air, as far as his strength may permit; and his clothing should be warm, and suited to the vicissitudes of the atmosphere and sudden changes in its temperature.

SECT. II.-On Diseases of the Pancreas,

The situation of the pancreas renders it a difficult matter to obtain any knowledge even of the existence of disease of this viscus during the life of the patient. We frequently, however, find, upon examination of bodies after death, very manifest changes in its organisation and size. These chiefly consist of simple enlargement, of enlargement with scirrhous hardening, and of cheesy tumours in its substance. But whether these lesions are always the result of slow inflammatory action, or of some change in the nutrition of its substance, or of both, is a question which admits not of a ready solution. Our knowledge, also, respecting the state of its function, or the qualities of its secretion during these states of disease, is equally defective.

The pancreas is sometimes found greatly enlarged, and in some degree hardened; occasionally it is reddened and evidently inflamed in parts, and this appearance may be remarked either alone, or conjoined with enlargement of the various lobules of the gland, and, in a few cases, with small collections of pus formed in the interlobular cellular substance: at other times it is tuberculated and irregularly enlarged; on some occasions enlarged and scirrhous, the texture of the organ being traversed by gristly bands, and a reticulated, firm structure, with a glairy fluid filling the interstices. Yet in these cases the patients presented only the symptoms of chronic inflammation of the liver, or at least they were considered as suffering under that disease. When the pancreas is much changed in its organisation, and much enlarged, it often presses upon the common duct, and either impedes or entirely obstructs the flow of bile into the duodenum. In this case, the derangement is generally assigned to the biliary apparatus, owing to the sallow countenance of the patient, and the jaundice which frequently supervenes from the obstruction of the ducts. In some cases, the enlargement of, and the tuberculated and knotty tumours formed in, the pancreas, may be mistaken for scirrhous pylorus; and it is often a matter of difficulty to decide which of the two diseases is actually present. In some instances, however, attention to the manner in which the function of digestion is performed, and to the presence of sickness,

and the period after a meal at which nausea or vomiting supervene, will guide the practitioner to a correct diagnosis.

In cases of diseased pancreas, inflammation often supervenes either in the viscus itself or in its surface or vicinity, uniting with it the pylorus, duodenum, biliary ducts, and even the gall-bladder, by firm adhesions. In these instances, if the diseased state of the pancreas was not primarily the result of inflammatory action, this action must have supervened in the progress of the disease, otherwise the consequences of inflammation could not have existed. In such cases the pancreatic disease may be viewed as having supervened primarily ; but it is probable that, in the great majority of instances where the pancreas has been found diseased, it has been consecutive to chronic disorder of the stomach, duodenum, or liver. I have found it consequent upon very severe dyspepsia, combined in many instances with an irregular and morbid state of the alimentary canal; in others, it seemed to have supervened to obstinate disease of the biliary organs.

Whether chronic inflammation of the mucous surface of the duodenum may be propagated along the ducts to the pancreas, as some pathologists suppose, is a question which is more readily proposed than answered: I believe that it may possibly supervene in this manner, but that it very seldom occurs. If inflammation actually extend from the internal surface of the duodenum along the pancreatic duct to the pancreas, it must still more frequently be propagated along the biliary ducts, and transmitted to both the gallbladder, and to the liver itself. I look upon inflammation of the panc reas as taking place more as a consequence of disorder of its functions, when it occurs primarily, than as proceeding from the extension of inflammation from the alimentary canal along its duct. When it is a consecutive disease, it is induced most frequently from inflammation having extended from the concave and posterior part of the liver, or from the gall-bladder and biliary ducts, and perhaps occasionally from the external surface of the duodenum. In a great many of those cases wherein this viscus has been found diseased, the more immediate cause must be referred to previous disorder of the function. But it is almost impossible to determine when such disorder commenced; as it is generally so much the result of, and complicated with, the more obstinate forms of dyspepsia, and functional and organic disease of the liver, as to put it out of the power of the most discriminating observer to ascertain what share of disorder ought to be attributed to this organ.

When, however, the functional disorder has induced either

organic change, or acute, sub-acute, or chronic inflammatory action, attentive observation and much experience may lead the practi. tioner to dread the existence of disease of the pancreas, although he will seldom be enabled, unless there be considerable emaciation and well-defined symptoms present, to form any idea as to the particular kind of disorder existing. If pain be felt, it may proceed either from the posterior and inferior edge of the liver, or from the gall-ducts, or from the duodenum or pylorus, or from the pancreas itself, or from any two or more of these parts. If enlargement be evident, it may be the consequence of thickening or scirrhus of the pylorus, accumulations in the colon, or morbid duplicatures of this viscus, or of enlarged glands at the root and in the folds of the mesentery, or of any of the organic changes of the pancreas enumerated above. Even when disease of the pancreas is present, it is seldom met with as a simple and uncomplicated malady. There is seldom an opportunity of investigating the post mortem appearances of acute disease of this organ, except in cases which terminate fatally, either altogether from disorder existing elsewhere, or from the complication of such disorder with the pancreatic disease; and even in the majority of those cases, we seldom observe more than the remote consequences of the disease which had been going on in the pancreas, and are still left much in the dark respecting the nature of the earlier changes induced in the structure of this viscus.

Diseased pancreas is not indicated by any very acute symptoms. The patient often feels an aching, heavy, or dull pain in the back, beneath the scapulæ, and deep in the epigastric region. This is often mistaken for chronic disease seated in the posterior part of the liver. When such mistake is made, it cannot be of any very material consequence as respects the treatment, as the means of cure are nearly the same in both cases. There is generally a sensation of compression, internal heat, constriction, and anxiety at the precordia and deep in the epigastrium. The tongue is generally white, and its papillæ excited, with dryness of the mouth and fauces, and occasionally there are eructations of a viscid fluid disgorged from the stomach. There are also generally loss of appetite, nausea, and occasionally vomiting and hiccup, with great emaciation in the advanced states of disease. The skin is usually hot and dry, and the pulse somewhat accelerated. The bowels are either costive, or a slight diarrhoea is present, characterised by mucous and glairy stools.

As disease of the pancreas is seldom met with in a simple or

uncomplicated form, being usually accompanied with inflammation of the liver, stomach, or duodenum; so it must be expected that the symptoms now enumerated will be attended with, and, in a great measure, obscured or entirely concealed by, the symptoms characteristic of these diseases. Indeed, the pancreatic derangement very seldom becomes apparent, when existing in any of these states of complication; for it is generally consecutive to the disease of the adjoining organs, and is much less acute, and less distinctly developed, than they are.

As respects the causes of disease of the pancreas, I have nothing to adduce with confidence. Its most frequent exciting causes seem to be, protracted or improperly treated disorders of the stomach, duodenum, and liver, and the causes already assigned for these maladies. The habitual use of heating and irritating articles of diet, and of spirituous liquors, may have some share in the production of disease of this viscus.

Of the treatment of diseased pancreas, little also can be stated with confidence. Antiphlogistic remedies should be resorted to. Local depletions, counter-irritations by means of blisters, setons, or the use of the tartar-emetic ointment, and cooling purgatives, seem best suited to the disease of this viscus; but the remedies must necessarily be chosen with a strict reference to the particular complication which it presents in practice. In the majority of instances, deobstruent aperients given internally, whilst the nitromuriatic wash is used to the trunk of the body, will be productive of some advantage, and at the same time tend to remove the disorders with which diseased pancreas is most frequently complicated, more particularly after local depletions have been carried sufficiently far. I do not recommend mercurials to be employed when the pancreas is obviously diseased, unless with a view to its purgative effect.

CHAPTER II.

ON INFLAMMATION OF THE SMALL INTESTINES.

INFLAMMATION of the small intestines may be seated chiefly in its mucous or villous tunic, or it may extend no further than to cellular tissue immediately subjacent to it, and connecting the villous to the muscular coat. In these cases, more particularly the former, the inflammation is generally slight; and if it advances no deeper, the disease is soon removed by judicious treatment. In many cases, however, especially when it is also seated in the submucous tissue, the inflammation extends through the whole cellular texture uniting the various membranes of which the small bowels are composed, or it attacks the bowel to this extent at first. When the disease commences in the mucous coat, and extends to the substance of the bowel, it becomes much more acute and dangerous. When acute enteritis is met with in warm climates, more particularly in India, it generally advances in this manner; but it also attacks, although more rarely, in a primary and more immediate manner, the substance of the bowel, forming what has been usually denominated phlegmonous enteritis. Even when it seizes upon the substance of the viscus, it seldom invades, at the same time, the free or serous surface of the intestinal peritoneum; but it soon extends itself to this membrane on the one side, and to the mucous coat on the other, so that the various tissues of which the bowel is composed at last become the seat of disease. Inflammation of the small intestines seldom commences in their peritoneal surface, unless from the extension of disease from some other organ.

SECT. I.—On the Pathology of Inflammation of the Small

Intestines.

Inflammation of the small intestines, as observed in warm climates, is frequently the consequence of morbid secretions and the accumulation of mucous sordes upon the internal surface of the bowel, assisted by the influence of the usual exciting causes of inflammation of internal organs, such as exposure to night air, to