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by simply withdrawing all that may excite or protract it; and where the causes of the bleeding are most relieved by its occurrence. Hæmoptysis even is not so much to be dreaded in itself, being often a partial relief to the pulmonary circulation, as in the indications it gives of future evil. Hæmatemesis, however large in amount, rarely needs any active control. It expresses more distinctly, perhaps, than any other hæmorrhage, the need of the relief which it actually affords to a part of the circulation; and I believe more injury than good to be done by the means often used to check it. The same remark will apply to hæmaturia; with some qualification for cases where it originates in calculi, or disease of the kidney. On these points, as on so many others, the experience of the physician must be brought to judgment on particular cases. Where precepts, to be applicable at all, need to allow for such numerous and important contingencies, they lose much of their value in practice.

Connected with this subject is the question as to the relative fitness and extent of bleeding, as a remedy, in advanced life; a matter of frequent doubt to the practitioner; and, like the preceding, best to be solved by sound experience applied to each case. The general rule, doubtless, is that of comparative limitation, and a still more cautious observation of the tests by which this limit is marked in actual practice. For the various disorders of inflammation or congestion occur in the same organs, and of the same kind, as in earlier life; but with diminished means in the system itself of resisting the disease, or repairing any losses sustained in its treatment.* Under the latter consideration, it becomes especially needful in old age (though the rule applies to all ages) that the remedy, when required, should be promptly used; before the

* The observations of M. Louis, on inflammations occurring under debility of the system at large, well merit every attention here.

disease gains stronger hold, before parts are disorganized, or the nervous powers exhausted by long illness.

The latter point is one to which attention is singularly due at this time of life; lest by continued active treatment of symptoms, which might have subsided after the first remedies, we bring on others more injurious in result. Here, too, there is need of a particular caution as to the pulse of old age. The artery brought nearer to the surface by the absorption of other parts, with its own texture and elasticity also changed, gives a pulse to which common interpretation will not apply, and which deceives the inexperienced or careless by the impression of more vigour of circulation than actually exists. A like deception often arises from ossification of some part of the heart or vascular system, so common at this time of life. An irritable jarring stroke is thereby produced, mistaken sometimes for one of power; and leading to a mischievous activity of depletion, the effects of which are not readily repaired.*

One of the best tests here is the equality, or otherwise, of the heart's action; and the more needful to be observed, seeing the frequency of structural changes in this organ in advanced age. If intermitting, and unequal either in strength or frequency of beat, caution as to bleeding must be doubled; and this caution is no less to be maintained, where there is pre

* In the application of the valuable means we now possess for discovering organic changes about the heart and great vessels through the parietes of the chest, the separate indications to the same effect through the pulse are too much neglected It is probable that there is no structural disease of the heart, certainly none of consequence, which is not represented in some manner in the pulse, beating along a vessel of the size of the radial artery. The difficulty, of course, is in estimating the slighter modifications, and in separating them from the analogous or identical effects of other disorders; the latter difficulty, indeed, one that is common in part even to the more delicate methods just referred to.

sumption of the irregularity depending on sensorial disorder. In this case it expresses more frequently deficiency of nervous power, than a state of brain requiring depletion: while if originating in the vascular system, it is oftener the result of mechanical difficulty from structural causes, or of unequal supply of blood to the heart, or of change in the quality of the blood itself, than of actual excess in the quantity of this fluid. Where, nevertheless, the symptoms are deemed to require bleeding, its influence upon the regularity of the heart's action must be carefully looked to as a test; and this not merely at the moment of depletion, but even yet more when the circulation has recovered from the sudden change of balance thus produced.

The effect upon the sensorium and nervous power is, undoubtedly, the most important part of the question as to bleeding in old age. In another place I have made some remarks which bear especially on this subject. It is certain that there are states of brain, with which its general condition in old age is closely connected, where sudden or considerable loss of blood brings on various morbid effects, paralytic or convulsive in kind, the occurrence of which is too exclusively attributed in common practice to fulness of blood in the vascular system. Errors in treatment, founded on this view, may be repaired at other periods of life, when such state of brain is brought on by casual causes: but in old age, where it is more or less permanent, and depending on organic changes, the mischief done is sometimes irreparable in kind. And the greater care and discrimination are needed here, from the singular similarity, as far as general aspect is concerned, of symptoms really arising from different causes, and requiring opposite


Further, it may be remarked that bleeding in advanced life, when manifestly required by the symptoms, does not of


necessity preclude the use at the same time of means to support the nervous power. On this point, indeed, as respects all periods of life, common practice is too straitened and exclusive. A disorder which requires depletion by bleeding, as the chief and earliest remedy, is presumed to admit none other than antiphlogistic means while this state continues: and, as a general rule, this is so; but there are cases of exception, and old age includes many such. The nervous and circulating systems, though so closely connected in every function of life, have yet their separate powers. Even taking the whole of each system, these powers are not always, it would seem, in exact relation to each other; and this is more particularly true where the vascular changes, whether of inflammation or simple congestion, are limited in extent. may need for relief the change in circulation which bleeding affords; yet may require at the same time that support or stimulus to the nervous power, which is essential to the equal distribution of the blood, and without which disorders of a new kind will supervene, or the one for which the remedy was applied be kept up under an altered form. We cannot rightly refuse the name of inflammation to certain cases which occur, not simply during debility, but even consequently upon it; and the just application of remedies of the two classes, concurrently or consecutively, to these cases, forms one of the most delicate points in medical practice. It is sufficient to mention it here, in its application to the treatment of the diseases of advanced age.

Several of these observations as to bleeding apply equally to the use of purgatives. The frequent employment of drastic medicines of this kind is injurious to the general powers of life, as well as to the particular organs on which their impression is first made. The necessity of many cases, even in extreme age, does of course supersede this rule; but

it is one fitly to be kept in mind in every part of practice. In applying it we must advert to the fact, that the feebler circulation, and deficient sensibility and secretion of the mucous surfaces in old age, often render medicines and doses ineffective which have acted readily at other times of life so that here, even more than in other cases, we are to measure our means not by common tables of doses, but by observation of effects on the body.

Many of the foregoing remarks are applicable to general practice; but I specify them here as comprising the principles which may best regulate the use of depleting remedies in old age. Another question regards the employment of opiates at the same period of life: nor is this without its peculiar perplexities. Besides the modifications which are required from the different relation of years to bodily powers, and those further made necessary by the various idiosyncrasies as to opium, we have another specialty in this part of treatment from the changes which the functions of the brain, and often even its obvious texture, undergo in advanced age. Some of these changes are of nature to render the action of opiates ambiguous at least, if not in many cases distinctly hurtful. The vague dozing state, which steals gradually upon the aged, and, without any acute disease, seems in the end to turn life into a mere dream this expresses an altered condition of the brain and nervous system, in which narcotics probably quicken the change and render it more complete. Happily these are the cases in which they are generally least required. The state in question is a benign dispensation to the extreme term of life, rarely coming within the proper scope of medical treatment, unless there be some sudden passage into what is obviously a condition of coma. And even where other organs are more actively diseased, the sensibility in such cases is often so far lessened, as to supersede the

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