BOOK IV. ON THE DISEASES OF THE SPLEEN, PANCREAS AND THERE is no class of diseases which requires more careful observation during the life of the patient, and minute research after death, than affections of the bowels, as they occur in India, and in warm climates generally. In many localities they constitute, both in their simple and complicated forms, the chief class of diseases, and are frequently attended with the greatest danger. The observations I shall offer upon this class of diseases will be chiefly the result of my own observations; but it is necessary to premise some remarks upon the disorders of the spleen and pancreas as they present themselves to our notice, particularly as they occasionally are complicated with the diseases already considered and those of which I have now to treat. CHAPTER I. ON THE DISEASES OF THE SPLEEN, PANCREAS, AND INTESTINES, THESE diseases are not generally very prevalent in warm climates: those of the pancreas, perhaps, not more so than in temperate countries. Affections of the spleen are prevalent only in particular districts of country and situations. In the Madras Presidency, they are not very frequent, unless in neglected or improperly-treated cases of ague or remittent fevers. SECT. I.-On the Diseases of the Spleen. Inflammation of the spleen, although not of very frequent occurrence in India, is, I believe, a common disease in Bengal Proper; it is, however, rare in the Madras Presidency. In some situations it is endemic, more particularly in low swampy places where agues abound; and in such districts the inflammatory action which supervenes is generally of a slow or chronic nature, and attended with congestion and obstructed circulation in the viscus. In some cases the enlargement which takes place is very great,—the spleen seeming to fill nearly the whole of the left hypochondriac and epigastric regions. When inflammation of this organ presents acute or subacute symptoms, it almost always is seated in its fibrous covering, and is attended with more or less pain, and a well defined enlargement, which, however, while the acute symptoms continue, is seldom very great. The most frequent states of organic change of the spleen are the following:-1st. Enlargements of this viscus. The enlargements sometimes are to a very great extent, the spleen weighing ten or twelve pounds, and yet no very sensible alteration can be detected in its substance by the unassisted eye. Frequently, however, its structure is at the same time much changed, its colour being much deeper, its consistence greatly diminished, and rendered more friable, so as scarcely to admit of examination without falling to pieces. Its external membrane is also often torn with ease: sometimes it is thickened, more vascular, and occasionally cartilaginous in parts. 2d. It is, in some cases, ossified in various places, and in others covered with large patches of coagulable lymph and albuminous concretions. In such cases, it frequently adheres to the adjoining surfaces and viscera. 3d. Its internal structure frequently contains purulent collections, sometimes apparently unencysted, and flowing through its substance; at others, enclosed in one or more distinct cysts. It also is subject to tubercular formations, and to hydatids. 4th. The spleen is occasionally found smaller than natural, and dry and shrivelled; but this is comparatively a rare occurrence in warm climates. 5th. Instances have occurred wherein it has been ruptured, from the congestion of blood to which it has been subject in the cold stage of an ague. And, 6th. Its internal substance has been occasionally found reduced to a grumous and pultaceous mass. The causes of diseases of the spleen are chiefly those inducing intermittent and remittent fevers. It is seldom observed as a primary disease, and seems to result, in a great measure, from the deficient energy of the system, particularly of the digestive organs. It is frequently observed as a sequela of agues, in low, marshy, and moist situations upon the sea-coast, more particularly in wet and warm seasons, and where there is a deficiency of spring or river water. In some places within the tropics, where the water consists entirely of rain-water, preserved in tanks, situate in low, marshy grounds, diseases of the spleen are endemic. In countries far inland, and considerably above the level of the sea, these diseases are comparatively rare. When the spleen is simply enlarged or tumefied, without inflammatory action being present, little inconvenience or pain is felt by the patient, even although the enlargement may be to a very great extent, the tumefied spleen passing across the umbilicus to the right iliac region, and filling nearly the whole abdomen. In these cases, the congestion in the spleen is usually the consequence of protracted agues, more particularly when they have been injudiciously treated. In cases of this description, the nature and progress of the disease are readily perceived, as the margin of the tumefied viscus can be readily traced, and the extent of enlargement very nearly ascertained. If the spleen be inflamed in a more or less active form, a dull, heavy, and aching pain is felt in the left hypochondrium, with occasional lancinating pains in the same situation, observed particularly upon quick motion, and after a full meal. In the more acute cases, there are chills or rigors to which succeed pain, nausea, and occa sionally vomiting, with thirst, tension, colicky pains, and impeded respiration. The tongue is generally white, foul, and excited; the pulse somewhat accelerated; the bowels constipated or irregular; the urine high-coloured, and frequently voided; and the skin sallow, dusky, and rather hot. In the sub-acute and chronic cases of inflammation, several of these symptoms are either altogether wanting, or are so slight as frequently to be overlooked. The spleen is generally tumefied to a considerable extent, at the same time that its proper coat is inflamed; but the tumefaction is never so great as in the cases of simple congestion of the viscus, already alluded to. Sometimes the enlargement is scarcely to the extent of allowing the spleen to be felt beneath the left false ribs, even in the most acute cases of the disease. Treatment.-In cases of simple tumefaction of the spleen, un. attended by inflammatory action, a general laxative system should be adopted to carry off the morbid secretions always present in such cases; at the same time attention should be paid to uphold the strength of the patient, and to give energy to the digestive organs. Full doses of calomel at bed-time, followed by the bitter aperient draught, or the pulv. jalap comp. in the morning, may be continued until the motions have assumed a healthy character. It must, however be remarked, that in giving calomel in these doses, it is not with the view of producing the specific action of mercury upon the constitution, but purely as a purgative; and it is selected as such because it acts more decidedly upon the vitiated secretions of the bowels than any other medicine, and prepares those secretions for removal by the ordinary purgatives recommended. I am particularly desirous of directing attention to this point, from the circumstance of my views of the treatment of diseases of the spleen, having been either misrepresented, or not clearly understood by an author (Mr. Twining), who has lately written on the diseases of Bengal; and who, from insufficient extracts of my opinions, has apparently been led to draw inferences which are not warranted, but which, I fear, have misled many as to the views I entertain upon this subject. After purgatives have been duly employed, the nitro-muriatic acid lotion should be applied over the region of the spleen, and the nitric acid may be given internally at the same time in the patient's drink. I cannot too strenuously recommend this treatment in diseases of the spleen, especially the nitro-muriatic solution. But in order that this latter may be beneficial, a continued and well-regulated course of purgatives, and afterwards of aperients combined with tonics, should be adopted. In cases of congested or tumefied spleen, we must support the powers of the system, while we purge the bowels by giving the blue-pill and the aloes and myrrh pill every night, and a full dose of calomel occasionally. But the purgative draught should be continued every morning until the disorder disappears. In cases of this description, the best purgative is that composed of the compound infusions of gentian and senna; to which may be added some of the bitter purging tincture, and a little of the sp. ammon, arom., or of the sp. æther. nitr. If we should find it requisite to act more energetically upon the bowels, this draught may be repeated at mid-day, or a drachm or two of the sulphate of magnesia, sulphate of soda, or sulphate of potass, may be added to it. Hæmatemesis, with a dark, grumous state of the stools, is not an unfrequent concomitant of congested spleen. In cases of this description, the treatment already recommended need scarcely be even modified; but the nitric acid drink is here especially indicated, with the external use of the nitro-muriatic acid lotion. If pain be present, with a plethoric state of the habit, leeches applied over the region of the spleen or stomach are evidently necessary; but in cases of this kind, no means should stand in the way of active and continued purging, as recommended, promoted by the injection of active cathartic enemas. When inflammatory action is going forward in the spleen, leeches should be applied upon the left hypochondrium, and the local bleeding carried as far as the condition of the patient, and urgency of the symptoms, indicate. After the leeches have ceased bleeding, a cloth, moistened with the nitro-muriatic solution, should be applied upon the splenic region, and covered with a hot poultice, which, with the moistened cloth, ought to be frequently renewed until the acute symptoms subside, when simple sponging with the solution night and morning will be all that is necessary. In addition to these means, the use of purgatives and tonic aperients must be persisted in until the disease is removed and the motions acquire a healthy appearance, when change of air and regular exercise should be adopted. During the treatment of diseases of the spleen, the diet and regimen of the patient should be carefully attended to. The patient's food should be light, nutritious, and in no greater quantity than his digestive organs can well dispose of. Vinous and fermented liquors should be avoided, and his drink be of the most mild and cooling description. He ought to take regular exercise in the open |