3>a 3 O P ^LIBRARY OF CONGRESS. ^^£fM UNITED STATES OP AMERICA. ' >5 3E> S^> 3g|=3R&iR >MSz&> xd:z>s> :^o> > : :> s^f ~>:.?:I 2>:xo> >o->> JS> »3X2>2> 3SQ5> 0> X> T> i> >-*5^> :xr&> AN ON THE DISORDERS OF OLD AGE, AND ON THE MEANS FOR PROLONGING HUMAN LIFE. BY ANTHONY CARLISLE, F.R.S. F.S.A. F.L.S SURGEON EXTRAORDINARY TO HIS ROYAL HIGHNESS THE PRINCE REGENT, AND TO HIS ROYAL HIGHNESS THE DUKE OF GLOUCESTER J PROFESSOR OF ANATOMY TO THE ROYAL ACADEMY ; PROFE8SOR OF SURGERY AND ANATOMY TO THE ROYAL COLLEGE OF SURGEONS OF LONDON ; AND SURGEON TO THE WESTMINSTER HOSPITAL. 11 Every stage of human life except the bst, is marked out by certain de- Shed limits; Old Age alone has no precise and determinate boundary. " Cicero on Old Jge. ^ PHILADELPHIA: PUBLISHED EY EDWARD EARLE, Corner of Fourth & Library Streets. 1819. W. M.vrr. Print BrunsK TO THE MASTER, GOVERNORS AND MEMBERS OF THE COURT OF ASSISTANTS IN THE ROYAL COLLEGE OF SURGEONS, LONDON. Respected Colleagues, I submit this short exposition of a part of my professional sentiments to your competent and equi- table judgment. My deliberate thoughts are here purposely laid open to all men of education, from a hope, that such proceeding will tend most effectually to pro- mote the Healing Art. Surgery must appear more respectable when it is known to be established upon rational and scientific foundations, and that its rules are deducted from the unvarying laws of Nature, and constantly subject to the corrections of progressive Experience and accumulating Observation. Gentlemen, Vrour much obliged, And faithful Servant, ANTHONY CARLISLE. S'oho Square, 29th Nov. 1817. ON THE DISORDERS OF OLD AGE. NUMEROUS medical tracts have been written upon Longevity, and on the Maladies of advan- ced Age ; and it might therefore be unnecessary to trouble the public with any further additions, were it not apparent, that many of those books are too voluminous for common readers, and others rendered objectionable by their technical perplexities. The present Essay is addressed principally to persons already advanced in years, and does not embrace the course of regimen which from an early period is best calculated to secure a long life. Experience has fully convinced me, that the later stages of human life are often abridged by unsuitable Diet, or prematurely ended by Disorders which are not treated with sufficient . wjp..> attention by the Faculty. It seems little better than a vulgar error, to consider the termination of advanced life as the inevitable consequence of time, when the immediate cause of death in old persons is generally known to be some well-marked disease. According to my observation, the disor- ders of Senility may often be relieved, and our declining years extended far beyond the ordinary number, by judicious management. I need not point out to the wiser and better part of mankind, the incalculable value of those sages of our race, whose long experience and knowledge, so difficult to be communicated, may be prematurely lost in the grave ; each day that we can prolong their comfortable existence, 7 may be of inestimable benefit to their families, and the addition of every hour to them may be of lasting use to society. All impartial observers must have noted in- stances of men with contrary habits arriving at old age ; and it is both easy and plausible for self-indulgence to adduce examples of intempe- rate men, who attain to advanced years ; but the numbers are not so fairly stated who fall un- timely by provoked disease, nor is it inquired how little those devotees have comparatively en- joyed or performed, in consequence of their dis- orderly conduct. I trust my brethren will receive this Essay as an attempt to increase the respectability of our profession, by enlarging its duties, and by offer- ing consolation and hope to those who are stricken in years. These observations necessarily comprise both the offices of the Surgeon and the Physician, be- cause I could not separate the consideration of 8 local distempers from constitutional influences ; nor does it seem beneficial to the sick, that such distinctions should be practically enforced. The infirmities of Age assail different parts of the frame ; but some individuals are habitually prone to special Disorders. According to the laws of our nature, the vicissitudes of every pass- ing hour begin to endanger the healthful structure of the body as soon as its growth is completed. A likeness in the composition of its materials, and an exacfsameness of every texture and tis- sue, cannot be expected to continue, because every part is daily wasting and repairing. The error of a subordinate part will, therefore, by degrees encroach upon the organs essential to health, and the accumulation of such derange- ments soon declares us to be mortal. In some persons, the vital formations fall into early and ruinous disorder, and a premature fate ensues, — but it would far exceed my pre- sent intentions to exhibit even a general view 9 of those causes, which so often destroy mankind before they approach Senility. After the middle period of life, the creature is supposed to have fulfilled the command of nature for continuing its race, and the bodily fabric then begins to decline. The teeth, those implements for grossly di- viding the food, are then liable to decay and hence the raw material of replenishment is in- troduced into the stomach under obvious disad- vantages. The compactness and vigour of the muscular flesh begin to diminish, and all the inward fittings and adjustments are prone to give way. The eyes and the ears, those out-guards for protection, lose their accuteness and sensibility, or have their physical accuracy deteriorated, and the value of individual life seems to fall. At this critical: period, it behoves the tenant to keep a strict watch over needful repairs ; and, if he have a skilful medical architect, he may 10 then obtain useful information respecting the best materials for keeping his building together, and on the fittest cements and supports to pro- tect it against approaching storms. The preventive art of Medicine, and the suit- ableness of Liet, are well worth considering; and, in the autumnal season of life, they will be found to comprise the most rational and the most practical resources of information. For, without fear of contradiction, it may be assert- ed, that the wholesome regulation of diet, cloth- ing, exercise and air, are often more important than the administration of drugs, blisterings, or bleedings. When the age of maturity has passed, and the lungs have escaped a derangement of struc- ture, most incident to youth, the common dan- gers of life are to be discovered in disorders of the head, the stomach, the bowels, the blood Vessels, and the liver ; and they display them- selves by apoplexy, palsy, indigestion, obstruc- tions, inflammations, jaundice, or dropsy. Ma- 11 ny of these diseases are happily within the reach of medical skill, if attended to in time ; but they are severally much more easily avoided, by prudent regimen and preventive methods. Few persons are attacked by dangerous dis- orders without due notice and repeated warn- ings: I have never known an instance of apoplexy or palsy, until after many previous intimations ; nor any serious affections of the stomach, bow- els, or liver, without the precedence of some morbid visitation, such as head- ache, flatulen- cy, acidity, or local pain. It is more than probable, that inflammatory diseases occur on- ly in vitiated habits ; and when they seem to arise spontaneously, or to be occasioned by in- adequate causes, they are in truth but roused into activity, and owe their remote origin to an ill-conditioned state. I cannot adopt the irrational opinion of those, who attribute all human maladies to a single source, or who pretend to remove all distem- pers by one remedy. The annals of Medicine 12 have been too often disgraced by these and similar absurdities, although common sense, lo- gic aad science have alike, and at all times, dis- carded them. Every experienced medical man must have felt the harfassing difficulty of discovering the real nature and the causes of diseases ; and he mi st have equally felt the deep responsibility of directing safe and ^efficacious treatment ; nor does extended practice clear away those intri- cacies. It behoves every man who takes upon him- self the charge of preserving human life, when endangered by the approach of fatal disorder, to search well for evidence, to ponder before he concludes, and to examine his stores of practical knowledge, before he determines to employ powerful — perhaps, desperate methods. This careful and cautious inquiry charac- terizes a good practitioner ; for, upon a quick, dear, and, as it were, an intuitive discrimination 13 between frivolous and leading facts, a sound judgment can alone be formtd, — that solemn and deliberate judgment which ought to govern the conduct of every medical man, and on which the momentous question of Life or Death so often depends. The age of Sixty may, in general, be fixed upon as the commencement of Senility.-*- About that period it commonly happens, that some signs of bodily infirmity begin to appear, and the skilful medical observer may then be frequently able to detect the first serious aber- rations from health. Lo^g continued professional experience has taught me to seek for such incipient disorders in the evidences of the state of the stomach, and in its dependencies, and from the condition of the blood and its vessels. Over-fulness of the vessels, contamination of the blood, impair- ed digestion, and consequent crudities, min- gling with the elementary materials of the blood, — obstructed bowels, and all the dangers 14 which result from impediments to that source of keeping the body pure and wholesome, arc to be reckoned the leading causes of many dis- eases ; — and a scrupulous attention to these points, will often discover the beginning of bad health. A dislike to blood-letting, founded on erro- neous opinions, is very prevalent in old per- sons, and even many Physicians sanction the prtj udice. I do not aver that plethora is an invariable condition of old age ; but, whenever it does oc- cur, it constitutes a dangerous feature. The state of the pulse, and other signs of an excessive volume of blood, would often mark out the expediency of bleeding, if a prejudice about its weakening effects did not obtrude ; but I am convinced, that the feebleness of age, when produced by sanguineous oppression, can only be removed by diminishing the quantity of 15 blood, and that, on the promptitude of such measure, the safety of the patient will depend. The fibres in old persons are relaxed, and the flexible solids, together with the blood ves- sels, are mere yielding than they are at a more vigorous period. From the same cause, that muscular engine, the Heart, labours under a diminished power, while it is obliged to drive on the circulation, under the disadvantages of weakened and distended vessels. The separating of fluids from the blood, call- ed the secretions and excretions, is also lessen- ed or deteriorated, so that the ordinary methods of its purification, and of balancing its quantity, become impaired ; hence, in extreme old age, the blood is liable to be disproportionedj or to be vitiated, in its composition. The heart and the blood vessels are subject, however, to disturbances, independently of any improper quantity of blood, or any discoverable change in its qualities. Of this kind are some 16 disorders of the stomach, which occasion sud- den and violent rushings of blood into the head, and which seem to be the immediate conse- quence of deleterious food. This example be- ing one from a long list of similar maladies* shows how inadequate the mere mechanical ex- planations of anatomy are, in the practical ser- vice of medicine. As to the allejged peculiarities and deviations from the ordinary course of the human consti- tution, which have been called Idiosyncracies, I profess myself doubtful ; and I apprehend, that a deeper scrutiny will assign those appa- rent incongruities to the variable degrees of power in the living organs. Fortunately for the value of medical precedents, and for the utilitjP of our experience, those alleged discre- pancies are very rare, otherwise the records and testimony of our faculty would be of little val- ue. It must, however, be confessed, that the usefulness of written knowledge is mostly con- fined to those who are prepared by experience to discern its correctness, and to measure its appli- 17 cations. Verbal representations are necessarily very general ; and the things treated of by lan- guage alone, must be the most intelligible to those who are already practically acquainted with them. Of all the preventive and curative remedies whose effects I have carefully witnessed, the most beneficial are Cathartics and Blood-let- ting ; but those powerful means are only effica- cious when skilfully directed. It is a gross and dangerous presumption for unprofessional persons to prescribe for the sick, because few disorders wholly depend on single errors of the body ; and when the co-operation of several means are called for, such as both ca- thartics and bleeding, their salutary effects may turn upon the precedency of the one to the other, on the selection or doses of the drugs, or on the quantity and mode of bleeding. In addition to those exertions of an experi- enced judgment, it is the indispensable duty 18 of a medical practitioner to order the Diet, and to adapt the special articles of food and drink to every vicissitude of health. When it is considered that many serious dis- orders are entirely occasioned by improper diet, and that in almost every disease, the direction of diet is perhaps of equal importance with the prescription of medicines, it is blameable to neglect this potent resource, and to rely on the unaided administration from the Apothecary's stores of a few grains of materials, whose quali- ties are ill understood. Numbers of learned and honourable men are engaged in the Medical Profession, and the rank which they deservedly hold in society, places them above the suspicion of any unworthy love of mystery. Those long continued technical obscurities, which at one time constituted the very form and body of the profession, seem to be now yielding to the fairer pretensions of sci- ence and intelligible observation. 19 When the concealments of the medical art are laid aside, and the candid avowal of plain sense and of natural knowledge is substituted for oc- cult proceedings, the Faculty will be more faithfully respected, and the customary fees as freely given for advice about regimen, as ever they have been for an elaborate prescription. - The propagation of what is termed general knowledge, threatens a speedy invasion of those privileged establishments which uphold medi- cal mystery ; and a prevailing suspicion attri- butes to all such concealments, the disgrace of mercenary motives, or the equally base design of covering presumptuous ignorance. In making this exposition, I entertain a gen- uine desire that my Professional brethren and scholars, m general, should see distinctly that its sole object is to advance the claims of well- qualified practitioners to the respect and confi- dence of a class of persons, who ought ever to influence the opinions and actions of the mass of society. 20 Many valuable works, exhibiting the pre- sent state of medical knowledge, have been lately published ; but as none of them corres- pond exactly with the results of my experi- ence, I feel it a becoming duty to present my own doctrines in this public manner. The particular restrictions on Diet, which I have found to be so useful to the Aged, are equally applicable to delicate and sickly persons, to young children, and to breeding and nursing women : and the divulging of these observa- tions may possibly awaken medical practition- ers to the important subject of general regi- men. The difficulties, uncertainties, and perils of our art, are sufficiently known, to justify eve- ry fair attempt to improve the knowledge of the causes of bad health, and to expand our means for alleviating or curing disorders. ■ This brief contribution of general sugges- tions, respecting the medical treatment of old persons, is but a specimen and small fragment of my professional collections ; it is, however. 21 sanctioned by experience, and composed under some peculiar advantages, at a mature age. The most numerous tribe of disorders inci- dent to advanced life, spring from the failure or errors of the stomach and its dependancies, (as already observed) ; and perhaps the first source of all the infirmities of senility, may be traced to effects arising from imperfectly digested food; nor does it seem probable, that any effectual means will ever be discovered to counteract this progressive and inevitable failure of our nature. It is obvious, as the organs for digestion lose their vigour, the food should be adapted to the degree of decline which invades the stomach and its subordinate parts ; and the state of the bile, and the discharges from the bowels, should be then attentively watched, and duly regulated by diet and medicines. It is logically evident, that if the same kind of nutritious materials were constantly produced in the human frame for its repairs and uses, the 22 same compounds and textures would continue unaltered by time, and the vigour of youth and health would be steadily maintained. It is therefore clearly obvious, that every defect in the composition of our bodily materials must al- ter its condition. From the steady causes which govern the ac- cretion of figured minerals, they increase in bulk with perfect regularity, and are exempt from the limitations of age or growth ; but the organized structures of living animals and vege- tables are differently constituted. The materials for the residence of life, being formed of unstable substances, are continually decaying, and giving place to new supplies de- rived from assimilated fluids, which are elabo- rated by the vital offices. By this system of borrowing and expenditure, a certain degree of renovation attends the maintenance of animal and vegetable bodies, which is w r isely adapted to their liability to accidents, and to the ordina T tions of a limited existence. 23 In every stage of human life, the functions of the Stomach are of principal importance to health ; and the same rules for diet, which prove beneficial to the aged, will generally ap- ply to all invalids, unless where the exceptions, hereafter to be mentioned, forbid an exact re- gimen. Whatever objections may be urged against young persons living by rule, they certainly do not apply to old age ; neither do I admit of much latitude for peculiarities of constitution, especially if they tend to license habits which are known to be injurious. The substances selected for the diet of old persons, and the cookery of their food, should be adapted to the state of their teeth ; and solid viands, or those kinds which are difficult of so- lution, should be minced, bruised, or otherwise prepared to meet the defects of the chewing in- struments. 24 In addition to the gradual failure of the teeth, the stomach itself suffers a diminution of its powers to convert food into the raw fluid mate- rial for bodily replenishment ; and hence it be- comes needful to be more choice and particular about the diet in advanced years. In old age the bowels are also liable to an in- creasing torpor, which demands that a prefer- ence should be given to meats not remarkably putrescible. On a general view of the most suitable Diet for the aged and the feeble, it may confidently be asserted that animal substances are more ea- sily changed into nutritious fluids by digestion, than vegetables ; and it is reasonable to infer, that the digested substance of animals is more readily converted into the medium of replenish- ment, than that of vegetables ; still, however, there are many exceptions to this rule, since the soluble muscilages, farina, and pulps cf some vegetables, are known to be more digestible, 25 than the tough and hard parts of animals, which are difficult both of solution and digestion. In like manner the several parts of meat, as the skin, tendon, muscle, and fatty membranes, differ from each other ; and they are severally capable of being made more or less digestible by the culinary art. The statement of special examples will, however, best illustrate this subject. It is a vulgar error to esteem white meats, on account of their apparent delicacy, as the fittest for feeble persons. Generally, it may be es- teemed a safe rule, that veal, pork, fowl, and tur- key, are less digestible, and afford less nourish- ment, than the redder- fleshed animals. The intrinsic goodness of meats is always to be suspected, when they require spicy season* ings to make up for their natural want of sapidity. In the course of practice, I have constantly found Veal to disagree with weak stomachs; 4r 26 the sugar of milk which it contains, disposes it to pass into the acetous fermentation ; and be- sides, it possesses an excess of tough fibre, des- tined to complete the bulk of the mature ani- mal, and which is a substance of difficult solu- tion. The pot-herbs and other seasoning em- ployed for savoury stuffing, add to its unsuita- bleness. Pork is also an unfit meat for the feeble, the excess of its fat rendering it liable to ferment ; the physical properties of Fat are also different from those of fluid nutriment, of which Milk and Blood may be considered the standards of comparison. Turkey, and the older domestic Fowls, are equally objectionable. Salted meats, as ham, tongue, bacon> and salted beef and pork are to be forbidden, be- cause the preserving material hardens the ani- mal fibres, alters the juices of the meats, and impregnates them wiih an excess of salt, be- 27 yond what is convenient for the operations of the stomach. The particular parts of meat which are im- proper for the aged, are the gristles, browned surfaces from over-roasting, tendons, and hard fat. Unless the processes of Cookery render the parts of meat quite soft and soluble, they often make them more difficult of digestion. Thus overdone meats, and outside portions, as the crusty and torrified surfaces, are less proper than the more juicy and underdone flesh. I am also of opinion that boiled meats are for the most part less digestible and contain less nutriment, than the same meats when roasted or broiled. Fish may be considered as ineligible for the aged, because of its aptitude to putrefaction, and because of the deleterious products of that fermentation when it happens in the bowels or 28 stomach. The relative degrees of their unwhole- someness may be, perhaps, fairly estimated in the following order : — The most pernicious are shell-fish, since they are often notoriously the cause of surfeits, erysipelas, Sec. more especial- ly when tainted ; and herrings, mackarel, sal- mon, and eels, seem to be next in the range of indigestible fish. The best sorts are whiting, perch, flounders, smelts, skate, haddock, tur- bot, and soals. It may be remarked, that boil- ed fish more frequently proves agreeable to the stomach than fried. The same objections may be adduced against salted fish, as were before alleged against salted meats. An excessive and cheap supply of Fish to the inhabitants of large cities, is a very questiona- ble policy ; but, in times of putrescent conta- gion, it seems especially dangerous. Milk is the food destined by nature for the infant period, and it seldom proves agreeable to old persons ; the sparing use of cheese and but- 29 ter should also rather be permitted than recom- mended. Of the Vegetable kind, those which are un- cooked, such as cucumbers, onions, celery, radish, salads, water-cresses, and likewise pickles, will be found injurious. Even the hard pulped fruits, such as apples, nectarines, peaches, seme kinds of pears, plums, and cher- ries, are apt to pass through the body undigest- ed, to ferment, and produce a train of evil con- sequences. Great choice and nicety are required in adapt- ing the kinds and quantities of fruits to the healthful diet of the aged. The sweeter refresh- ing juices of strawberries, raspberries, grapes, oranges, and currants, may be occasionally salu- tary ; but either excess, want of selection, or the indiscriminate indulgence in them is nox- ious. Dried fruits, such as raisins, figs, prunes, &c. are more indigestible, than when fresh ; and, I believe, it is incorrect to ascribe to them, generally opening properties. The nut and so almond tribe should be excluded from the ta- bles of the aged ; and, perhaps, the whole cata- logue of dessert refreshments, and sugared con- fectionary, should be forbidden, with the excep- tion of the fruits already enumerated. When Fermented Liquors are good for the feeble, those which are well fermented, and which have little sugar or free acid should be preferred. The Rhine and French wines are objectionable, as well as luscious sweet wines, and Malt liquors, because they either contain a free acid, or readily pass into the acid state in the stomach. Long continued and watchful obser- vation induce me to conclude, that the acid qual- ities of fermented liquors are. no less injurious than the spirit which they contain. The acid pro- perties appear, however, to be less hurtful to youth, than the spirituous ; while the reverse obtains with aged persons. As the determination of the relative quantities of F'-ee A- id in ordinary fermented liquors seemed to be important, I requested my accu- 31 rate pupil, Mr. Hare, to make a series of chymical experiments for that purpose, under my own superintendence, the gross results of which appear in the following, table :■ 32 TABLE of the Medicinal Alkalis and Earths required to neutralize the Free Acids contain- ed in certain Wines and Malt Liquors. Port Wine. A moderate sized glassful, contain- ing two ounces avoirdupoise wt. NEUTRALIZED BY Henry's calcined Magnesia Carbonate of Potash Snb-carbonate of Soda Prepared Chalk Liquid Potash Liquid Ammonia .2 "8 Drops, by fluid measure 3^ 6* 4 9 11 13 Vidonia. Two ounces, as above stated. Henry's calcined Magnesir. Carbonate of Potash Sub-Carbonate of Soda - Prepared Chalk Liquid Potash Liquid Ammonia - 5 7 6 12 32 19 Sherry. Two ounces, as above stated. Henry's calcined Magnesia Carbonate of Potash Sub- carbonate of Soda - Prepared Chalk Liquid Potash Liquid Amu onia - s - 3 5 8 9 11 London Draught Porter. Two ounces, by weight as above. Henry's calcinei Magnesia Carbonate of Potash Sub-carbonate of Soda - Prepared Chalk Liquid Potash Liquid Ammonia - 5 3i 3 6 2 2 5 6 10 JHem y's calcined Vlagne^ia Brewers' fresh Ta- jCarbonate of Potash ble Beer. Sub-carbonate of Soda - Two ounces, by Prepared Chalk weight as above. Liquid Po' ash 'Liquid Ammonia - 4 6 S3 The Alkalis and Earths used in Medicine, as correctives for acidity in the stomach, and ob- tained from Apothecaries' Hall, were preferred for obvious reasons. Specimens of several kinds of good Wines from Gentlemen's cellars were employed, with- out any regard to the years of vintage or the dates of bottling, and the average of numerous trials upon Wines of different qualities are faith- fully recorded. - Due time was always allowed for the operation of the tests, and much pains bestowed upon as- certaining the exact state of neutralization. The facts elicited from those trials, being wholly intended for medicinal and dietetic appli- cation, all particular minutiae are intentionallv omitted. Some remarkable and unexpected discordan- ces occurred in the relative proportions of Alka- lis and Earths, required to neutralize different S 34 wines, and which may be owing* to the varying affinities of native acids, derived from the fruits, and the acid products of fermentation, as they regarded the several tests. The peculiar acids of Fermented Liquors be- ing at present but imperfectly known to Chy mists, some practical good may arise from this gross display of acid liquors, both in the adaptation of the medicinal doses of anti-acids, and in the choice of wines where disordered acidity of the stomach prevails. The annexed table exhibits gross proofs of the quantity of Free Acid contained in some or- dinary fruits, and which may serve as a dietetic indication ; exclusive of the additional acid pro- duced by fermentation in the stomach : 35 TABLE of the Medicinal Alkalis and Earths required to neutralize the Acid Juices con- tained in Lemons, Oranges, and certain Ap- ples. » For a common sized Lemon. NEUTRALIZED BY Henry's calcined Magnesia Carbonate of Potash Sub-carbonate of Soda Prepared Chalk Liquid Potash Liquid Ammonia - DD .2 *3 c Drops, by measure 30 38 34 52 80 92 A common sized Sweet Orange. ■-7 Henry's calcined Magnesia Carbonate of Potash Sub-Carbonate of Soda - Prepared Chalk Liquid Potash Liquid Ammonia - 12 9 6 16 15 18 An ordinary sized Nonpariel Apple. Henry's calcined Magnesia Carbonate of Potash Sub-carbonate of Soda - Prepared Chalk Liquid Potash Liquid Ammonia - 7 6 5 15 14 16 The sum of these tabulated experiments may be practical- ly reduced to the following conclusions. An average bottle of ordinary Port wine contains as much acid as will demand 38£ grains of magnesia, or 71$ grains of carbonate of potash, to saturate it : or the free acid in a bottle of Port wine may be roughly computed as equal to that of two lemons, or four nonpariel apples. 36 A habit of drinking any diluent-liquors very freely appears to be pernicious ; such fluids not only relax the stomach, but also present the best medium fo» fermentations of the most unwhole- some kind. Every medical man ought to possess more accurate knowledge of the disorders which have occurred in his own person, than of those which belong to others ; and I am satisfied, from that source of experience, that acids not only act upon the stomach and its contents, but they likewise pervade the whole bcdy. I have con- stantly had an eruption of serous pimples on the skin within two hours after eating crude fruits, and have repeatedly felt a goury pain and swell- ing in the large joint of the great toe, while drinking half a point of Claret ; and similar facts have been mentioned to me by numerous Pa- tients. If the Gout should be a humoral disease, oc- casioned by alimentary acids, then the Diet and the corrective remedies are obvious, and expert 37 cnce seems to support this notion. That the gout is not a disease wholly attributable to fer- mi lied liquors is certain, because many water drinkers, and restrictive vegetable eaters, are sub- ject to its attacks ; but, perhaps, the true source of gout in such temper? te persons may be found in the crude and fermentable articles of their Diet. It is both an act of justice to the public and myself to add, that my practice, whenever it has come in contact with gouty per- sons, has been governed by the preceding views, and attended with unvarying beneficial results. The dark red fleshed meats are the fittest arti- cles of Diet for feeble and invalid stomachs ; such as venison, game, mutton, and beef, which should be chosen of the tenderest kinds and ju- diciously cooked. The duck and goose tribe have wholesome flesh, but the fatness of their skins, and the usu- al mode of seasoning, render them objectiona- ble. 38 The good old custom of dining in the middle of the day will be found conducive to health and sleep ; it is best adapted to the decline of animal vigour, because it affords a timely replenish- ment, before the evening waning of the vital powers, and which naturally precedes the hour of rest. Bland and simple soups made of game, beef, mutton, or giblets, are often suitable, but veal and indissoluble vegetables should be excluded. Some preparations with milk, and arrow- root, flour, bread, biscuit, macaroni, or ground rice, may afford an eligible diversity ; but the custom of eating much fermented bread, or of break- fasting on spongy rolls, muffins, &c. is improper, as they are less digestible than softened biscuit, and contain an excess of yest sufficient to pro- mote fermentation. That elegant, fragrant, and refreshing beve- rage, Tea, the hourly refection of the largest and, perhaps, most civilized nation in the world, 39 need not be denied to the aged. It is well suit- ed to cleanse and wash the stomach in the mor- ning, preparatory to the substantial meal ; and when taken in moderation, it is a delicious di- luent immediately after that repast. If the Dinner be eaten at mid-day, the equivo- cal entertainment, called Luncheon, is superflu- ous. The purity of Water for drinking is so essen- tial, that it may be questioned whether any healthful residence can be found, where the con- trary is notorious. Toast- water is best made with hard biscuit, reduced by fire to a coffee colour. This drink being free from yest, is a most agreeable beverage. Long established use may render Coffee inof- fensive, but it is more apt to become sour than either Tea or weak Chocolate, and it seems to be more heating. 40 The vegetable additions to dinner ought to be of the softer or farianaceous kinds, such as green pease, asparagus, cauliflower, beans, mea- ly potatoes, and rice, or simply dressed macaro- ni. Cabbage and brocoli are coarse and offen- sive, unless when boiled in two successive wa- ters and rendered bland. This process of twice boiling frees the cabbage-tribe from noxious matter, which occasions flatulencies and other unhealthy effects. j Carrots are better reduced to a pulp, and Tur- nips should be free from woody fibres. Spinach should be treated in the French manner, by pressing its pulp through a hair sieve, and with the addition of spicy seasoning. Onions, and roots of that sort, contain accrimonious juices, and are in no way nutritious. • Several changes may be obtained by stewing Celery, Cucumbers, and other dissoluble veget- ables ; but it may be safely adopted as a rule, that whatever food produces flatulency, is un- suitable. 41 With all kinds of vegetables, as also with soups, and fish, either black or Cayenne pep. per may be taken freely : they are the most useful stimulants to old stomachs, and often supersede the craving for strong drinks, or di- minish the quantity otherwise required. A little Ginger in the Tea is also stimulating, and grateful -to the palate. No apology can be expected for discussing subjects connected with Cookery, and the do- mestic ordering of Diet, which in my estima- tion are highly important matters ; ' and a close attention to them has often proved satisfactory, when the Materia Medica has failed. The great Father of the Medical and Chirur- gical Art, Hippocrates, laid much stress up- on diet, and a whole sect of later Physicians pro- fessed to reiieve disorders by Diet alone* Although regularity in Diet and strict Tem- perance, both as to the quantities and qualities 6 42 of viands and drink, are of the highest conse- quence for the health of the aged, yet a long continued and exact sameness in strict habits is not always beneficial. Little deviations from one kind of proper Diet to another, still keep- ing within the bounds of moderation, are con- sonani with the system of Nature, and are ap. proved by experience. Perhaps the changes of the Seasons and the consequent variety of ali- ment thereby presented to the animal creation, may be needful and wise ordinations to induce alterations of Diet, and of the external influen- ces from the Air ; both of them having the effect of interrupting the continuance of constitution- al errors. Thus by a general, simple, and un- observed governing power, the bodies of the Animal creation are beneficially adapted to the revolution of the Seasons, and the harmony of the vegetable and animal kingdoms is beauti- fully preserved. It may be doubted, whether the artificial re- sistance to the seasons which Affluence com- mands, is on the whole beneficial to the families 43 of its possessors, in consequence of their fre- quent misapplications ; and I am, therefore, obliged to consider this operation of wealth, as a great source of both heredetary disease and of enfeebled progeny, A long continued sameness of local and of family habits, does not act in the same degree up- on labouring persons ; but, in all cases of locally protracted generations, the consequences are, the augmentation or establishment of some con- stitutional and heredetary disorder. It seems probable that many diseases are more immediately propagated by the influences of lo- cal and dietetic habits, than by taint of blood, or by corporeal and organic similitudes ; and this view extends equaily to Scrophula, Gout* and Insanity. Where, however, Riches are wisely employ- ed, the effects of unhealthful local causes may be interrupted by change of residence, adapted to the peculair disordered tendency, and to the 44 unsuitableness of particular seasons. For as the animal energies are never stationary, perhaps health may in all cases be promoted by occa- sional vicissitudes. It might be wished that Art could secure an equable state of health, but the laws of animal life seem to forbid it, and the following notorious facts support a contrary de- cision. In the training of athletic men, of race horses, and fighting cocks, experience has shewn tint their strength cannot be preserved in its highest vigour for many weeks together, and every at- tempt to force its continuance is followed by dis- orders. Temperance may be carried so far as at length to border on abstinence, or it may be altogether erroneous and directed to wrong ob- jects. Excessive abstemiousness is seldom conducive to health, because a copious supply of fresh and wholesome material seems to be peculiarly needful for the aged, whose bodily offices are becoming every day less perfect : frequent and abundant supplies of renovating j uices are more requisite in a vitiated condition 45 of the fluids, and where the maintenance of a due quantity of blood is precarious, both of which occur when the vital operations are en- feebled. The obstinate fasting of maniacs of- ten occasions a disease which resembles the sea-scurvy. The errors of temperance depend- ing on an unsuitable chcice oi food and drink, as they regard different constitutions and the younger stages of life, form an expansive sub- ject far beyond the intended limits of this Trea- tise ; it may, however, prove expedient at pre- sent to remark, that a weak stomach is wholly incapable of digesting many substances, which are commonly esteemed simple and inoffensive. For example, persons liable to Heart- burn, or St. Anthony's fire, may think it right to re- strict their diet to fruits, raw vegetables, shell- fish, and lemonade, although each of them are adequate causes for such habitual disorders. In like manner, the victims to Gout may assume great merit to themselves by abstaining from animal food, and by living upon a simple aces- cent diet, most pernicious to their constitutions. 46 Diet, judiciously ordered, equally promotes bodily and moral health ; for good digestion fa- vours refreshing sleep, and causes a state of corporeal hilarity conducive to moral enjoy- ments; while, on the contrary, a disordered state of the stomach and its dependancies cre- ates troubled dreams and irritations of the tem- per. May not some kinds of mania be attribu- table to continued disturbances of the stomach and bowels, and which in time deprive the op- pressed sufferer of the power to distinguish be- tween his sleeping and waking impressions ? Cold baths, and what is called " bracing air," do not appear to produce much tonic effect up- on old persons ; and, besides, any sudden chill- ing of the skin repels the capillary circulation throughout the surface of the body, and drives the blood upon the inward parts, which is al- ways attended with danger to persons advanced in life. Tepid baths may be recommended, as no less pleasant than salutary ; for ablutions of war 47 ter have a constricting influence upon the living fibres, independent of temperature, an effect per- haps similar to that of crimping fibh. Warm clothing is proper for the aged, and the maintenance of a temperate atmosphere in lofty and well ventilated rooms. Where a choice of climate can be made, a preference should be given to that which possesses a dry warm air, and where the vicissitudes of the sea- sons are moderate. Exercise should never be imposed as a task, nor continued until it produce fatigue ; but should be moderate and suited to the inclina- tion of the party, otherwise it becomes labour. The tranquil sorts of indulgence are to be preferred ; and it is pleasing to reflect, that most of the essential accommodations for Old Age are nearly as attainable by persons in moderate circumstances as by the affluent. 48 Those simple and wholesome requisites for advanced life are not expensive ; since when the vanities and turbulent propensities of youth have subsided, and the bad passions of envy and ambi ion have passed away, it is the con- dition of our nature to be more easily satisfied. The medical administrations for old persons which experience warrants me to commend, are few, and, I trust, rationally supported. In addition to special Diet, they consist of cathar- tics, bleeding, acids, alkalis, mercurials, and chalybeates. The health of the body cannot be maintained, unless the bowels perform their natural offices regularly and sufficiently, and when this whole- some evacuation is impeded, it must be forced by art. There are various causes of obstruction of the alimentary passages ; they may be rendered torpid by oppression of the brain, or sluggish by the advancing insensibility of age ; or the 49 muscular powers of the stomach and the intes- tines may be exhausted upon crude and indi- gestible food, so as to disable them from duly protruding their feculent contents. The Bile, that natural cathartic stimulant, may be defi- cient, or obstructed ; it may not possess its re- quisite qualities, or its effects may be counter- acted by improper Diet. The class of cathartic medicines comprises a numerous list, and each differs in its mode of operation, either as it affects the stomach, or the upper or the lower intestines ; some act by in- creasing the muscular contractions, some by causing an increased flow of watery juices into the bowels, and others by stimulating the bil- iary vessels to pour out their cathartic fluids. Although each of such medicines may be fit remedies for particular disorders, yet the suc- cess of their employment will depend on the adaptation of the drugs to the nature of the mal- ady, the amount of their doses, and the times of their administration. In exhausted states of the 7 50 body, dry and hard pills are slow of solution, and they are apt to create head-ache and great distress, until their concentrated materials dis- solve and become diffused over the interior of the stomach. I have found such pills undis- solved in the stomach on the third day after they had been taken ; but my professional thoughts upon Cathartics are before the Public in a copious tract, printed in The London Medical Repository, for the year 1814, Vol. 1. The leading indications which guide the skil- ful and discriminating practitioner in directing cathartics, are to be observed on the tongue, which shows the condition of the stomach and bowels ; in the colour of the urine and iaeces ; and on the appearance of the skin ; by which tokens, the state of the biliary system may be discovered. These evidences are, however, liable to be blended with disordered states of the sanguifer- ous vessels, and on the detection of such errors 51 the question of blood-letting depends. The signs of over-fulness or scantiness of blood are commonly well marked. A strong beating, large pulse, with high temperature of the body and limbs, deep-coloured lips, and tense, swol- len veins, express the state called plethora, or excess of blood. When those symptoms are accompanied by frequent obscurations of sight, swimming in the head, giddiness, intense head-ache, drowsi- ness, laborious breathing, or feelings of terror, blood-letting should be confidently directed without any reference to the age of the patient. Many fatal diseases of the head or lungs in very old persons originate from plethora or lo- cal congestion, and free bleedings with the lan- cet, by cupping, or leeches, are the only effec- tive remedies. How many persons in the most advanced stage of life are respited from the grave, by spontaneous bleedings from the nose, or from piles ? 52 It is true, that mere anatomical or mechani- cal practitioners, are unable to appreciate the peculiar advantages of topical blood-letting, but the more scientific part of my brethren, who have considered the hydraulic discoveries of Venturi, and the experiments of Spalan- zani on the circulating fluids of animals, will perceive the practical bearings of those disco- veries. Intermissions of the pulse in old persons af- ford no justifiable objection to blood-letting; but, on the contrary, that irregularity rather seems to depend on oppression of the heart from surcharges of blood beyond the rate of its en- feebled muscular powers, and the pulse gene- rally becomes more equable after the excessive volume of blood is reduced. Neither does a sudden oedema supervening on true inflamma- tory diseases furbid blood letting, because se- rous effusions are frequently the known effects of such diseases. I have seen persons above the age of seventy, labouring under dangerous Inflammation of the lungs, with a sudden acces- 53 sion of dropsical swelling in the legs, and who were acknowledged to be saved from the jaws of death by resolute and copious bleedings in contempt of the oedema, The judicious direction ofB'ood letting forms a£n essential part of medical skill, but unfortu- nately the judgment which is to guide the practitioner, is unattainable except it be derived from experience. A small, weak beating pulse, pale lips, a low temperature of the body, cold hands and, feet, and a remarkable aptitude to become chilled in cold weather, are the signs of paucity of the blood and feebleness of the circulation. The complexion of the face is not a criterion of the quantity of the blood, for I have often known the true sanguineous apoplexy to attack persons with remarkably pale countenances. That dis- ordered condition which is produced by scanti- ness or poverty of the blood, must be remedied by plentiful and nutritious diet, suited with re- spect to quantity, quality, and times of refresh- 54 merit to the digestive capacities of the individu- al. Wines, if agreeable to the constitution and habits of the weakened invalid, are often benefi- cial. They seem, when congenial, to invigo- rate the heart, to augment the bodily tempera- ture, and to improve the nervous and sensorial powers. They are diffusible and temporary stimulants to the whole vital system. In some instances of debility, suitable wines appear to strengthen digestion ; but, perhaps, that saluta- ry consequence is rather due to their influence upon the sanguineous and nervous organs. The intimate connection between the health of the stomach and the circulation of the blood, ren- ders wine allowable where the vascular system is habitually weak ; and, probably, in such cases, wine prevents greater evils than those which it is known to produce. The most cordial Wine for old persons seems to be mild and old Sherry, when free from acidity. There is a poverty of blood which seems to arise from deficiency of the red colouring par- ticks, and for which medicated preparations of 55 iron and chalybeate waters are well known spe- cifics ; of all the remedies for pale-faced debili- ty at any age, chalybeates are the most effica- cious : it appears from the best chymical analy- sis, that the red colour of animal blood is deri- ved from iron, and the exhibition of it as a medicine is only the artificial supply of a con- stituent part of the body, where it is obviously wanting. Impaired Digestion is an extensive source of disorder ; for, whenever the food is not quickly acted upon by the living stomach, it becomes liable to fermentations. In old persons the food remains longer uncontrolled by the vital energies than in young persons, and is never so perfectly digested ; hence the food of old per- sons admits more readily of both the acetous and putrefactive fermentations, either of which happening, even in a small degree, occasions disorder of the stomach or intestines, and suffus- es the body with vitiated fluids. The acetous fermentation is most common, and it is especial- ly incident to those who eat raw vegetables,. 56 fruits, sweets, and fatty substances ; and every excess in diluent liquors is apt also to produce it. Experience and meditation persuade me, that alimentary acidities are the chief if not the sole cause of gout, of one kind of erysipelas, and of many herpetic diseases. When this ten- dency to acid has long prevailed, it is not easily corrected; and unless the most circumspect at- tention be constantly given to Diet, it will con- tinually recur. Acidity of the stomach is, moreover, a cause of obstruction to the flow of bile, and, under such disordered state, the whole body becomes tainted with crude humours. I have known many examples of acid stomachs linked with eruptions on the skin, and which were always sensibly aggravated within five minutes after taking acid food or acid drink. The rapid consequences which follow that state, called a surfeit, are further proofs of the 57 quick transition of disordered humours from the stomach into the rest of the body. Some of the dangerous and sudden disor- ders which arise from intemperance, may be averted by instant emetics ; but vomiting is an unsafe operation for old persons, and it is only warranted by pressing necessity. Purgatives should follow those emetics to expel the re- liques of corrupted aliment, and great precau- tion must be adopted afterwards respecting diet, and the free passage of the bowels. From neg- lect of these rules many disorders are allowed to accumulate, until at length they assume a for- midable aspect. Diseases, purely inflammatory, appear to be few and of rare occurrence ; whilst the most dangerous spontaneous inflammations are con- nected with established and vitiated conditions, which only require an exciting circumstance to bring them into activity. 8 58 Diseases of the sanguineous system are the most frequent causes of death in all ages ; but they seldom occur to persons, whose alimentary organs and whose blood might be considered free from impurities. To these causes may be confidently ascribed erysipelas, gangrenous in- flammations, carbuncles, and many kinds of ap- oplexy, pneumonia, and gout, — diseases which, according to my apprehension, are closely allied to each other : obstructed bowels are likewise not un frequently the cause of an obstinate and distressing species of sciatica. Alkalis are the medicil remedies for occasion- al or habitual acidity in the stomach ; and twen- ty grains of carbonate of potash given as a cor- rector, in a wine-glass full of milk twice a day, will generally answer the temporary purpose. This medicine seems to act beyond its chymi- cal operation in the stomach, and . when used frequently it probabiy may pervade the whole body. I have often known it to speedily re- move painful conditions of the bladder and uri- nary passages, which were connected with sour- 59 ness of the stomach, although the disorders had continued for several months. The affections, called gravel, are generally of this kind. Alkalis, judiciously employed, possess both preventive and curative virtues for man^ disor- ders, especially for herpetic and long established eruptions of the skin ; and the rationale of their uses is better understood than those of most other medicines. In all cases of lowness and depression the vol- atile alkali is preferable, because of its cordial property. May not its utility, when taken for gangrenous erysipelas, be owing to its anti-acid effects ? To whatever extent hypothetical doc- trines may assign the powers of life, as capable of destroying all chymical effects within the hu- man body, experience affords practical evidence to the contrary ; and a scientific observer will soon perceive the great utility of administering Acid sand Alkalis as chymical remedies, making due allowances for the abatement of their action and want of precision in their doses, from the 60 variable and complex operations of living struc- tures. A popular hypothesis is now very prevalent, which attributes nearly all diseases to a disturbed state of the Liver ; and for which, mercurial drugs are lavished almost indiscriminately, as the professed remedies. The folly of expecting to repel this, or any other opinion which is fa- vourable to the natural indolence of mankind, is obvious, especially when it is at the same time upholden by the empirical interests of greedy individuals. The patrons of the universal bilious system, and the abbettors of its universal remedy, Mer- cury, may, perhaps awake from such reveries when they are warned of the variable and oppo- site ways in which the liver and its vessels may be deranged. The organ which makes the bile, may yield too much or too little ; or the bile may possess too much acrimony, or it may be deficient in the requisite degree of stimulus. The bile may be too rapidly discharged from 61 its reservoirs, or it may remain too long con- fined. The issues of the bile may be disturbed by disorders of the stomach, or errors of the bile may cause those disorders ; added to which, the liver and its functions may be healthful, while the intestines upon which the bile is des- tined to act as a stimulant, may be too irritable, or not sufficiently so. From this view it can- not be questioned whether bilious disorders ought to be considered as of one and the same kind, or whether the same remedy can be ration- ally employed for maladies so widely different. Such intricacies and complexities in the per- ilous art of Medicine ought to deter unqualified pretenders, and to demand greater deliberation and study from the regular Faculty. It is, how- ever, but justice to say, that the respectable and grave Referees of the profession are seldom turned aside by popular delusions. The various preparations of Mercury are, doubtless, of great value in the Medical Profes- sion ; but their excessive employment for eve- 62 ry supposed disorder of the liver cannot be de- fended, and the indiscriminate use of them as cathartics is often injurious. The profession of Medicine seems to be ad- vancing quickly into a rational and physical Science, and its progress must be accelerated by viewing the natural causes of diseases, and the rationale of remedies, according to the rules of Natural Pnilosophy. The free and unsophisticated practice of Eng- lish Medical Officers in the Army and Navy, during the late war, has done much to elevate the rank of their art, heretofore abused by mys- teries, formalities, and mercenary intrigues. Under the auspices of common sense, the treat- ment of two putrid diseases by acid antiseptics, which, perhaps, differ very little in their nature, — namely, Sea Scurvy, and pure Typhus Fe- ver, — has been most successful. The latter has been also alleviated in one of its direful symptoms by a mere reduction of bodily tempe- rature. The improvers of Medicine seem also 63 • to be on the verge of determining with practi- cal certainty the respective physical causes of putrid and intermittent Fevers, and of fixing the curative Diet and Medicines for each. I know full well the danger of stepping be* yond the pace of the multitude, and of antici- pating improvements ; but having taught these doctrines satisfactorily for more than twenty years, I may now venture to claim and offer them to my Brethren. Both the mineral and vegetable acids are pow- erful correctors of putridity, but they do not contain any substantial nourishment ; as arti- cles of Diet or Medicine, their uses are of the antiseptic kind, and become needful where ex- cessive quantities of animal food are employed. The Aged are liable to untoward disorders of the urinary passages, and when any sudden ob- struction of this sort occurs, which does not arise from strictures or stone, it is commonly the sign of oppression of the brain; tending to * 64 Apoplexy or Palsy, It is of leading impor- tance to discover whether the urinary impedi- ment has any connection with vascular plethora, or with alimentary depravities, because the life of the patient will hinge upon speedy, powerful, and proper administrations. The temporary and delusive relief derived from drawing off the water artificially, is of no avail to the patient's safety ; whilst diseases of the brain or the bow- els are sapping the chief organs of life. This ill-omened malady requires the aid of an experi- enced and resolute master of his art ; and under his auspices, the uplifted hand of death may be often turned aside, even at a very advanced age. It is a vulgar error to consider all dropsical diseases as the signs of debility, and the results of mere weakness. They are generally symp- tomatic of impaired constitutions ; but they of- ten proceed immediately from inflammatory causes, and from organic derangements. The local dropsy in the scrotum, called Hydrocele, is seldom of serious character, and ought not to create alarm. I pass over the diseases peculiar 65 to women, because it would be improper to in- troduce them in a work, which is addressed to general readers. In reverting to my first assertion, that Diseas- es and not the mere exhaustion of Age, are the ordinary causes of death in old persons, it may be beneficial to recapitulate those of most dan- gerous tendency, the* apparent origin of them, and the remedies which medical skill has disco- vered for their prevention or cure. Apoplexy, palsy, or pneumonia, arising deci- dedly from plethora, require vigorous bleedings, cathartics, and abstinence. The same diseases, when occasioned by intemperance, or injurious diet, require evacuanis and correctives. Ery- sipelas, carbuncle, or gangrenous inflammation, arising from surfeit in the stomach, or from foulness of the bowels, must be treated accord- ing to their ascertained causes. Gouty diseas- es, which are provoked and maintained by im- proper diet, can only be remedied by having recourse to a diet that is exact and appropriate* 9 66 While the great excretory outlets of the body, the bowels and the urinary passages, with all their connections, must be constantly watched ; and when impeded, they must be timely assist- ed by art. From a wish to awaken the attention of my Brethren to these important cares and duties, I have ventured to solicit the confidence of the Elders of our race toward the Medical Profes- sion, with a full assurance that the Faculty now possess the power to protract life, and assuage suffering, under many of the circumstances which I have attempted to describe. To pass over the long list of Materia Medica in modern use, may be thought presumptuous ; but I prefer to risk the imputation, rather than waste my own and my reader's time in treating of the qualities of medicines, which are either al- together useless or uncertain in their operation. The art is already too much encumbered with frivolous prescriptions, and obscured by unwor- thy mysteries. Experience has satisfied me, that 67 many diseases may be prevented or removed b)5 Temperance, and by the rational administra- tion of Medicines whose operations are under- stood, without much encroachment on the fair enjoyments of life. It is a wise maxim in Physic, that diseases which are long in their advancement, are gene- rally only to be remedied by long continued curative attentions. Common sense points out the fallacy of expecting to eradicate old estab- lished errors of the body, by any single or sud- den remedies. The warnings of dangerous dis- eases should never be forgotten ; and the diet, or medical regimen of such persons, should be undeviatingly suited to their disordered tenden- cies. To this general exposition of my individual experience and opinions, I shall add a few re- marks upon the moral propriety of Surgical ope- rations on Old persons. 68 The greater exertions of my life have been devoted to the collection of materials for a gene- ral review of Surgical Ethics ; a subject which appears to be at this time imperiously demanded, both for the welfare of the Public, and for the character of the profession of Surgery. Dangerous operations are rarely adviseable in advanced age ; because the living powers are then diminished, and old persons are seldom ex- empt from constitutional disorders. The disas- trous consequences of unsuccessful or impru- dent operations are most extensively injurious; and those desperate expedients are not justifia- ble upon the false and horrible plea, that the val- ue of life decreases as age advances. Whenever the immediate danger to life from a surgical operation exceeds the probability of recovery from its effects, the act is unjustifiable. When the consequences of a mortal disease are only to be averted by a dangerous operation, the enterprise may then be expedient. 69 When a contemplated operation involves the immediate danger of life, it should be carefully balanced with the pending danger from the dis- ease for which it is proposed ; and the operator should be governed by that prospect, which af- fords the best hope of procrastinating life. When a safe operation will alleviate the suffer- ings, or remove the inconvenience of a disease, it is preferable to one which promises perma- nent relief at the risk of life, When there is any striking probability that a patient may die under an operation, or of his being constitutionally unable to recover from its immediate effects, such operation is unwarrant- able. When other fatal diseases' are known to be lurking in the frame, such as consumption or tendency to apoplexy, it is right to avoid ail vi- olent operations. 70 The performance of surgical operations upon old persons, for the removal of harmless tumors or mere deformities, ought to be objected to. It is unsafe to perform operations upon old persons who are liable to erysipelas. The satisfaction which follows the observance of these rules, induces me to submit them to my Brethren of the profession ; but as the vital powers vary in' old persons, some exceptions will arise to any general rules which may be laid down for their treatment. I consider all the larger amputations, as those of the arms and legs, to be seldom adviseable for persons on the confines of Seventy, unless the occasion be sudden, and the patient of sound habit. The operation for the stone is, at ail times, dangerous ; and I think it better for men ad- vanced in life to bear the pains of that affliction, in preference to the risks and consequences of a 71 terrible expedient. I have at this time the care of three old Gentlemen, who have each had the stone for several years, and who are all thankful to me for dissuading them from the operation. One Gentleman, now in his Eighty-fifth year, has passed the last twelve months in comforta- ble ease from living quietly, temperately, and taking alkalis. Strangulated ruptures, in old debilitated per- sons, are generally reducible by the hand, the parts being more lax and yielding than in young persons, and the propensity to violent and dan- gerous inflammation is at that period abated. Hydrocele is most prudently treated by sim- ple tapping, particularly when the patient is fee- ble or in bad health ; because the attempt to cure that disease radically has often proved de- structive to old persons. It is revolting and disgraceful to hear of the numerous instances of fatal operations performed upon persons who are altogether uneiigible ; and 72 it may be remarked, that these mischievous ef- fects are not confined to the suffering parties, since evil reports spread widely, and are gene- rally unaccompanied by the paliative explana- tions which may belong to them. These rash proceedings are also injurious to Society, by deterring many persons from avail- ing themselves of Surgical skill, in cases where they might derive real benefit. However earnestly the afflicted may desire re- lief from loathsome, painful, or incurable dis- ease, even if they prefer the sacrifice of life to the endurance of protracted suffering, still the Surgeon should refuse to comply with their im- proper wishes, and not become a party to homicide. To prolong life under any circumstances, and to diminish the intensity and duration of bodily misery, is our bounden duty ; but we are not called upon to decide, whether it be better for a Patient to die under a violent struggle, or to 73 wait for the Almighty command, — such ques- tions are indeed above human authority. The same imperative objection is likewise applicable to the practice of giving poisonous doses of Opium, toward the close of painful and apparently fatal diseases, — a measure which ought to be equally reprobated, both from pro- fessional and moral considerations. Medical judgment is not infallible, and the event of recovery from the most hopeless state, is seldom impossible ; but to preclude even a forlorn chance, or to abridge the sufferer of one lingering moment, is far beyond the province of Medical Men. Desperate operators should be reminded, that it is not uncommon for persons to recover from diseases, which are generally supposed to be mortal ; — but I must reserve the further obser- vations upon that grave and momentous subject, 10 74 until I am enabled to lay before the Public the particular evidences of my own practice, and my special deliberations upon Surgical Ethics. F I N I S. e <^ «l w>^ # : ^Secc <.r • cms:: <03r: = cr'csocC:'cc