown off from the stomach by vomiting, which may be presumed to be derived from the stomach itself. Lehmann says that the rice-water fluid vomited in cholera, both in its physical and chemical properties, is almost perfectly identical with the fluid vomited in uræmia, and that the reaction of these fluids may be either acid, neutral or alkaline. Now, such fluids differ as much from the physiological product of secretion as does that discharged in pyrosis; and presuming the one to be

derived from the stomach, a parallel is offered which renders it not unreasonable to assume that the other may be derived from the stomach also. A catarrhal state of the stomach is sometimes regarded as constituting the condition associated with pyrosis. Broncorrhoea is an affection attacking the respiratory mucous surface which presents a close analogy in character to pyrosis,

The suggestion that the fluid eructated in pyrosis results from disease of the pancreas, and constitutes a product of secretion of this gland, which has passed by regurgitation into the stomach, seems to me too hypothetical to require any special comment.

I have examined some specimens of fluid discharged in cases of pyrosis, with the view of ascertaining if it possessed digestive properties. In one instance the fluid was thrown up, mixed with a little food. It presented a strongly acid reaction, and evidently contained a quantity of good gastric juice, as it produced a rapid digestive effect upon the hind legs of a frog suspended in it at the proper temperature. Upon another occasion a portion of two quarts that had been thrown up was examined. As this was only faintly acid, it was treated with strong hydrochloric acid in the proportion of twenty minims to the ounce. At the end of six hours there was only slight evidence of digestive action apparent, which shows that the liquid could have contained scarcely any pepsine. In another instance some fluid was taken that was clear and neutral. It· was treated with acid, and at the end of eight hours had only produced a moderate digestive effect. This, therefore, again, contained very little active pepsine.

In connection with these observations I have per