STUDIES 
 
 OF 
 
 OLD CASE -BOOKS
 
 PRINTED BY 
 
 8POTTISWOODB AXD CO., NEW-STREET SQUARE 
 LONDON
 
 STUDIES 
 
 OF 
 
 OLD CASE-BOOKS 
 
 BY SIE JAMES PAGET, BART. 
 
 LONDON 
 LONGMANS, GEEEN, AND CO. 
 
 AND NEW YORK: 15 EAST I6' k STREET 
 1891 
 
 Ml rights retcmd
 
 Bicmedical 
 Library 
 
 PBEFACE 
 
 FEW things of the kind seem to be more useless than 
 old Case-books. To the writer himself they may 
 have some value and even great personal interest ; 
 he may profitably study himself in them as well as 
 some of the facts which he has recorded. But to 
 others they have no such utility. It would be 
 difficult to find an instance, during this century, 
 in which the old Case-books left by even the best 
 observers in our profession have been of any use to 
 their successors. 
 
 Thus I have often thought when, from time to 
 time, during the last few years, I have looked through 
 the volumes and the piles of separate records of cases 
 that I had written. They range through a period of 
 about forty years, beginning with an account of the 
 first case I ever saw. A young boatman in February 
 1830 was accidentally shot, with a big charge from 
 a swivel-gun, through his left knee and elbow. Both 
 limbs were at once amputated by Mr. Costerton, of
 
 PREFACE 
 
 Yarmouth, to whom I was soon afterwards appren- 
 ticed, and the poor fellow recovered well and lived 
 long. Thence onward the books or collections of 
 cases were continued according to my various oppor- 
 tunities till 1870 ; and then I became so occupied in 
 hospital and official work, as well as in private prac- 
 tice, that I could no longer fully record anything. 
 The custom once given up has never been resumed in 
 any form beyond that of short notes for private use. 
 While looking through and in some degree study- 
 ing the many thousand cases thus recorded, it has 
 not been difficult to find why they would be now 
 so nearly useless and uninteresting to any but my- 
 self. For example, there are, in one volume, care- 
 fully tabulated reports of the daily progress of all 
 my patients after operations, both in hospital- and 
 private practice, during three or four years. They 
 are quite useless now, for they were made before the 
 introduction of antiseptic surgery, and before those 
 improvements in nursing and the inventions of new 
 ligatures and instruments, by which the risks of 
 
 o 
 
 operations have been made comparatively trivial. 
 Many of them might even be mischievous, for they 
 would give evidence of considerable success under 
 treatment which would now justly be deemed utterly
 
 PREFACE Vii 
 
 legligent. In another volume are records of all the 
 post-mortem examinations that I made while I was 
 demonstrator of morbid anatomy at St. Bartholo- 
 mew's. These, too, are useless, for they were before 
 the time of exact microscopic work, and of fine 
 adjustments and thin sections, and various stainings 
 and cultivations. They tell, indeed, of strange over- 
 sights ; of typhoid ulcers of the intestines carefully 
 described, but regarded as a sort of accident in 
 cases of typhus fever for Sir William Jenner had 
 not yet made their meaning clear ; and there are full 
 accounts of the naked-eye appearances in cases of 
 capillary embolism, which before the time of Kirkes 
 and Virchow were passed by as unintelligible. And 
 when one looks for facts that might help to the 
 discovery of any of the things we now most want to 
 know, none can be found, for such facts were not 
 looked for fifty years ago, or were not seen, though 
 they may have been within the easy range of sight. 
 
 Thus, as one looks through volume after volume, 
 they seem to prove nothing but a waste of time, till 
 one reflects that the present use of old Case-books is 
 no just estimate of their value in past years. For, 
 to say nothing of the materials they may have sup- 
 plied for work already done in lectures or in books
 
 and papers published at various times, they were 
 among the very best means of self-education. The 
 habit of recording facts is nearly essential to the 
 habit of accurately observing and remembering them. 
 That which we intend to record we are bound and 
 may be induced to observe carefully, and the very 
 act of carefully recording is nearly equivalent to a 
 renewed observation. Thinking of this, and of their 
 personal interest to myself, I ought, perhaps, to have 
 been content with the good service that my Case- 
 books have rendered to me and with the hope that 
 they have been, in some measure, indirectly useful 
 to others. But I hope that what is here gleaned 
 from them may serve some good purpose, whether 
 in the description of a few diseases or injuries not 
 sufficiently well known, or in the suggestions of pro- 
 bably useful lines of enquiry, or of some general 
 principles which it may be well for younger men 
 to bear in mind and test as to their probability. 
 Perhaps, even, they may have an admirable result, 
 if they provoke some of my contemporaries to do 
 similar but better work with their old Case-books. 
 
 The several studies, if they may be so called, 
 have been written at various times during the last 
 six or seven years, and some of them have been made
 
 PREFACE JX 
 
 even less useful than they might have been by the 
 publication during the same time, but after they were 
 written, of excellent papers on the same subjects ; 
 for example, of that by Mr. Teale on subcutaneous 
 ulceration. 
 
 Various as are the subjects of the studies, an 
 orderly arrangement of them was not possible even 
 if it would have been useful. I hope, therefore, that 
 I need not apologise for what may seem too great 
 disorder, or for the almost complete omission of 
 references to other works on the same subjects. I 
 could not have added these without reading very 
 much more than in the last few years has been 
 possible, and a multitude of references would have 
 looked like a pretence of completeness of study, 
 such as, for sketches like these, would have seemed 
 absurd.
 
 STUDIES OF OLD CASE-BOOKS 
 
 CHAPTER I 
 
 SEVERAL cases have been published in which necrosis 
 has occurred in a portion of a bone on which a 
 straining muscle has pulled with unusual force either 
 once or, in quick succession, many times. 1 But I 
 think that the production of various less degrees and 
 different forms of periostitis 2 by violent pulling has 
 not been sufficiently considered. Such cases are, I 
 believe, frequent ; as, indeed, they well may be if we 
 consider the enormous force of the strain often put 
 on the periosteum, whether by the contraction of 
 muscles whose tendons or shorter fibrous attachments 
 
 1 Among the first and best are some by Mr. Solly, in the Lancet, 
 November 3, 1855. 
 
 2 I say ' periostitis ' without meaning to imply that the periosteum 
 alone is inflamed, and not the subjacent bone as well. 
 
 B
 
 2 PERIOSTITIS FOLLOWING STRAINS 
 
 are mingled with its structures, or by the pulling of 
 ligaments stretched in violent wrenchings of joints. 
 It must be, at least, advisable to remember always 
 that, together with the mischiefs done in severe 
 strains to ligaments and -other proper structures of 
 the joints, there may be serious injury done to the 
 periosteum on the adjacent portions of the bones. 
 Some of the consequences of strains may thus, I 
 believe, be better understood and better dealt with. 
 
 I had a good example of necrosis produced by 
 muscular pulling in a young lady sixteen years old, 
 of rather weakly general health, who was overworked 
 in exercises which required all the force which she 
 could use with her right deltoid. Sharp inflammation 
 about the shoulder followed, and then abscess over 
 and behind the acromion ; and when I let out the 
 pus I could feel a part of the acromion bare. In a 
 few weeks the dead end of this process separated 
 and was easily removed, and then, without further 
 trouble, all healed. 
 
 No cause of the necrosis could be suspected ex- 
 cept the pullings by the muscle, and the general 
 disturbance of health was only such as was explained 
 by the acute local disease. 
 
 In another case, a gentleman, training for the 
 Universities' boat-race, felt his habitually good health 
 failing, and became unusually weak, and during the
 
 PERIOSTITIS FOLLOWING STRAINS 3 
 
 last few days before the race had a good deal of pain 
 in his left upper arm. Still, he continued rowing 
 hard every day, and he rowed very hard in the race. 
 In the evening after it he had severe pain in the left 
 elbow and upper arm and some swelling about the 
 joint. A few days later, when he was first surgically 
 examined, there were swelling and redness at the 
 elbow-joint, especially over the olecranon and the 
 condyles of the humerus. The joint evidently con- 
 tained fluid, and was extremely painful when moved. 
 The back of the arm, also, especially about the 
 origins of the triceps, appeared intensely inflamed, 
 and there w^as acute fever. Briefly, this was the 
 beginning of acute deep inflammation of the whole 
 upper arm with acute necrosis of portions of the wall 
 of the shaft of the humerus, and suppuration of 
 both the shoulder and the elbow-joints. 
 
 In the course of the year numerous sequestra, 
 chiefly from parts of the humerus at and near the 
 insertions of the triceps and biceps, were separated 
 and removed. At the end of the year I excised the 
 still suppurating elbow-joint, and then all healed. 
 The patient remains well after many years. 
 
 Among a few more cases illustrating the same 
 points as these do, I find one of a weakly boy, with 
 evidently scrofulous brothers, who strained the ante- 
 rior muscles of his thigh in kicking hard at a slate. 
 
 B 2
 
 4 PERIOSTITIS FOLLOWING STRAINS 
 
 He kicked it only once ; but acute necrosis of the 
 feinur followed, and quickly fatal pyaemia, and lie 
 died in little more than a week. 
 
 Next to necrosis, I believe that the most injurious 
 effect of periostitis due to pulling is that which we 
 see in some cases of caries. Cases are only too com- 
 mon in which caries of the bones of a hand or a 
 foot, ensuing after slowly progressive periostitis, are 
 ascribed to strains at the affected part. Scrofulous 
 children's hands are pulled hard, and caries or chronic 
 periostitis ensues in one or more metacarpal bones or 
 phalanges ; or they sprain a wrist or a foot, and 
 similar results follow in the bones of the carpus or 
 the tarsus. In cases such as these, when the force 
 used is not in a blow or in pressure, the strain of 
 pulling on the periosteum may fairly be deemed the 
 only injury likely to be followed by such disease. 
 The structures of the joints are, indeed, commonly 
 involved ; but this is by extension rather than by 
 coincidence of inflammation. 
 
 I believe that caries of the lumbar or lower dorsal 
 vertebras, such as precedes angular curvature of the 
 spine, may often be justly referred to similar injury 
 of the periosteum when hard-pulled by the psoas, as 
 in high-jumping or in preventing a backward fall. 
 The progress of the disease may often be too slow to 
 be sure as to its origin ; but it was not so in the case
 
 PERIOSTITIS FOLLOWING STRAINS 5 
 
 of a man, of twenty-four, who was under my care at 
 St. Bartholomew's. Three weeks before his admission 
 he. had fallen with a heavy load on his back, and fell 
 with his right leg twisted beneath him. He had had 
 a great deal of pain at the right groin and had re- 
 mained quiet since the accident ; and on admission a 
 firm painful swelling was felt above the outer half of 
 the crural arch, well defined in front but not behind, 
 and apparently filling the hollow of the ilium. And 
 he could not completely straighten his thigh. 
 
 The swelling was the beginning of a large psoas 
 abscess, which was opened and discharged a great 
 quantity of pus. Its cavity soon after became full 
 of blood : then was washed out and cleaned ; and 
 then the case went on after the usual manner of the 
 time, near thirty years ago, and the patient died 
 about five months after the accident, exhausted with 
 suppuration, hectic, blocked femoral and iliac veins, 
 and bed-sores. 
 
 The abscess extended through the whole space 
 occupied by the iliacus and psoas muscles, and 
 scarcely a trace of them remained. It extended 
 upwards to the first lumbar vertebra, a portion of 
 which was bare. There was a larger bare surface on 
 the posterior part of the crest of the ilium, but no 
 necrosis or evident ulceration of the surface of either 
 bone. Besides, the abscess had opened through one
 
 6 PERIOSTITIS FOLLOWING STRAINS 
 
 of the bed-sores, and the cavity of the right hip-joint 
 and the whole of the articular cartilage of the head 
 of the femur had been destroyed by ulceration. 
 
 Cases such as these, proving so grave injury of 
 periosteum and bone after strains, may be enough 
 to make it sure that strains of less severity, or in 
 healthier persons, may produce many degrees of less, 
 yet not unimportant, damage. An excellent example 
 was in an elderly gentleman who came with a well- 
 marked circumscribed periosteal swelling a node it 
 might have been called on the inner border of his 
 tibia, which had formed quickly after a severe night- 
 cramp in the muscles of his calf. Much more common 
 are the enlargements of the tubercle of the tibia 
 which are often seen in young people much given to 
 athletic games. They complain of aching pain at 
 and about the part, especially during and after active 
 exercise, and the tubercle may be felt enlarged and 
 is often too warm. The pain often continues, more or 
 less, for many months, and there may be enlargement 
 of the bursa under the ligamentum patellse, and the 
 tubercle may remain too prominent ; but common as 
 are these cases, especially in our public schools, I 
 have never known grave mischief ensue in any of 
 them, and they get well of themselves. They may re- 
 present one of the least degrees of periostitis due to 
 strain ; the increase of the prominence of the bone
 
 PERIOSTITIS FOLLOWING STKAINS 7 
 
 is only just beyond that which may be deemed the 
 normal limit for the attachment of vigorous muscles. 
 A yet less degree, I believe, is indicated by the 
 pain and tenderness at the anterior edges of the outer 
 condyle of the humerus which some feel after drivino- 
 
 o 
 
 a ' pulling ' horse. And similar to this is the share 
 which the periosteum has in the < lawn-tennis-elbow ' 
 and the less frequent %-fisher's-elbow ' ; and in both 
 of these the result of the periostitic part of the trouble 
 is often seen in the uneven nodular edge of bone like 
 that formed in common osteo-arthritis. 
 
 The large number of cases such as these which I 
 have found in my case-books makes me think that 
 1 sprains ' ought to be thought of as more complicated 
 injuries than they usually are. It seems common 
 to think only of the stretching or rending of the 
 ligaments and other structures on one side of the 
 sprained joint ; but besides this there are the crush- 
 ing of those on the other side, and the hard tugging 
 of the muscles which strive to prevent the injury, and 
 which in this strife pull hard on periosteum and bone. 
 Such pulling may tear some part of the muscle itself, 
 or it may be followed by long-abiding complete loss 
 of power, or permanent wasting, or, I believe, by 
 wide-spreading abscess ; or it may rupture the tendon 
 of the muscle, or separate it from its attachments. 
 All these injuries due to the hard strain of muscles
 
 8 PERIOSTITIS FOLLOWING STRAINS 
 
 are well known ; but the immense force which they 
 indicate may, sometimes, tell most on the periosteum 
 with which the fibrous structures fastening the muscle 
 are mingled, and in which aching pain is apt to last 
 very long. 
 
 I think that differences in the injuries done to one 
 or another of these structures may often be associ- 
 ated with differences of age. In the elder, the tendons 
 are apt to be weakened or partially wasted or softened, 
 as one sees in the tendons of the biceps and the 
 quadriceps, and in the Achilles-tendons ; and these 
 changes are often symmetrical. The periosteum, on 
 the contrary, in. advancing years becomes more tough 
 and more inseparable from both bone and tendon. In 
 the younger, the tendons are strong, they do not 
 waste more than the muscles ; but the periosteum is 
 much less firmly fixed and is softer and more vascular 
 than in later years. Hence, probably, it is that the 
 periosteal troubles which I have described are much 
 more common in the young, especially in the less 
 robust young, than in the middle-aged and old. 
 
 So many of the injuries of which I have spoken 
 occur in athletic sports, that I may be expected to 
 write urgent protests, and even claims for some sort 
 of legislation. I am not disposed to do anything of 
 the kind. The advantages, both moral and muscular,
 
 PERIOSTITIS FOLLOWING STRAINS 9 
 
 of the free and self-managed games in our schools are 
 immeasurably greater than the disadvantages of the 
 occasional damages done in them. And the pleasures 
 of nearly all sports and the associated ambition for 
 success in them are augmented by a consciousness 
 of some danger. In schools, ordinary prudence on 
 the part of masters playing with the boys, or looking- 
 on, may suffice ; especially if they are careful about 
 those who are evidently weakly in their health. 
 After school-life, men must be trusted for self-care 
 in sports.
 
 10 DISEASES OF METATARSO-PHALAXGIAL BURS.E 
 
 CHAPTER II 
 
 DISEASES OF METATARSO-PHALANGIAL BURS^E 
 
 ONE has often been consulted for aching pains in the 
 sole of the foot, and some of my cases make it nearly 
 sure that the pains were due to disease in some of 
 the large number of bursse connected with the origins 
 and insertions of muscles on bones of the tarsus or 
 metatarsus. But the only cases that I can fairly 
 localise and group are those due to disease of the 
 metatarso-phalangial bursse. 
 
 The anatomy of these bursze is described with a 
 truly marvellous accuracy by Wenzel Gruber. 1 There 
 is usually one in each of the four intermetatarso-pha- 
 langial spaces. They lie between the dorsal and the 
 plantar ligaments of the heads of the metatarsal bones, 
 
 1 In a paper in the Memoires des Savants Etrangers, published by 
 the Academic Imperiale des Sciences de St. Petersbourg, t. viii., 4to, 
 1859, p. 297. He rightly suggests that they may have great patho- 
 logical interest, especially on account of their occasional communica- 
 tion with the adjacent metatarso-phalangial joint-cavities; but he 
 describes only one case, a probable wound of one of these bursae by a 
 nail driven through the sole of the foot and inducing long-continued 
 suppuration.
 
 DISEASES OF METATARSO-PHALANGIAL BURS.E 11 
 
 and are usually rounded, elongated, laterally com- 
 pressed, and from a quarter of an inch to half an inch 
 in their longest diameter. Their cavities are often 
 partially divided by incomplete septa; and they 
 sometimes, but rarely, communicate with the adjacent 
 joint-cavities or with synovial sacs or other bursse. 
 
 In some cases, disease of one of these bursae is 
 evident ; in more, it is very probable. In the case of 
 a woman about forty-five years old, an out-patient at 
 St. Bartholomew's, I found a nearly spherical swelling, 
 from three-fourths of an inch to an inch in diameter, 
 between the distal ends of the third and fourth 
 metatarsal bones, separating them so as to make a 
 wide interval between the corresponding toes and 
 appearing as a round smooth swelling on both the 
 dorsal and the plantar surfaces of the foot. It felt 
 elastic, moderately tense and firm, and pressure on it 
 gave a sensation as of fluid moving in a sac from the 
 dorsal to the plantar part of the foot. All the sur- 
 rounding parts appeared quite healthy, except in 
 being displaced by the swelling. No cause could be 
 assigned for it, unless it were a consequence of un- 
 gainly walking due to complete rigidity of the knee 
 after acute inflammation fourteen years previously. 
 
 I advised puncture of the swelling and complete 
 rest of the foot ; but the patient did not return to the 
 Hospital.
 
 12 DISEASES OF METATARSO-PHALANGIAL BURS-E 
 
 In another case, I saw what I cannot doubt was 
 due to suppuration of the bursa between the second 
 and third metatarso-phalangial joints ; a minute fis- 
 tulous passage extending from the back of the foot to 
 the sole between the distal parts of these two meta- 
 tarsal bones. A probe passed through it did not 
 detect any diseased or bare bone, or feel either joint 
 exposed. It was a mere straight canal which had 
 remained after discharge from a small suppurating 
 cavity, and it slowly, but, I believe, permanently 
 closed. 
 
 In the cases less marked than these, the disease 
 of the bursa, as I believe, has been indicated by pain 
 in one of the distal intermetatarsal spaces. This pain 
 is felt usually or most distinctly or sometimes only 
 during standing or walking; the part then aches 
 more or less severely, and sometimes even so severely 
 that patients cannot enjoy the active exercise they 
 wish for. The longer this pain continues, the more 
 widely it extends from the place at which it began. 
 It may be less or more according to the kind of shoes 
 or boots that are worn. Commonly, also, pain is 
 produced or increased by pressure between the heads 
 of the two metatarsal bones, or by firmly graspincr 
 and compressing the whole width of the metatarsus. 
 No pain is produced by pressure of either joint, unless, 
 as I suspected in one case, the affected bursa com-
 
 DISEASES OF METATARSOPHALANGIAL BURS.E 13 
 
 municates with the joint. No evident signs of in- 
 flammation may exist ; no swelling or felt heat of the 
 part. 
 
 The description of the pain has often reminded 
 me of that described by patients who have bursas 
 over exostoses subject to muscular or tendinous 
 rubbing, or by those in whom there are enlarged 
 bursas under the tendon of the biceps femoris or 
 semi-membranosus. Perhaps in all these latter cases 
 the pain is induced or increased by the bursge being 
 rubbed over such nodules of bone as are formed in 
 the common osteo-arthritis. 
 
 I do not know any speedy cure of these cases. I 
 have never tried incision ; having thought that it 
 might sometimes bring in much worse troubles than 
 it was intended to drive out. Eest and hot sponging 
 and warm coverings of the part will always, I believe, 
 give comfort, and the patient should wear none but 
 well-fitting, roomy boots or shoes of good soft leather, 
 not lined with the usual unyielding canvas, but lined 
 with wash-leather or fur. Sometimes an elastic strap 
 or an adhesive one worn around the distal part of the 
 metatarsus will prevent or diminish the pain, as if by 
 hindering the friction of the bursa in the movements 
 of the foot ; or a thick horse-shoe-shaped felt-plaster 
 worn on the sole of the foot, so as to prevent pressure 
 on the painful part when the weight is borne on the
 
 14 DISEASES OF METATARSO-PHALANGIAL BURSJ3 
 
 foot. With these or similar means, and in course of 
 time, the troubles of these cases do come to an end, 
 leaving no mischief behind them. 
 
 After writing this paper I found that the same 
 subject, or one like it, had been treated by Dr. Mor- 
 ton in an essay ' On Cases of Painful Affection of the 
 Foot.' l He regards the disease as neuralgic, and in 
 many cases has remedied it by excising the fourth 
 metatarso-phalangial joint. I can well believe that 
 in otherwise unmanageable cases this operation may 
 be resorted to ; it would remedy bursal disease as 
 well as neuralgia. 
 
 1 In the American Journal of Medical Sciences, January 1876, and 
 in the Philadelphia Medical Times, October 1886.
 
 15 
 
 CHAPTEB III 
 
 ON SOME DISEASES OF THE COEPORA CAVERNOSA PENIS 
 
 Gouty inflammation, Some of the affections of the 
 penis associated with gout are commonly described. 
 Among these are the frequent and almost painful 
 nocturnal erections to which some elderly and old 
 men, with too acid urine, are liable ; and the hsemor- 
 rhages in the bladder, and much more rarely from 
 the urethra, like the common gouty nasal hemor- 
 rhages ; and the gouty arthritis, which closely imi- 
 tates acute gonorrhoea, but is not usually, if ever, 
 infectious, and which, like gonorrhoea, is often as- 
 sociated with and sometimes evidently produces 
 stricture. But I have not found records of what 
 may justly be called acute gout of the penis, such 
 as I once saw many years ago. It may, indeed, 
 be observed that with gouty inflammation of the 
 urethra there is commonly more swelling, heat and 
 aching of the whole penis than is found in any but 
 the most acute infective gonorrhoea ; and that this
 
 16 ON SOME DISEASES OF THE 
 
 may be counted among the diagnostic signs of the 
 gouty disease, especially when it has continued long 
 or recurred often. But in the acute case which I 
 saw the swelling was much more than usual and was 
 the chief sign. 
 
 The patient was a gentleman sixty-six years old, 
 tall and thin, often gouty, rather weakly and anaemic, 
 with very irritable, capricious digestive organs, 
 which he had not spared from work. Forty years 
 before his present illness he had been treated for 
 urethral stricture after gonorrhoea ; but he had long 
 thought himself cured of this. In the last seven 
 
 o 
 
 years he had often had gouty attacks, some of them 
 typical and acute ; and in the last of them had what 
 he described as severe inflammation of the penis, 
 with pain, redness, turgescence, and purulent dis- 
 charge from the urethra. All this, except the dis- 
 charge, subsided together with the other signs of 
 gout, and, during the last year, he had had better 
 general health than usual, though the urine- stream 
 remained much smaller and more feeble than it was 
 before. 
 
 In the last week before I saw him, the penis, 
 which had been of natural size, had again enlarged. 
 The glans and the anterior three-fourths of the 
 body were as large as during full erection, though 
 not nearly so firm or tense as in that state. They
 
 CORPORA CAVERNOSA PENIS 17 
 
 were tender to the touch, not over-hot or throbbing, 
 pendulous, not rigid or curved ; and the scrotum, 
 perineum, and adjacent parts were healthy. There 
 was a thin purulent discharge from the urethra, and 
 its orifice and the visible part of its canal looked as 
 if lined with a thin layer of yellowish false mem- 
 brane. The urine was turbid with excess of acid ; 
 the tongue was thickly coated, but there was no 
 fever. 
 
 Calomel, colchicum, and liquor potassae were 
 given, in the manner in which he usually took them 
 when evidently gouty ; and after four days the 
 swelling of the penis had much subsided, but he had 
 severe lumbago. This lasted about two days, and 
 five days later he had gouty pains in the left great 
 toe. The penis had steadily decreased, and four 
 days later, when the gout in the toe had become 
 more marked, it had nearly returned to its usual 
 size. The attack had lasted nearly three weeks. 
 
 When the urethra had become fit for exami- 
 nation, a very narrow stricture with surrounding 
 induration was found near its orifice. Probably 
 some narrowing had long existed, and had been in- 
 creased during the recent acute inflammation ; for 
 during that attack the stream of urine had not only 
 been very painful, but had been evidently decreasing 
 in size. The stricture was gradually dilated with 
 
 c
 
 IS ON SOME DISEASES OF THE 
 
 instruments, and for four years the patient was free 
 from serious local trouble. At the end of this time 
 he had another attack of inflammation of the penis, 
 just like that which I have described, associated with 
 well-marked signs of gout, with excessively acid, 
 turbid urine, but without any increased difficulty 
 in passing it. This attack, also, subsided like the 
 others, and he died some years afterwards with the 
 constantly increased defect of his power of diges- 
 tion. 
 
 Induration of the Corpora Cavernosa. In the 
 case just described of acute and evidently gouty 
 inflammation of the corpora cavernosa, and in others 
 similar, but less acute, no permanent change of stric- 
 ture was produced ; the urethral stricture in the 
 chief case had long existed and was only increased. 
 But many examples of permanent hardening of the 
 erectile structure or of its sheath seem to be con- 
 nected with habitual and incomplete gout. 
 
 This is especially true of those tough thickenings 
 of portions of the fibrous sheath and septum which 
 produce curvings upwards or sideways during erec- 
 tion. The toughened structure is very like that of 
 the usually gouty, contracted palmar fascia, which is 
 common in many who can ascribe no local cause for 
 the change. I have once seen similar changes in both 
 the penis and the hands of the same gouty person.
 
 CORPORA CAVERNOSA PENIS 19 
 
 But there are differences between the two con- 
 ditions which should be noted. The indurations of 
 the palmar fascia do not, so far as I know, ever be- 
 come bony or calcareous as those of the sheath and 
 septum of the corpora cavernosa sometimes do, when 
 they form substances rather like those which Ger- 
 man writers have classed among Exercirknochen. 
 The changes in this sheath, also, may be found in 
 some who have no evidence of being gouty ; and 
 they sometimes form quite rapidly, so that, within a 
 few days, the thickening becomes sufficient to give 
 an extreme curvature to the penis in erection. 
 
 Among indurations of the proper substance of the 
 corpora cavernosa some may justly be deemed gouty, 
 especially such as are coincident with the thickening 
 of the fibrous sheath and not with any urethral dis- 
 ease. The induration of the substance is generally 
 behind the glans, thence extending towards the pubes, 
 and in both directions well-defined. Sometimes it 
 affects both halves of the penis equally ; in other cases 
 unequally, and in these the induration not only limits 
 the increase of size in erection, but produces distor- 
 tion, and gives pain. 
 
 Another form of gouty disease in the corpus 
 cavernosum is that described by Sir Prescott Hewitt 1 
 
 1 Transactions Clinical Society, vol. vi., p. 40. 
 
 c 2
 
 20 OX SOME DISEASES OF THE 
 
 as in the form of firm nodules, produced by blocking 
 of the veins or venous spaces with organised blood- 
 clots due to a kind of gouty phlebitis. 
 
 But, however rarely, cases of induration of the 
 corpora cavernosa may be found very different from 
 all these. I had such an one under my care in St. 
 Bartholomew's in 1853. 
 
 The patient was a dyer, thirty-five years old, a 
 pallid, sickly-looking man, but with fair muscular 
 strength, and not complaining of anything but his 
 penis. Its anterior half was enlarged to nearly the 
 size it might have had in erection, but the glans was 
 less enlarged than the body. To the touch and sight 
 the glans appeared of healthy structure, but at the 
 corona, and behind it, when the prepuce was drawn 
 back, there was an appearance of superficial scar 
 which might have been from former syphilis. An 
 inch or more of the corpora cavernosa behind the 
 glans felt intensely hard, as hard as in cancerous 
 disease, but rather less so at its boundaries than in its 
 very substance. A thin layer of the erectile tissue 
 at the dorsum of the penis felt healthy ; but some 
 degree of induration appeared to have extended over 
 a portion of the corpus spongiosum urethras. The 
 shape of the whole induration was irregular ; its boun- 
 daries were ill-defined ; the parts of the penis above 
 and behind it and the integuments over it felt and
 
 CORPORA CAVKRXOSA PENIS 21 
 
 looked healthy. Only the lining of the prepuce was red- 
 dened and moist as if from constant slight irritation. 
 
 Around and just above the corona glandis were 
 five minute apertures, and on the glans itself were 
 three ; and these all led into minute canals which 
 opened into the urethra, at the part within the indura- 
 tion. When urine was passed it flowed freely ; but it 
 gave much pain in the diseased part of the urethra, 
 and fine jets escaped from all the minute openings on 
 the glans. Small quantities of pus and blood were 
 often discharged from the natural orifice of the urethra, 
 and it was tender on pressure of the hardened part. 
 
 This disease began sixteen months before the 
 patient's admission, but he was very obscure as to 
 its manner of beginning. There seemed to have been 
 some general but not severe inflammation of the 
 penis, after which, at the end of a month or sooner, 
 the induration was found and it was not less in 
 extent, though less hard, then than now. The aper- 
 tures at the glans had formed about twelve months 
 before the patient's admission, but he could not give 
 any account of how they formed ; only, there had 
 been nothing like the formation of an abscess. He 
 had freely taken mercury and iodide of potassium, 
 but with no effect. 
 
 The diagnosis of this case was very difficult ; 
 but on the whole it seemed most probable that the
 
 22 OX SOME DISEASES OF THE 
 
 disease was due to some rare morbid compound, of 
 which syphilis was the chief element ; and in this 
 view he took iodide of potassium with sarsaparilla, 
 and they seemed to do good. After three weeks the 
 induration was evidently less, the tissues bounding it 
 could be more freely moved on it, and all the aper- 
 tures around the glans were closed : the three on 
 its surface remained. After this time the improve- 
 ment was very slow ; the slight stricture in the 
 urethra was easily dilated, and, with injections, the 
 discharge from it was diminished. At the end of two 
 months from the patient's admission one of the open- 
 ings on the glans healed ; and at the end of four 
 months another ; but after he had been in the hos- 
 pital for nearly five months there still remained 
 very considerable induration of the anterior part of 
 the corpora cavernosa, and one fine fistulous passage 
 from the urethra to the dorsum of the glans. 
 
 He now returned to his home and lived carefully, 
 and occasionally passed a full-sized catheter. Thir- 
 teen months afterwards, Mr. Whiting, of Lynn, who 
 had watched his case, wrote to me that he was in 
 good health, that the hardness was nearly all gone, 
 and the urethra was quite pervious and very rarely 
 seemed to need a catheter. The fistula was, I sup- 
 pose, closed, for it was not mentioned. 
 
 I am still inclined to think that this disease
 
 CORPORA CAVERXOSA PENIS 23 
 
 was chiefly syphilitic, and that the induration was 
 of the nature of a gumma which softened and sup- 
 purated, and opened both into the urethra and on 
 and around the glans. Certainly there were in this 
 case no indications of the fistula being due to escape 
 of urine from an ulcerated urethra ; and among some 
 very brief notes on out-patients I find mention of 
 one with syphilitic disease of the skull, in whom 
 small urinary fistulas like these formed in nearly the 
 same quiet way ; and of two patients of whom it is 
 said that ' two or more exceedingly minute channels 
 extended from the urethra to the surface of the glans 
 penis. Their orifices were scarcely visible, but, 
 when the patient passed urine fine jets of it were 
 impelled through them, or drops issued from them. 
 Their mode of formation could not be traced ; they 
 were " found by chance," ' 
 
 I may as well add a few words on some other 
 facts relating to these conditions of the corpora 
 cavernosa, which may, perhaps, be useful. 
 
 I know of no treatment likely to be beneficial in 
 the indurations of either the sheath or the substance 
 which are or seem to be due to gout. When they 
 are painful, or, as they sometimes are at first, asso- 
 ciated with any general congestion of the part, 
 alkalies or other things useful in gout may relieve 
 these symptoms. At other times they have no in-
 
 24 DISEASES OF THE CORPORA CAVERXOSA PENIS 
 
 fluence. Sometimes, however rarely, the induration 
 spontaneously decreases. When this occurs the 
 hardened part of the corpus cavernosum remains 
 always softer than is natural, and incapable of full 
 erection. 
 
 Similar softness and loss of erectile power some- 
 times comes without induration in the part just 
 behind the glans, and makes copulation nearly im- 
 possible; but in the very rare instances in which I 
 have been told of this the patients had so unsound 
 nervous systems that I have suspected a local nerv- 
 ous rather than a structural error. 
 
 In some persons the same part of the corpora 
 cavernosa, for half an inch or more behind the 
 glans, is naturally more than commonly tough ; and 
 some of them suspect cancer. But in these as well 
 as in the really morbid hardenings of the part, the 
 diagnosis from cancer is very seldom difficult. The 
 hardening is less intense than that of cancer ; it is 
 more tough, elastic, flexible ; the textures about it, 
 unless inflamed or scarred, slide over it easily ; there 
 is no corresponding disease of the skin or mucous 
 membrane, in or just beneath which, in an immense 
 majority of cases, cancer of the penis begins ; and, 
 even after months or years, there is no ulceration or 
 infection of lymphatic glands.
 
 CHAPTEE IV 
 
 ON SPINES SUSPECTED OF DEFORMITY 
 
 AMONG the fears of disease for which one is consulted 
 none is more frequent than that of lateral curvature 
 of the spine. These fears are felt, especially, by 
 mothers among the richer classes ; and usually the 
 fear is only for their daughters' spines. It is thought 
 essential to the welfare of a young lady that her 
 spine should be straight, and her form not notably 
 unsymmetrical, and that she should habitually sit 
 upright with her back unsupported. There is no 
 such thought for young gentlemen, and it appears to 
 be, chiefly, a consequence of this difference that in 
 the well-to-do classes lateral curvature of the spine 
 is at least twenty times more frequent in girls than 
 in boys. For mothers seldom look at their sons' 
 spines ; and they let them sit with their elbows on 
 the table, loll back in their chairs, and lie flat on 
 their stomachs, and do many more such prudent 
 things as in the daughters would be deemed shame-
 
 26 ON SPINES SUSPECTED OF DEFORMITY 
 
 ful. Thus boys' spines grow straight ; the muscles 
 helping to support them are not over-tired, or, when 
 they are, they can be rested in any comfortable 
 posture. But among girls the postures deemed 
 graceful must be maintained till some deformity is 
 discovered or suspected, and then the poor girls 
 must be made miserable by the treatment deemed 
 necessary for its cure. 
 
 The folly and the mischief of this contrast are 
 happily becoming known : the good rule of letting 
 girls grow up like boys is becoming more and more 
 widely observed, and a larger proportion of them are 
 well-formed, graceful, and strong. 
 
 Still, the unfounded fears of deformity of the 
 spine are far too frequent, and they are maintained, 
 in many instances, by the existence of slight devia- 
 tions from the supposed pattern-shape which are 
 quite harmless. It seems to be assumed by some 
 that all spines should have curves and other char- 
 acters exactly similar to those which are seen in 
 artists' models or in anatomical plates. It is much 
 more probable that there are as many varieties of 
 healthy spines as of healthy chins or cheeks, or as 
 many in the human species as in the horse or ox. 
 Round shoulders, straight backs, hollow loins, and 
 other such shapes are as common in members of the 
 same family as are any other family features, and
 
 ON SPINES SUSPECTED OF DEFORMITY 27 
 
 they are due to the imitation of parents in only the 
 same degree as may be the expressions of similarly 
 formed limbs or faces. 
 
 I wish I could describe the variations of shape as 
 accurately as are the forms of spines studied and 
 measured in skeletons or sections by such anato- 
 mists as Sir William Turner and Professor Cunning- 
 ham. But this is not possible ; and yet the varieties 
 of form may be well enough observed, even as those 
 of faces or of any single feature may be, though they 
 be not exactly measured. 
 
 I find notes of some of these varieties which may 
 supply hints useful to be remembered when exa- 
 mining cases of ' Suspected Spines.' They relate to 
 the dorsal and lumbar portions of the spine in which 
 alone the feared lateral curvatures are usually looked 
 for ; and they relate to none but young persons. 
 
 But, first, the suspicions are often founded on 
 pains in the back which are, by some mothers, re- 
 garded as sure forerunners of deformity. When 
 they are complained of, the whole length of the spine 
 should always be examined, for they may be signs 
 of disease in it, though, indeed, they rarely are so. 
 The most common result of the examination is that 
 the spine is found well formed, but tired through 
 having been too much exerted in holding the body 
 upright while sitting or standing. The tired muscles
 
 28 ON SPINES SUSPECTED OF DEFORMITY 
 
 ache prudently, needing rest and more various 
 activities. 
 
 I often quote for such cases, and for many more, 
 an excellent sentence which I learned from Sir Henry 
 Holland : ' Standing has all the disadvantages of 
 posture without any of the benefits of exercise.' 
 And for spines it may be said that sitting upright 
 has similar disadvantages without the benefits of 
 rest. 
 
 Such aching muscles are, I think, most common 
 in girls whose spines are very flexible ; and this 
 flexibility in all directions should always be tested. 
 An apparent excess is harmless, unless it be asso- 
 ciated with such muscular weakness that when the 
 spine is extremely bent in one direction it can hardly 
 be lifted up again. A very defective mobility is 
 more suggestive of disease, especially if it be associ- 
 ated with pain at any definite part of the spine, and 
 if the pain be increased in very wide movements or 
 in violent and not guided movements, as in sneezing 
 or laughing. Such pain with restraint of movement 
 may be due to a rheumatic trouble, but it should 
 always suggest a suspicion that there may be cari- 
 ous disease of the spine and a possibility of angular 
 curvature. If careful examinations of this kind be 
 always made it will be found that only a very small 
 proportion of the aching backs of young or recently
 
 ON SPINES SUSPECTED OF DEFORMITY 29 
 
 young persons are associated with spinal deformity. 
 Many of them, as I have said, are due to fatigue and 
 the want of various exercise ; many more may be 
 called neurotic, and may be remedied by improve- 
 ment of the general health. In this group are most 
 of the cases in which the pain is described as intense 
 or agonising ; l intense pain is extremely rare in 
 young persons whose spines are really diseased. 
 
 Next to the cases of suspicion due to back-ache 
 the most frequent are those due to awkwardness or 
 carelessness in posture. Many, perhaps the majority, 
 of cases of real deformity have their origin in wrong 
 postures too long maintained, whether through care- 
 lessness or under compulsion. But, commonly, the 
 imitation of deformity long precedes the reality, and 
 may be known by the facility of at least a temporary 
 remedy or concealment in a proper posture, espe- 
 cially in bending low. If a patient bending down, 
 and nearly touching the ground with her hands with- 
 out bending her knees, shows not only a rectilinear 
 spine but similar muscular forms on each side of it, 
 there should be no fear of deformed spine ; there is 
 none present, and there will be none unless through 
 
 1 I speak here only of cases in which ' back-ache ' is referred 
 erroneously to disease or deformity of the spine. It may depend on 
 renal or ovarian or other internal disorders : but of these cases I do not 
 venture to speak. 

 
 30 ON SPINES SUSPECTED OF DEFORMITY 
 
 mismanagement. 1 Fitting exercises and well-propor- 
 tioned restings will prevent any permanent deformity. 
 They must vary according to the error in each case, 
 but one general rule may be given, and it is good for 
 many cases besides these, namely, that all exercises 
 and habits, postures, games, drills, and the rest, should 
 be such as may best conceal the defect ; for such con- 
 cealment is one of the best ways towards cure. The 
 muscles which can conceal a defect are those which 
 most need exercise, and which, being strengthened, 
 may most help to a cure. Such concealment of 
 defect may be hard for children and others like 
 them ; but with care even these may be taught, and 
 for a very large number of drooping and tilted 
 shoulders, and limp spines, and other such imitations 
 of deformity, the cure by concealment is sufficient. 
 It is thus that strict drill often teaches soldiers to 
 conceal such defects as an unequal length of limbs, 
 ill-made feet, partial stiffness of a joint, and by con- 
 cealment to diminish some of them. 
 
 Of the cases in which deformity of the spine is 
 feared on account of some more abiding unusual 
 shape, some are associated with inequality in the 
 lengths of the lower limbs. In the most marked of 
 
 1 If there be doubt when this test by stooping is applied, it is 
 often useful to see the spine while the patient sits on the ground and 
 then bends down.
 
 ON SPINES SUSPECTED OF DEFORMITY 31 
 
 these the inequality is due to imperfect growth or 
 other change after disease of one hip or knee, or 
 after a temporary infantile paralysis ; but some are 
 only instances of a more than usual defect of sym- 
 metry. Exact equality in the length of the limbs is 
 rare ; * but if the inequality be not more than a 
 quarter of an inch, it will hardly be observable at 
 the spine. A greater inequality may so lift up the 
 side of the pelvis above the longer limb that the 
 flank will appear sunken in, and the lumbar part of 
 the spine must be habitually, however slightly, 
 curved, so as to hold the upper part of the body 
 erect ; or else the spine, though straight, will be 
 oblique. 
 
 In all examinations of the spine for supposed or 
 real curvature the lengths of the lower limbs should 
 be looked to ; not only because of the obliquities and 
 even the curvatures wholly due to their inequality, 
 but because such inequality may increase the degree 
 of curvature when it is real and chiefly due to other 
 causes. The measurement may be made in many 
 ways ; but anyone in the habit of exercising his 
 sight in discerning exactness of levels, as in the 
 hanging of horizontal bars or other such things, may 
 
 1 Numerous careful measurements of limbs have been published 
 by Dr. Garson, Dr. Cox ( American Journal of the Medical Sciences, 
 and others.
 
 32 OX SPINES SUSPECTED OF DEFORMITY 
 
 measure the limbs accurately enough by placing his 
 hands on the crests of the ilia while the patient stands 
 erect and equally on both feet ; or it may be tested 
 by making the patient sit on the ground on a low 
 seat and bend forwards. 
 
 This inequality of the lower limbs is only one 
 example of the very common deviations from exact 
 lateral symmetry in even healthy and beautiful per- 
 sons. 1 Such deviations may be almost always 
 seen, if closely looked for, in the size and form 
 of the two sides of the face, in the shoulders, the 
 sternal ends of the clavicles, the sides of the neck, 
 the breasts ; and some of these may suggest false 
 suspicions of deformity. Especially may these arise 
 when the two sides of the chest are evidently unequal. 
 In some of these the difference is only an original 
 defect of symmetry, and it often co-exists with similar 
 difference in the two sides of the face, well marked in 
 the eyebrows, or the lower borders of the jaw ; in 
 some, and these more evident, the difference may 
 be due to contraction of the chest after pleurisy or 
 empyema. In cases of extreme inequality there may 
 be well-marked dorsal curvature of the spine towards 
 
 1 It might be better to speak of deviations from lateral symmetry 
 as being constant rather than ' very common,' but in such cases as I 
 am describing I have in mind only those which may be evident to the 
 naked eye. I doubt whether exact symmetry, such as might be 
 deemed mathematically exact, can be found in any organic form.
 
 ON SPINES SUSPECTED OF DEFORMITY 33 
 
 tlie larger side, and this is scarcely alterable unless 
 by the gradual expansion of the contracted side of 
 the chest. In less marked cases, such as are most 
 of those which are due to original deviation from 
 symmetry, the curvature is unimportant and may be 
 remedied, in very young persons, by exercises giving 
 wider movements to the arm on the smaller than to 
 that on the larger side. 
 
 Together with these deviations of the spine, 
 associated with naturally defective symmetry of the 
 lower limbs, may be observed those associated with 
 habitual resting on one limb more than on the other : 
 whether because of weak ankles, or corns, or any- 
 thing else. For all alike it has to be remembered 
 that bad postures, long maintained, will bring in bad 
 shapes, and even good postures maintained in weari- 
 ness are hardly less injurious. 
 
 Many of the cases of inequality of the two sides 
 of the chest are attended by that which some mothers 
 regard as a sure sign of spinal deformity, an out- 
 standing of the scapula on the larger side. But the 
 fear is erroneous, and I think it may safely be held 
 that no position of the scapula is alone a sufficient 
 sign that there is spinal deformity. An unusual 
 position of one or both must always make it right 
 to examine the spine ; but, if there be no unhealthy 
 curvature, rotation, or other sign of deformity in the 
 
 D
 
 34 OX SPINES SUSPECTED OF DEFORMITY 
 
 spine itself, the position of the scapula is not evidence 
 of any. Their dissimilarity may be due to inequality 
 of the two sides of the chest, or to one-handedness, 
 and the associated inequality of growth of the two 
 limbs, or to a deviation from symmetry in muscles or 
 in bones, like that of any other pair of parts. 
 
 Among the varieties of shape in spines which 
 may be regarded as personal, in the same sense as 
 are the varieties of faces, or of hands or feet, I need 
 not speak of any but those that suggest fears of 
 deformity. 
 
 One of the most common is the too great curvature 
 of the upper dorsal part of the spine, giving the owner 
 the appearance of ' round shoulders ' and of ' poking.' 
 If it be a regularly arched curve, not angular, it is 
 not to be regarded as morbid ; good drill and similar 
 exercises may conceal and nearly cure it. 
 
 At the other and lower end of the dorsal part of 
 the spine there may sometimes be found a defect, or 
 as it were a delay, in the curving forward towards 
 the lumbar concavity, and the hollow of the loins 
 looks less both in length and in depth than it should 
 be. But neither this nor the opposite peculiarity, in 
 which the loin is extremely hollow, is the result of 
 disease. The hollow-loin is sometimes very short, 
 sometimes long. In the former case it looks like a 
 diseased sinking-in, the more so the fatter the patient
 
 ON SPINES SUSPECTED OF DEFORMITY 35 
 
 is and the higher the rising of the fat on the nates. 
 But neither of these varieties may be regarded as in 
 any sense a deformity, unless all unusual faces are 
 to be so called. 1 However much the anterior or the 
 posterior curves of the spine may in these cases vary 
 in length or depth however long-loined or short- 
 loined anyone may be if there be no deflection to 
 the right or left, and, if there be no angular bend- 
 ing or local unreadiness to move, the patient may 
 be ' let be.' 
 
 I would not seem to imply the same in respect of 
 cases of apparent bending forwards of any part of the 
 cervical spine. It is sometimes seen at the beginning 
 of caries, and had better be seriously suspected if it 
 be associated with defective movement or unready and 
 painful movement of the head. 
 
 And there are some appearances of lateral curva- 
 ture and even of posterior projection which are not 
 to be regarded as deformities. Some think, indeed, 
 that the upper dorsal part of the spine has always, 
 when well formed, a slight curve towards the right. 
 Such a curve is not rare, but it is far from constant, 
 and appears to be sometimes imitated by a slight 
 lateral deviation of the spinous processes, as if they 
 
 1 They are examples of such varieties of form as Sir William 
 Turner has shown may, probably, be found characteristic of different 
 races of our species. Journal of Physiology. 
 
 D 2
 
 36 ON SPINES SUSPECTED OF DEFOPtMITY 
 
 were drawn over by the muscles or the weight of the 
 
 stronger arm. 
 
 Instead of such a general deviation from the true 
 median position of a part of the spine, there may 
 sometimes be seen a slight lateral deviation of the 
 spinous processes of one or two dorsal vertebras. 
 Whether it be due only to their own shape, or to 
 any irregularity in the position of their vertebras, or to 
 a slight rotation of them, I cannot tell, but I have 
 never known any harm associated with it, or with any 
 similar condition of a lumbar or cervical vertebra. 
 
 In other cases, in which the whole length of the 
 spine may be justly median, one, or sometimes two, 
 of the lower dorsal or of the lumbar spinous processes 
 are more prominent than they usually are, or than 
 they would be in a model. They stand out from the 
 uniform curve towards the hollow of the loin as if 
 due to a partial or commencing posterior or angular 
 curvature. The appearance is often deceptive, and 
 should be tested by making the patient bend low 
 down till the hands are near the ground. If this is 
 painless and the spinal curve becomes uniform there 
 need be no fear. But the examination should be 
 very carefully made, and, if there be doubt, if the 
 bending down be difficult, or really painful, or if the 
 other movements of the spine, especially the curving 
 backward, be restrained, and, still more, if the general
 
 ON SPINES SUSPECTED OF DEFORMITY 37 
 
 health be impaired, or there be clear evidence of 
 tuberculous inheritance, it is best to be suspicious 
 that the projection may be due to caries or softening, 
 and may be the beginning of angular curvature. 
 And this is advisable in the case of adults as well as 
 of young persons, for even in adults, as I have said 
 in the next paper, it is not very rare to meet with 
 instances of disease of one or two vertebras or inter- 
 vertebral ligaments, slowly progressive and scarcely 
 to be recognised till the spinous processes are pro- 
 minent. Of course, help to diagnosis may sometimes 
 be found in knowing how long the projection has 
 existed ; but the evidence on this point is usually 
 doubtful. 
 
 More rarely one sees spines in which two or three 
 of the spinous processes, far distant from each other, 
 stand out prominently and singly. They give a 
 strange look to the spine, but imply no more disease 
 than a naturally ugly nose does. They are a good 
 example of what I have already said, that in different 
 persons healthy spines may be as unlike as any other 
 of their features. 
 
 I am conscious that this paper may seem to 
 encourage a temper of mind which is in some of us 
 habitual, and I suppose is in all occasionally felt the 
 temper that disposes one to make too light of a case,
 
 38 ON SPINES SUSPECTED OF DEFORMITY 
 
 and be ready to think and say ' There's nothing the 
 matter.' If I am in this risk of doing mischief I 
 would try to prevent it by reminding the reader of 
 the great difficulty of proving a negative, and that, 
 as a general rule, it requires much more time and 
 care in examining a patient to justify a decision that 
 there is no disease than it does to ascertain what the 
 disease is if there be any.
 
 39 
 
 CHAPTER V 
 
 OBSCURE CASES OF CARIES OF THE SPINE 
 
 AMONG or in connection with, these may be found 
 instances of great difficulties of diagnosis, especially 
 among cases which occur after puberty. On the one 
 side are the cases of l nervous mimicry,' in which all 
 that are commonly supposed to be signs of disease of 
 the spine are imitated with emphasis, but in which 
 no organic disease is found. On the other side are 
 cases, much more difficult and serious than those, in 
 which grave spinal disease exists in unusual con- 
 ditions, or with so little indication that it is likely to 
 be completely overlooked. Of the first set of cases 
 I have written in one of my * Clinical Lectures ' on 
 Nervous Mimicry, and in the preceding paper on 
 Suspected Spines ; of the second I will here tell 
 briefly one case in illustration of the difficulty of 
 diagnosis in each of three groups. In the first of 
 these are cases of caries of the spine beginning in 
 persons more than fifty years old ; that is, at an age
 
 40 OBSCURE CASES OF CARIES OF THE SP1XE 
 
 when it is so rare that symptoms which, in early 
 life, would be deemed characteristic are apt to be 
 misunderstood. In the second group are cases of 
 adults in whom the symptoms are vague, and the 
 pains so misplaced that they are commonly referred 
 to some disease deemed much more likely to occur 
 than spinal caries. In the third group may be cases 
 in which there is so little indication of disease of any 
 kind or anywhere that the whole process, including 
 the angular curvature, is completed before anything 
 is observed. 
 
 In the first of these groups, the case of which I 
 had the best, though far from complete, knowledge 
 occurred in a barrister, about fifty-five years old, a 
 member of a family deemed delicate though they 
 lived long. He had had weakly health, but had 
 worked hard at the Bar and in Parliament, and had 
 had no marked illness till in March 1858, when he 
 appeared weakened by overwork. He had at this 
 time a severe shivering fit, which was followed by 
 some kind of fever, and then by increasing weakness. 
 At the end of May he began to have pains at his 
 back and sides, which were deemed rheumatic, and 
 were carefully treated ; but he became more feeble 
 and lost weight, and still suffered pain and panted in 
 the exertion of walking even a few steps. No intra- 
 thoracic disease could be found, and an accurate
 
 OBSCURE CASES OF CARIES OF THE SPINE 41 
 
 diagnosis seemed impossible to Sir George Burrows 
 and others, who at that time watched him. 
 
 After four months, in September, spinal disease 
 was suspected, and he was advised to rest, recum- 
 bent ; but he still continued to have almost constant 
 pain, and it was felt as if shooting from the spine 
 along the direction of the six lower ribs, and some- 
 times at the epigastrium. At the end of six months 
 from the beginning of his illness his pain was more 
 limited to the lower part of the dorsal portion of his 
 spine, and now, when I first saw him, I found that 
 he had a more than natural sensibility, and a feeling 
 as of -jarring, on pressure or striking of the spinous 
 processes of the lower dorsal vertebrae. Two of 
 these processes, also, were prominent and had a 
 marked deviation to the right ; they had previously 
 been quite duly linear. He now moved his back, in 
 whatever direction, with extreme caution, holding it 
 usually very straight; his lower ribs, also, moved 
 very little in respiration, and in any muscular exer- 
 tion, even in much talking, he became nearly breath- 
 less and as if quite exhausted. There were no signs 
 of pulmonary or any other internal disease, or of 
 affection of the spinal marrow. But the diagnosis 
 was now clear : disease, probably caries, of some of 
 the lower dorsal vertebrae. 
 
 He was kept absolutely at rest, and took iodide 

 
 42 OBSCURE CASES OF CARIES OF THE SPINE 
 
 of iron and such good food as lie could digest ; and 
 issues were made and kept open by the sides of the 
 most painful part of his spine. Thus treated, his 
 condition slowly improved. In about four months 
 he could sit without pain, and his breathing power 
 had increased, and, with gradually diminishing pain 
 and increasing power, he was in about thirteen 
 months from the beginning of his illness able to leave 
 town, and to walk short distances without distress. 
 The prominence and lateral deviation of the spinous 
 processes continued, but became less abrupt, the 
 adjacent vertebras above and below having gradually 
 adjusted themselves to the change. 
 
 He regained health, and was at eighty strong 
 and active, above the average of men of that age. 
 He did when eighty-one. His case was certainly one 
 of ulcerative disease of the spine, whether in the 
 bodies of some of the dorsal vertebras or in some 
 of the intervertebral cartilages. Few cases could be 
 much more difficult of diagnosis than it must have 
 been at its beginning. 
 
 The other cases of this kind which I have seen 
 were in two men between fifty and sixty. In both 
 the disease was in the lowest dorsal vertebras ; in 
 both it was, at first, scarcely indicated ; in both it 
 ended with angular projection of the vertebral spines. 
 One of these cases was believed to have followed
 
 OBSCURE CASES OF CARIES OF THE SPINE 43 
 
 a ' fever ' ; both recovered with nothing evidently 
 worse than the slight deformity. 
 
 One of the best examples in the second group 
 of cases was in a surgeon about twenty-eight years 
 old, who had lost two brothers in phthisis, and had 
 generally had delicate health, but had been in active 
 country-practice for five years. He believed that his 
 disease began eighteen months before he consulted 
 me, and that it was due to his having, for several 
 months, ridden a fast, rough-going horse. The chief 
 signs had been pain and weariness between his 
 shoulders and in his flanks, and slight general loss 
 of strength. These were much increased by walking 
 far, and so much by riding that he had been obliged 
 of late to give it up entirely, and to do his work 
 driving with cushions at his back. During these 
 eighteen months, but at what period was not exactly 
 known, the mid-dorsal portion of his spine had ac- 
 quired an angular curvature ; the seventh or eighth 
 spinous process having become very distinctly pro- 
 minent, and those above and below it rather less 
 so. There neither was when I saw him, nor had 
 been, any pain or tenderness at the place of the 
 curve or on any other portion of the spine ; but he 
 had some aching or feeling of constraint in it when 
 he used his arms very actively. Besides the angular
 
 44 OBSCURE CASES OF CARIES OF THE SPINE 
 
 curvature of the spine, there was at the same part 
 a slight lateral deviation. In his general health 
 there was nothing plainly wrong except the loss of 
 strength. 
 
 Dr. Baly and I advised him to give up work, and 
 live very quietly on the coast for two or three 
 months, and take iodide of iron. It seemed certain 
 that the case was one of caries of some of the 
 vertebrae, slowly destroying their substance or that 
 of the intervertebral cartilages. 
 
 At the end of three months he told me that he 
 had followed the advice given him and felt well 
 enough for all his work. Two years later he was still 
 in active practice, and the projecting portion of his 
 spine appeared rather less sharply prominent, but 
 his general health was feebler, he was sooner tired, 
 and sometimes had the old aching between the 
 shoulders or pain in his intercostal muscles. Still he 
 was fit for work, and so he continued for three years 
 more, making nearly seven years from the beginning 
 of his illness ; but now he began to have a bronze 
 colour of the face and scrotum, and rapid loss of 
 weight and power, and other signs of disease of the 
 renal capsules, and with these he died. 
 
 The diagnosis of this case before the change of 
 the shape of the spine would have been very diffi- 
 cult; and the difficulty was still greater in three
 
 OBSCURE CASES OF CARIES OF THE SPINE 45 
 
 otherwise similar cases which I have seen. In 
 these the pain near the diseased, but not yet de- 
 formed, part of the spine was so acute, not in the 
 spine itself, but at one or both sides of the chest, 
 that it was thought the patient had some strange 
 kind of pleurisy. The angular projection becoming 
 evident explained the pain. But in all of them the 
 disease appeared more limited than it usually is in 
 children and young persons ; for the angular curva- 
 ture was formed by only one vertebra becoming 
 prominent, and the deformity was not noticeable 
 unless they were undressed. The recovery appeared 
 for a time complete : but some had recurring pains ; 
 and of the three cases of which I heard the ends, 
 one, I was told, died with disease of the renal cap- 
 sules, and two with pulmonary tuberculosis. 
 
 The best case that I have seen of the third set, 
 in which the caries of the spine passes through its 
 whole course unobserved, was in a gentleman who 
 consulted me in July 1859. He was between twenty 
 and twenty-five, very stout and strong, addicted to 
 the most athletic exercises, to hard drinking, and 
 often to sexual excess. Except in being over-fat, 
 which he ascribed to his being out of training, he 
 considered himself in perfect health, and capable of 
 the most violent exercise ; he was ready for any
 
 46 OBSCURE CASES OF CARIES OF THE SPINE 
 
 violence in anything. He had no sign of general 
 illness, and I could find no organ in fault, unless in 
 so far as his digestive organs were disturbed by his 
 intemperance. But he had well-marked angular 
 curvature of his spine, involving about the last three 
 dorsal vertebras ; a curvature characteristic of carious 
 disease. His lower ribs moved very little, and his 
 breathing was chiefly diaphragmatic and sternal ; 
 but of this and of any history of disease he knew 
 nothing. He knew that he had always been hollow- 
 loined, but he was sure that this angular deformity 
 had not existed more than three weeks. He was not 
 aware of its forming ; it was noticed by mere chance ; 
 and even now no pain could be felt in it, and it did 
 not seem to affect his health in any way. 
 
 I told him that if the deformity were really so 
 recent it would imply very dangerous disease, and 
 that he had better give up his present manner of 
 living ; but he was doubtful whether he would. 
 
 A month later he again came to me and said he 
 had been living quietly, with only occasional violence 
 in exercise ; but he was now less sure of the de- 
 formity being recent. He thought it might have 
 been only unobserved, and he remembered that for 
 three years he had been subject to frequent pains 
 along the course of his lower ribs on both sides, and 
 to sensations of sinking and weakness in the lower
 
 OBSCURE CASES OF CARIES OF THE SPINE 47 
 
 part of his chest. These pains had been very irregu- 
 lar in their occurrence, and were generally increased 
 by fatigue, and often by violent horse-exercise. 
 They had been thought rheumatic, neuralgic, or 
 pleuritic ; but they had never prevented him from 
 hunting, or any other amusement that he wished 
 for, and he had never laid-by for a day on their 
 account. 
 
 Believing that the disease was thus shown to be 
 of at least three years' standing, and was now riot 
 in progress, and feeling sure that he would not ob- 
 serve any rigid rules of treatment, I advised him to 
 avoid hard riding, railways, and all jarrings of his 
 spine, and to lie down after exercise and live in all 
 ways carefully. He would not follow even this 
 advice, and I heard that he went-on leading a 
 thoroughly dissolute life, suffering, at times, with 
 symptoms of disease in the spinal marrow, and 
 gradually losing power in his lower limbs. He did 
 not become paraplegic, and the deformity did not 
 increase, but in the winter of 1861 he became phthi- 
 sical, and he died in 1862. 
 
 It may, with some reason, be said that this is 
 hardly a fair case to cite in evidence of the over- 
 looking of the progress of spinal disease, and that a 
 less reckless patient would have given and asked for 
 more attention to his pain. I could have told a case
 
 48 OBSCtRE CASES OF CARIES OF THE SPIXE 
 
 in which, in similar unobserved progress, the pain 
 was trivial ; but this which I have related may be 
 the more notable because of such an absence of all 
 the other usual signs of the disease that the patient 
 was never once obliged to spend a day quietly. 
 
 And the case is a good instance of that which 
 I have referred to in another note, namely, the 
 effects of the contrast between the neglect and over- 
 looking of pain by a reckless athletic fellow such 
 as this was, and the watchful outlook for pain by 
 any sensitive woman who suspects that she has a 
 diseased spine. In the one, the real disease goes on 
 unobserved, uncared for, rarely felt ; in the other the 
 mimicry of disease is with constant suffering : in the 
 one, life is enjoyed, though, it may be, after a vile 
 fashion, even while disease is going on to death ; in 
 the other, life is made miserable by that which will 
 not shorten it. 
 
 In the third volume of the Clinical Society's ' Trans- 
 actions ' and in my ' Clinical Lectures and Essays,' I 
 published a paper on what I called ' Quiet Necrosis,' 
 giving cases in which necrosis of bone, such as is 
 usually attended with many and well-marked signs, 
 went on through a long course unobserved. I see 
 the name sometimes used by others describing similar 
 cases, and the. examples of caries of the spine con-
 
 OBSCURE CASES OF CARIES OF THE SPINE 49 
 
 tained in the last paper induce me to point out that 
 ' quiet diseases ' are much more frequent in surgical 
 practice than seems to be generally supposed. Every- 
 one must have observed the various intensities of 
 the symptoms in different examples of what must be 
 called the same disease ; and in some the usual sym- 
 ptoms are either absent or so little marked that they 
 may be unobserved even by those who are watchful. 
 Especially among cases of diseases of joints I have 
 known several of these. The most marked was in a 
 lad of whom, though he had been very carefully 
 brought-up, it was never known that his left shoulder 
 was completely stiff till he went to Eton and was 
 found defective in some of the school-games. The 
 joint was immovable, the muscles around it wasted, 
 but it was free from all signs of active disease, and, I 
 fully believe, always had been so ; and, whatever had 
 been the disease, it was now past. I remember two 
 similar cases in which, in children of ten or twelve 
 years old, always well cared-for, the hip-joint became 
 stiff without any evident sign of disease beyond the 
 increasing local discomfort. Both these were such 
 as might be deemed scrofulous, and it might fairly 
 be believed that in both of them scrofulous disease of 
 the hip-joint went on c quietly ' till it ceased when 
 the joint became stiff. The same quietude may 
 sometimes be observed in osteo-arthritis (chronic 
 
 E
 
 50 OBSCURE CASES OF CARIES OF THE SPINE 
 
 rheumatic arthritis) of the hip-joint in elderly persons. 
 The limb becomes shorter and the joint stiff without 
 any other discomfort than may be referred to these 
 two changes, or, perhaps, with some pain in the knee 
 which withdraws attention from the real seat of 
 disease. 
 
 Other cases might be mentioned. They would 
 help to show that it is useful to keep in one's mind 
 the name of ' quiet disease.'
 
 51 
 
 CHAPTER VI 
 
 PERFORATING ULCER OF THE SEPTUM OF THE NOSE 
 
 IN my volume of ' Clinical Lectures and Essays ' I 
 mentioned this ulcer as one among the many signs of 
 a scrofulous or tuberculous constitution ; but I have 
 notes and recollections of so many cases of it that I 
 think it deserves more consideration than, so far as 
 I know, it has yet received. 
 
 The characters of the ulcer are well marked and 
 nearly constant. With very rare exceptions, it is 
 limited to the cartilaginous part of the septum, not 
 extending to either bone or skin. Only in one case 
 a patient had, at the same time, a lupous pustule on 
 the tip of the nose, but there was no continuity of 
 apparent disease between it and the ulcer of the 
 septum. In shape the perforating ulcer is broadly 
 oval, from one- fourth to three-fourths of an inch in 
 diameter. Its borders are well defined, passing 
 directly or obliquely through the septum, not thick- 
 ened or upraised or with overhanging mucous mem- 
 
 E 2
 
 52 PERFORATING ULCER OF 
 
 brane. In different cases, the closely adjacent mucous 
 membrane is glossy or granulated or encrusted ; in 
 some it feels soft or slightly swollen, and it may 
 be florid or dusky. 
 
 Previous to ulceration the cartilage is, I think, 
 softened, and loses its resistance to pressure. I think, 
 too, that sometimes there may be soft morbid growths, 
 like granulomata, on the mucous membrane preceding 
 the ulceration; but very often the early conditions 
 of the disease give so little trouble that they are not 
 observed, and patients are rarely seen before the 
 perforation is complete, though it may be to a very 
 small extent. Even in its further progress the disease 
 may give very little trouble. I have found ulcers of 
 full size in some who were unaware of their existence 
 and had suffered only what might have been deemed 
 a chronic nasal catarrh. In some, however, the ir- 
 ritation is more : there is a frequent troublesome 
 running of this mucus, occasionally bloodstained ; 
 in some, frequent small bleedings, or accumulations 
 of thick gummy mucus, or of dried mucous crusts 
 irritating the nostrils. 
 
 In every case of this disease that I have yet seen 
 there was evidence on which the patient might justly 
 be deemed scrofulous or tuberculous, whichever he 
 might be called. There had been slowly suppurating 
 lymph-glands or follicular fauces, carious bone, sus-
 
 THE SEPTUM OF THE NOSE 53 
 
 pected phthisis, generally delicate health, or a marked 
 inheritance from tuberculous persons. All the cases 
 of which I have notes occurred in persons between 
 eighteen and fifty years old ; all seemed to derive 
 some benefit from treatment appropriate to scrofula. 
 In all that I could trace the edges of the perforating 
 ulcer healed, however slowly ; in none was the voice 
 altered ; in only one did the ulcer extend beyond, or, 
 I think, reach the very borders of the cartilage ; in 
 only one did there occur any change in the shape 
 of the nose. In this one the patient was certainly 
 syphilitic ; he had had both primary and secondary 
 syphilis, and his case might be regarded as an illus- 
 tration of what I think is generally true, that the 
 various characters of tertiary syphilis are determined 
 in great measure by the ' constitutions ' of the dif- 
 ferent persons in whom they occur. Tertiary syphilis 
 is usually a composite disease, and its characters are 
 modified by its being combined in one person with 
 tuberculosis, in another with gout, in another with 
 whatever may have been his inborn tendency to 
 disease. 
 
 The group of diseases with which I think that 
 this of the nasal septum may justly be classed is that 
 of the ulcerating forms of lupus. It is especially 
 like the lupus of the soft palate ; like it having a 
 distinctive localisation and limitation, perforating in
 
 54 PERFORATING ULCER OF 
 
 the same direct or oblique manner, and then com- 
 monly healing ; but, in the nose, with less diminution 
 of size than is possible in the yielding tissues of the 
 palate. The method of perforation is, indeed, in 
 these and some other ulcers, especially in the chronic 
 perforating ulcers of the stomach, so nearly uniform 
 that it may well indicate that they have one and the 
 same specific character, being all such as may be 
 called tuberculous. And their definite shape may 
 be a characteristic of their being due to parasitic 
 influence, just as are the definite shapes of parasitic 
 diseases on leaves. 
 
 The position, the shape, and the limitation oi 
 this perforation suffice for its diagnosis. Syphilitic 
 ulcers in the nose have not these characters ; they 
 have no such limited shape or place ; they invade 
 bone or skin rather than cartilage, or they invade 
 all alike. Bather more likeness to the perforating 
 ulcers may at first appear in cases of small abscesses 
 which form between the mucous membrane and 
 the cartilage of the septum. With these the portion 
 of cartilage beneath the pus may be softened or 
 ulcerated ; and it may be perforated when similar 
 circumscribed abscesses form on both sides of it ; 
 but when the pus is discharged there does not, I 
 believe, follow any extension of ulceration in either 
 the cartilage or the mucous membrane, and they
 
 THE SEPTUM OF THE NOSE 55 
 
 heal, leaving only a small thin-edged opening in the 
 septum. 
 
 For the treatment of these cases of perforating 
 ulcer, that which is deemed generally appropriate 
 for scrofula may, I think, be relied on. Iron, with 
 or without iodide of potassium, good food, good 
 open-air and bright daylight ; and, locally, gentle 
 washing and clearing from crusts and adherent 
 mucus, and the occasional painting with strong 
 solutions of nitrate of silver.
 
 56 THE DETECTION OF ABSCESS 
 
 CHAPTEE VH 
 
 THE DETECTION OF ABSCESS 
 
 I SUPPOSE that no one who has had much practice 
 would deny that he has sometimes been mistaken in 
 the diagnosis of abscess ; has sometimes punctured 
 swellings, in the expectation of letting out pus, and 
 has found none ; and sometimes failed to find it 
 where it certainly was. The general accepted means 
 for the diagnosis are many and well known ; they 
 are told in all surgical text-books, and are often 
 asked for in pass-examinations ; and yet, in some 
 cases, they are all, whether singly or together, in- 
 sufficient or misleading. I can remember more cases 
 proving this than I can find notes of ; but my notes 
 tell two or three things which may be useful to any 
 who can remember them, and may help them to be 
 less frequently mistaken than I have been. 
 
 Among these is the condition of ' central soften- 
 ing,' such as gives a feeling of softness or easy 
 yielding to pressure in some small portion of a
 
 THE DETECTION OF ABSCESS 57 
 
 swelling, or of any part of which the rest is firmer or 
 more tense than is natural. The softness is usually 
 central; but, when the swelling or the increased 
 firmness or tension is extensive, it may be at one or 
 more places distant from the centre. Of course, if 
 the softened part is raised or ' points,' the diagnosis 
 may be easy ; but the cases I have in mind are those 
 in which there is no such change of level, even 
 though the integuments be ruddy or mottled. 
 
 The most frequent examples of such softening 
 and these are well known are in suppurating lymph- 
 glands, especially the scrofulous, in which, as the 
 finger is drawn with uniform steady pressure over 
 one that is swollen, it sinks in at a soft place sur- 
 rounded by more or less of the firmer gland-sub- 
 stance. Of course, if the gland is manifestly inflamed, 
 the evidence of suppuration is more sure ; and it is 
 still more so if the central softened part is distinctly 
 more sensitive than that around it. But well-marked 
 central softening in an enlarged lymph may alone 
 suffice. It is due, I suppose, to the fact that suppu- 
 ration, like many other processes of degeneration, is 
 apt to begin at the parts farthest from the free sup- 
 ply of blood ; and this is, probably, the more likely 
 to happen when the disease is in any measure tuber- 
 culous. The softening and the formation of pus 
 gradually extend to the circumference till the whole
 
 58 THE DETECTION OF ABSCESS 
 
 gland-substance is replaced by pus ; and now there 
 may be a feeling of fluctuation, the quantity of fluid 
 being sufficient for undulations from side to side 
 wide enough to be felt by two fingers ; but this is 
 not possible at the beginning, and should not be 
 waited for ; the central softening must be detected 
 with one finger, and is enough to justify puncture, 
 incision, scraping, or any other operation that in 
 each case may be deemed best. 
 
 Few signs of suppuration are more characteristic 
 than this. Only, in the case of inflamed clusters of 
 lymph-glands, let care be taken to distinguish cen- 
 tral softenings from soft interspaces between the 
 glands. 
 
 Other good examples of this help to diagnosis are 
 in many abscesses in the perineum and near the anus. 
 In either of these places a soft spot in or near the 
 centre of an induration, especially if it be distinctly 
 painful on pressure, will always justify puncture. 
 The softening may be the more significant in these 
 cases because of the probability that many of these 
 abscesses are associated with tuberculosis. It is often 
 well marked in small abscesses near the anus ; they 
 feel like those which are common on the faces of 
 children ; beginning like boils, very slowly softening 
 and suppurating, and slowly healing after discharge. 
 And the likeness to tuberculous suppuration is the
 
 THE DETECTION OF ABSCESS 59 
 
 greater for the frequency with which these abscesses 
 tend to spread in branches or narrow tracks round 
 the anus or in the perineum, and not rarely open into 
 the rectum or the urethra. It is thus, I think, that 
 the majority of the rectal fistulse in children are 
 formed. 
 
 Similarly, this central softness may often suffice 
 for the diagnosis of swellings on the lower jaw, and 
 generally of periosteal swellings. They may look like 
 small sarcomata, but the pressure of the finger may 
 detect safe evidence of abscess in some soft and 
 tender spot. And the same test may often be used 
 for the diagnosis of hard swellings of the epididymis. 
 
 I have found great help from this sign in some 
 rare cases of abscesses very deeply placed, which 
 had made their way to the skin by narrow channels 
 through muscle and fascia. In one case, a gentle- 
 man had on the middle of his left buttock a patch of 
 firm brawny integument, three or four inches in 
 diameter, which gradually became dusky red and 
 pink, and over-hot. There was nothing to indicate 
 clearly what this condition of the integument was 
 connected with, but in about ten days a small por- 
 tion at its centre became soft, sinking under the pres- 
 sure of the finger, not upraised or pointing. I punc- 
 tured it, and a little serous pus escaped, and then I 
 found a track many inches deep, passing through the
 
 60 THE DETECTION OF ABSCESS 
 
 glutei into the cavity of the pelvis, probably into the 
 hollow of the sacrum. The discharge after this punc- 
 ture became so abundant as to make it clear that 
 a large abscess had thus discharged through a de- 
 vious track. In time, I believe, the track completely 
 closed. 
 
 Similar discharges through the nates may some- 
 times be observed in cases of diseases of the hip-joint 
 when all urgent symptoms have passed by, and when 
 there are no openings nearer to the joint. What is 
 sometimes called ' shirt-stud abscess ' may illustrate 
 a similar condition in the breast. Pus is formed and 
 collected behind the mammary gland, and is indicated 
 externally by a brawny patch on the integument of 
 the front of the breast. This softens at or near its 
 centre, and, being punctured, a large quantity of 
 pus may flow through a canal traversing the whole 
 substance of the gland. Similar conditions may be 
 observed in some cases of deep subfascial abscess. 1 
 
 On the whole, I think that this sign of central 
 softening is less fallacious and less often imitated 
 
 1 As I am writing of far-tracking abscesses, I may as well say that 
 I have notes of a case in which what was deemed a pelvic abscess in a 
 man opened behind high up in the rectum and, in front, at the reflection 
 of the prepuce on the glans penis. Small puffs of air with fsecal odour 
 used to pass out under the prepuce, and the minute hole, through 
 which they escaped, led to a small canal along the healthy-looking 
 dorsum of the penis and under the symphysis pubis. The case had 
 been in this state for a long time, and I do not know how it ended.
 
 THE DETECTION OF ABSCESS 61 
 
 than any other of the usual signs of abscess ; even 
 less often than fluctuation. The best coincident and 
 confirmatory signs are an oedematous or brawny state 
 of the integument, pain or tenderness on pressure 
 on the soft spot, and its remaining for a few seconds 
 after the pressure pitted or depressed as if the tissues 
 were oedematous. 
 
 The imitations of the fluctuation, which is the 
 sign of abscess always felt for, may be found in many 
 instances of collections of fluid, as in cysts, enlarged 
 bursse, and many more ; and if there be not, or have 
 not been, some signs of inflammation the doubt 
 may remain. And very often, though this doubt 
 may not be settled by the mere to-and-fro movement 
 of the fluid, it may be by the general softening, or 
 the flushed or mottled colouring of the skin over 
 it, or by the greater firmness of the surrounding 
 parts. 
 
 But the more puzzling cases are among those of 
 what may be called ' soft oedema ; ' an oedema which 
 is found in softened, wasted, loose-skinned parts, as 
 at an ankle, or the back of a hand, or a thigh, where 
 there has been acute inflammation which has sub- 
 sided. The tissues in these cases are usually so 
 softened by the inflammation that they can scarcely 
 restrain the movement of the fluid with which they
 
 62 THE DETECTION OF ABSCESS 
 
 are soaked ; it moves to and fro as the fingers press 
 it, and closely imitates a real fluctuation. Similar 
 imitation is found in cases in which very soft pulpy 
 synovial membrane is protruded at the parts of 
 scrofulous joints which are least firmly bounded by 
 tough fibrous structures. And, again, it is found in 
 the feeling of soft wasted fat on the nates of those 
 who have been long bed-ridden, 
 
 In all these cases of suspected suppuration in 
 limbs, the to-and-fro movement like fluctuation is 
 always more deceptive when the alternate pressures 
 made for its detection are made transversely or 
 across the axis of the limb. Transverse pressure 
 for diagnosis of nearly every disease should always 
 be tested by longitudinal pressure, and if they do not 
 agree, the longitudinal should be deemed the more 
 trustworthy of the two. 
 
 This test, with all others, needs to be carefully 
 applied for the diagnosis of abscess from the softer 
 kinds of tumours, especially the deep-seated, soft, and 
 cystic sarcomata. Among these, indeed, may be 
 found, I think, the most difficult of all the diagnoses 
 that depend chiefly on the sense of touch, and they 
 should impel everyone who is to practise to culti- 
 vate that sense to the highest possible degree ; even 
 as the skilled pianist does, or the skilful silk-buyer, 
 or as one who is blind and learns to distinguish by
 
 THE DETECTION OF ABSCESS 63 
 
 the touch the colours of the worsteds with which 
 she works. 
 
 I have said little or nothing of the general or 
 constitutional signs of suppuration, for in the great 
 majority of such cases as I have referred to they are 
 absent or are little to be relied on. Of course they 
 should always be asked for, and their presence may 
 not rarely be decisive ; but their absence in cases in 
 which they might be fully expected is not decisive. 
 Cases occur in which abscesses, such as, for the swift- 
 ness of their formation, might justly be called acute, 
 have more of the characters of those that are called 
 chronic or cold. I have notes of such cases in which 
 I think there was no probability that the abscess had 
 existed long before it was observed. 
 
 One of the most marked of these cases was in a 
 man fifty-two years old, who was in St. Bartholomew's. 
 He considered himself healthy and fit for his work 
 as an engineer, though he had tubercular syphilitic 
 eruption and, probably, chronic pulmonary tuber- 
 culosis. He came only on account of a large swell- 
 ing situated partly below the left scapula, partly 
 between that bone and the walls of the chest, and 
 thence extending into the axilla. It was smoothly 
 rounded, measured from ten to twelve inches over 
 its surface, was painless, soft, fluctuating, ' bagging '
 
 64 THE DETECTION OF ABSCESS 
 
 hither and thither in changes of posture or under 
 hand-pressure. It lay under the serratus and 
 latissimus dorsi muscles, but both these and the skin 
 over it appeared healthy, and there was no surround- 
 ing induration. 
 
 The patient had not been aware of anything 
 wrong at or near the seat of this swelling till three 
 weeks before his admission, when suddenly he found 
 himself unable to pick something from the ground. 
 Then he found the swelling ' as big as his fist,' and 
 was sure it could not have existed more than a few 
 days. He could not suggest any cause for it unless 
 it were that just before he found it he had slept for 
 an hour with his shoulder against the engine-boiler, 
 which was as hot as his hand could well bear. But 
 he continued at work after finding the swelling, and 
 it increased regularly and without pain. 
 
 On puncture this abscess discharged a large 
 quantity of thin pus, like that of an ordinary * chronic 
 abscess,' and it was slowly healing, without pain or 
 general disturbance, when the patient was obliged 
 to leave the hospital. Three years later he died 
 with phthisis. 
 
 In another direction of misguidance the signs 
 of acute abscess, which may be absent from one 
 quickly formed, may be present when cancerous 
 or sarcomatous tumours are rapidly softened, but
 
 THE DETECTION OF ABSCESS 
 
 65 
 
 not with suppuration. I observed such a case in 
 a lady who had intense shiverings, sweatings, and 
 high temperatures, and had pain, with increase, 
 softening, and a feeling of fluctuation and tender- 
 ness in some large swellings in the liver. The 
 propriety of puncture was discussed in consultation, 
 but death seemed too imminent, and after death the 
 disease was found to be cancer in large masses soft 
 and creamy. 
 
 I have once seen similar events in a case of 
 acute cervical lymphadenoma, and here the imita- 
 tion was that of the central softening in the 
 acute inflammation of diseased glands. It com- 
 pletely deceived me but, happily, puncture did 
 no harm. 
 
 And here I may mention two groups of cases in 
 which, though there may be no doubt as to the 
 existence of abscess, it is well to be cautious in 
 foretelling what will follow its discharge. The one 
 group is that of syphilitic gummata, especially of those_ 
 
 that form in muscles ; they sometimes suppurate, and 
 the event is sometimes a relief from the suspicion of 
 sarcoma ; but it is not commonly followed by com- 
 plete recovery, unless after long treatment. The 
 other group is that of obscure diseases in the 
 abdomen, with or without a feeling of something 
 
 F
 
 CO THE DETECTION OF ABSCESS 
 
 suggesting cancerous disease in the cavity or tlie ab- 
 dominal walls. Abscess may form in the walls, and 
 is often thought to be a happy event, but very com- 
 monly there is cancerous disease behind or beneath 
 it. Few cases lead more often than these do to erro- 
 neous forecasts.
 
 CHAPTEE VIII 
 
 ERRORS IN THE CHRONOMETRY OF LIFE 
 
 I HAVE often found reason to believe that, in the 
 study of pathology, we do not sufficiently consider 
 how much of disease or of its variations may be 
 due to disturbance of the time-rate at which the 
 organic processes should be discharged. And I 
 think this may be because too little thought is be- 
 stowed on the law that all the processes of organic 
 life are regulated as strictly in regard to the time 
 in which their work is to be done as they are in 
 regard to the quantity of material employed in them 
 or the size and shape of any structure formed by 
 them. We are too apt to forget that there is a 
 Chronometry in Life as well as a Chemistry or a 
 Mechanics. 
 
 I venture, therefore, to reprint a condensed 
 report of a lecture which I gave at the Eoyal Insti- 
 tution some thirty years ago. It may make some 
 more ready to study the errors of chronometry in 
 disease if they are in the habit of thinking of the 
 
 v 2
 
 58 ERRORS IX THE CHRONOMETRY OF LIFE 
 
 exactness with which rates of time are, in all living 
 creatures, observed in health. It is, indeed, very 
 difficult to determine, in any case of disease, how 
 much may be due to chronometric errors, and how 
 much to other errors or defects ; and nothing might 
 show this better that some of the notes in my case- 
 books. Still, it is certain that errors in the time-rates 
 which should be observed in all parts of the body 
 are frequent, and that the study of them may be very 
 useful. 
 
 The following abstract of the lecture is copied 
 from that which was published in the Eeport of the 
 Royal Institution, Weekly Evening Meeting, Friday, 
 April 8, 1859. A complete report of the lecture 
 might have been more easy to read, but I was not 
 able to write one. And I may as well add that the 
 lecture was delivered to a mixed audience, not to a 
 medical one. 
 
 The design of the discourse was to illustrate the law that 
 the processes of organic life are regulated with a regard to 
 time, as exact as that which is observed by them in respect 
 of size and weight and quantity of material employed in 
 them ; and to show that such an observance of time is charac- 
 teristic of life, depending essentially on properties inherent 
 in the living bodies themselves, and not on conditions external 
 to them. 
 
 Laws indicating the limitation of the organic formative 
 processes, in respect of quantity, are evident in the facts that,
 
 ERRORS IX THE CIIROXOMETRY OF LIFE 69 
 
 in the ordinary conditions in which each living being is 
 found, it and all its parts have appropriate size and weight 
 and mutual proportion. These may, indeed, be modified by 
 the variations of external conditions, or by events that are of 
 the nature of accidents : but the range of possible variations 
 is, in nearly all cases, comparatively narrow ; and the boun- 
 daries are soon reached in which changes of external condi- 
 tions become incompatible with life. 
 
 An instance of a corresponding limitation of the organic 
 processes in regard to time might be noted in the natural 
 duration of each creature's life. It is, indeed, not possible 
 to assign any exact number of hours, days, or years, as the 
 constant limit of life in any species ; but it is enough to 
 prove a law of time, as limiting the total duration of the 
 organic processes in each, when we see that, in man, and 
 in other species, the length of life, when not diminished by 
 disease or violence, is as fixed as the natural weight or 
 stature is, and that the term of life is marked by changes 
 whose source is inherent in the living body. Watching 
 these changes in the senile degenerations of the human body, 
 it is evident that life does not cease, naturally, because of 
 any change in the external conditions of living ; and that 
 the body is not, with advancing years, gradually worn out, 
 as if there were a gradual consumption of a store of material 
 or of force ; but that as, at a set time, the development of 
 the body ceases and growth goes on, and then growth ceases 
 and the body is only maintained in its perfection, so, after 
 a time of such maintenance, the method of the formative 
 processes in the body changes, it slowly degenerates, and 
 through degeneracy dies. And all these stages are, alike, 
 natural, constant, timely ; all, too, are together, character- 
 istic of life ; there is no such succession of events to be traced 
 in any form of dead matter.
 
 70 ERRORS IX THE CIIRONOMETRY OF LIFE 
 
 Observance of time may, again, be noted in the forma- 
 tive processes concerned in any of the organs whose changes 
 mark the divisions of a life into its chief periods ; e.g., in 
 the teeth. Considering merely the conditions in which the 
 teeth of the first set are placed before they project from the 
 gums, there appears no reason why one should be cut before 
 the other, or why they should not all grow with equal speed. 
 Yet while they all grow alike in regard of structure and 
 composition, they have very different rules in regard to the 
 time-rate of their formation. And a yet more marked 
 instance of time-regulation is in the contrast of the teeth of 
 the first set with those of the second. In all essential charac- 
 ters, except those of strength and size, the two sets are much 
 alike ; yet there is the widest difference in the rates at which 
 they are formed, and in their duration. The second teeth 
 require as many years for their formation as the first require 
 months ; the first live but a few years, the second should live 
 as long as the rest of the body, and sometimes do so. Now 
 there appears nothing to which, as to an efficient cause, this 
 difference can be referred. Its utility and final cause can ba 
 discerned ; but, as to that which verily determines the rates 
 of growth, and the durations of the teeth, it can only be 
 referred to a First Cause ; or it may be said, as of other 
 things subordinate to a First Cause, that it depends on 
 some of those properties which each living being inherits 
 from its parents, and through which it results that, in respect 
 of time, as well as of method and quantity, the formative 
 processes in the offspring are a repetition of those of the 
 parent. 
 
 The observation of the development and changes of the 
 teeth affords, moreover, an excellent instance of the punc- 
 tuality with which time-work is regulated in the organic 
 processes, and of the manner in which several different, and
 
 ERRORS IN THE OIIROXOMETRY OF LIFE 71 
 
 really independent, processes, being set to the same time- 
 rate, are made to co-operate to the end of utility in the 
 economy. This is evident in the coincidence of the develop- 
 ment of the teeth of the second set, with the removal of those 
 of the first ; and in the coincident growth of the jaw and 
 all its muscles and other apparatus for mastication. In all 
 of these (and the same might be said of any other system 
 of organs in any species) the formation of every part is 
 achieved with an admeasurement of time as precise, and as 
 perfectly designed, as that of its shape, or size, or structure. 
 
 For examples of organic processes, adjusted to be com- 
 plete in definite periods of time, the germination of seeds, 
 and the hatching of eggs, could be cited. In plants, and in 
 cold-blooded animals, the time varies according to tempera- 
 ture, yet not without evidence of a proper time-rate ; but 
 among birds, each species has its own time for incubation, as 
 fixed as its other specific characters. In other words, the 
 development of the structures of an egg into those of a young 
 bird, appropriately fitted for life in the open air, is timed to 
 a certain rate of progress ; so much work is to be done in so 
 many days, neither more nor less : and on each day its appro- 
 priate and special portion of the work. And it is evident 
 that the time occupied in the process is determined by the 
 inherent properties of the egg itself. For if the eggs of any 
 number of species be exposed to the same heat and other 
 conditions in a hatching machine, then, as surely as the bird 
 produced from each will be like its parents, so surely will it 
 be hatched in the same time as its parents were ; in other 
 words, the observance of a specific time-rate in the process 
 of development is as exact as that of any other specific 
 character. 
 
 With this observance of time in the development of the 
 young might be noticed that which is, commonly, coincident
 
 72 ERRORS IN THE CHRONOMETRY OF LIFE 
 
 in the parent. Not to cite the example of all the mammalia, 
 that of pigeons might be taken, in which, during the incuba- 
 tion of their eggs, the crops of the parents are remarkably 
 developed, so that they may be fitted for the secretion of a 
 fluid destined to make the food of their young offspring more 
 suited for their sustenance. The correspondence of these 
 time-rates, observed, at once, in the development of the young 
 pigeons, and in that of the crops of the parents, demonstrates, 
 in both, a division for chronometry in their organic processes, 
 as clearly as the faces of two clocks, constantly keeping time 
 together, would prove that they both have some apparatus 
 for chronometry within. 
 
 Further, the provisions made by parents for their future 
 young afford evidence of the time-regulation of organic pro- 
 cesses, in so far as those provisions seem to indicate a reckon- 
 ing of the time necessary for their completion. For example, 
 certain turtles lay their eggs in hollows made in the sand, 
 leave them there to be hatched, and at the time of hatching 
 return to them for the sake of their young. It might be 
 asked, how can these creatures, and many others in similar 
 cases, reckon the passage of time ? Most probably, they do 
 not reckon it at all ; but just as the timely attained fitness 
 of their organisation for preparing and filling their nests 
 impelled them to those acts, so some time-regulated organic 
 processes, taking place in them after the laying of their eggs, 
 bring-about at length a new condition, of which a dim con- 
 sciousness becomes an impulse to them to return to their 
 nests. Such an explanation would involve little guesswork ; 
 for changed organisation is, manifestly, often the source of 
 impulse to instinctive actions, and the parental organisation 
 does commonly change at a rate commensurate with that of 
 the development of the offspring. And a similar reference 
 to chronometric processes in the body might explain many,
 
 EHK011S IX THE CHRONOMETRY OF LIFE 73 
 
 though probably not all, other instances in which animals 
 seem to have a power of reckoning the passage of time. 
 
 The phenomena of disease, especially in fevers, agues, the 
 consequences of injuries, and many cutaneous eruptions, 
 would afford abundant instances of the observance of time in 
 the organic processes. The vaccine disease might be gene- 
 rally watched as an illustration, being characterised by a 
 vesicle at each place of insertion of the virus, which vesicle 
 begins to appear on the third day, and on the following days 
 passes through changes which are as exactly regulated in 
 time as they are in visible characters. The changes in this 
 vesicle are, moreover, indicative of a coincident succession of 
 events in, or produced by, the virus inserted, which, in the 
 blood of the vaccinated person, increases, and, incorporating 
 itself in the vesicle, reaches its highest development and 
 greatest inoculating power on the eighth day, and then 
 degenerates. 
 
 The vaccine might, in most essential points, be regarded 
 as a type of morbid poisons, i.e., of such as are the products 
 of disease. Whether inserted in the blood by inoculation, or 
 bred therein, they commonly occupy definite periods of time 
 in their development, and increase, and decline ; as with a 
 life which is chronometric in all its phases and in its total 
 length. 
 
 The instances of morbid poisons would supply examples 
 of organic processes timed to various numbers of days ; and 
 many that are completed in a day, or in given portions of a 
 day, are traceable in the events of sleep and waking in animals 
 (and, perhaps, also in plants), in the daily variations of the 
 pulse, and of breathing, the returns of hunger and thirst, the 
 regulated times of the digestive functions, &c. In man, in- 
 deed, consciousness and will are so concerned in some of these 
 functions, that they may seem to lack that regularity which
 
 71 ERRORS IX THE CIIROXOUETRY OF LIFE 
 
 belongs to merely organic processes ; but, if studied generally, 
 and in other species as well as man, they all tell of such pro- 
 cesses accomplished with regular measurement of time, and 
 not determined by the external events or conditions of the 
 day or night. Thus, for sleep and waking, and the times of 
 hunger and thirst, man's independence in regard to day and 
 night, or light and darkness, and the habits of different species 
 whose times of activity are, severally, in the early or later 
 day, in twilight or at night, may prove that the earth's diur- 
 nal changes are not the causes of these diurnal peculiarities 
 of animal life. The very cause of sleep, and of that which is 
 yet more mysterious, waking, may be unknown ; but they 
 are evidently connected and correlated with those alternating 
 conditions of the structures, of which men, and probably all 
 animals that sleep and wake, are conscious in the sensations 
 of fatigue and of refreshment. The ordinary activities of one 
 portion of the twenty-four hours, the activities, especially, of 
 the muscles and nervous centres and the senses, produce an 
 amount of structural, or chemical, change which is exactly 
 repaired in rest during sleep. In other words, the organic 
 processes for the repair of structures changed (as all structures 
 are) by exercise, are adjusted to such a rate, that, in general, 
 and on an average, in the time of sleep, they may completely 
 restore the parts that are impaired in the activity of waking 
 time. And so, of that replacement of substances in the 
 several structures and in the blood, which is the purpose of 
 feeding ; the processes of digestion and of the several stages 
 of assimilation are so timed as to accord exactly with the 
 times of daily taking food. 
 
 The most minute observances of time in organic processes 
 might be noted in organs that have rhythmic motions, as in 
 hearts and breathing muscles, ciliae, the vacuoles of certain 
 zoospores, as Volvox and Gonium. In the Croonian Lecture
 
 ERRORS IX THE CHRONOMETRY OF LIFE 75 
 
 at the Royal Society, in 1857, ! the speaker had endeavoured 
 to prove that these and other rhythmic movements in plants, 
 as well as animals, are due to corresponding time-regulated 
 nutrition. He had expressed his belief that ' rhythmic motion 
 is an issue of rhythmic nutrition, i.e., of a method of nu- 
 trition, in which the acting parts are, at certain periods, 
 raised, with time-regulated progress, to a state of instability 
 of composition, from which they then decline, and in their 
 decline may change their shape and move with a definite 
 velocity, or (as nervous centres) may discharge nerve-force.' 2 
 And this would be still maintained; but whether it were 
 true or not, the rhythmical nutrition of rhythmically acting 
 muscles would be certain. If not a cause, it must be a con- 
 sequence of such acting ; for it is inconceivable that the heart 
 (for example) or the diaphragm, or any other rhythmic muscle, 
 
 1 Proceedings of the Royal Society, vol. viii. p. 473. 
 
 2 It seems well, now that the action of cardiac nerve-centres has 
 been more studied, to add that the reference of the rhythmic move- 
 ments to them does not tell how rhythm is really produced, for the 
 qiiestions remain, What determines rhythmic action in these nervous 
 centres ? how is the time -regulation determined for the discharges 
 of nerve -force which we believe induce the successive contractions of 
 the heart ? The time-work must be done first in really elemental 
 structures as it is in the simple pulsating hearts of embryos, mere 
 clusters of apparently simple cells, altering their forms with as well- 
 timed a rhythm as does the cornpletest mammalian heart. They 
 show, as do many other organs, that an exact chronometry may pre- 
 vail in changes quickly wrought in structures which, to our present 
 powers of sight, appear so simple that we call them elemental ; they 
 compel us to believe that in these elemental structures, these mere cells 
 or their contents, there are regulated chemical changes producing the 
 regular discharges of mechanical force which are manifested in their 
 changes of shape and the movement of the blood. And we may 
 believe that in the course of development the rhythmic action of the 
 muscular structures of the heart is subordinated to regulated changes 
 in the elemental structures of the cardiac nerve-centres ; the discharges 
 of force due to these changes being transmitted along the cardiac 
 nerves.
 
 76 ERRORS IX THE CHROXOMETRY OF LIFE 
 
 should be free from waste or impairment in its action, or 
 fi'om the necessity of being renovated in its rest. Difference 
 of mode of action could not determine a difference in the im- 
 mediate effect of action. With long exercise, muscles become 
 so changed that their changed state can be felt in the sensa- 
 tion of weariness, and proved by chemical analysis. But the 
 change thus proved is only the accumulation of the changes 
 wrought in many muscular actions, each of which has contri- 
 buted a share to the whole amount, just as each revolution of 
 a wheel contributes to the final wearing out. Similarly, every 
 action of the heart, or of the breathing muscles, is attended 
 with change or impairment of composition ; but the impair- 
 ment is repaired in the next following period of rest or relaxa- 
 tion. In other words, the alternating actions in shortening, 
 and rests in lengthening, of the muscular fibres are correlative 
 and synchronous with their alternating impairments and 
 repairs of composition. The chronometry of such organic 
 processes seems perfect; nutrition is in them divided, as it 
 were, into units ; and for each unit, there might be reckoned 
 a unit of time. 
 
 Two results of this constant maintenance of rhythmic 
 muscles are remarkable ; namely, the enormous power they 
 are capable of exerting, and their freedom from fatigue when 
 only naturally acting. The latter result is proved to depend 
 on the constant maintenance of the muscles, in their timely 
 intervals of rest, by the weariness which is produced in the 
 same muscles when they act otherwise than rhythmically, as 
 in the muscles of respiration when employed in any voluntary 
 movements, or in coughing or other violent respiratory acts. 
 
 The instances adduced thus far might supply examples of 
 organic processes adjusted to periods of time varying from 
 the length of human life to less than a second. They were 
 all examples of large classes of facts, from which might be
 
 ERRORS IX THE CIIRONOMETRY OF LIFE 77 
 
 filled up the instances of observance of other and very diverse 
 periods of time ; and in all of them, the time-rate is essen- 
 tially determined, not by external conditions (though these may, 
 in some measure, modify it) but by the inherent properties of 
 the organic bodies themselves. 
 
 In another large group of instances, those, namely, in 
 which vital processes are completed, or attain some climax, in 
 a year or in a set portion or season of a year, an independence 
 of external conditions appears less evident. The higher or- 
 ganisms, chiefly by reason of their having in themselves the 
 power of generating heat, may manifest their own time-laws 
 with comparatively little disturbance from without. But in 
 the vegetable world, and in the lower animals, the organic 
 processes are, for the most part, suspended during part of the 
 year, for want, chiefly, of the heat which is a necessary con- 
 dition of their activity, and the variations of which, for the 
 rest of the year, very greatly affect their rate. Yet even in 
 these, there appear sufficient indications that the times in 
 which the processes of organic life are accomplished depend, 
 essentially, on the specific properties of the several organisms 
 themselves. 
 
 Thus, under the same external conditions, each species 
 observes a proper rate of its own. All the plants, for example, 
 of a given locality are subject to the same temperature, and 
 other seasonal conditions ; but their rates of living, like those 
 of various eggs placed in the same heat, are different ; each 
 reaches the chief events of its life at a certain period of the 
 year. Variations of the seasons may affect all of them ; but 
 their method of succession is not thereby changed ; they ob- 
 serve the same proportions in the times severally required for 
 their organic processes ; and this unaltering proportion in- 
 dicates a time-rate specific for each, though equally variable 
 in all.
 
 78 ERRORS IX THE CIIROXOMETHY OF LIFE 
 
 Moreover, among plants, there are numerous examples of 
 varieties, which differ from the general characters of their 
 species only, or chiefly, in regard to the times at which their 
 vital processes are accomplished. Such are the variations 
 that are known as ' late,' and ' early,' among flowers or fruits ; 
 of which some may be propagated by seeds. [Specimens were 
 shown from two horse-chestnuts growing near to one another 
 by the great gate of the Kew Gardens, of which one is, every 
 year, three weeks earlier than the other, in all the processes 
 of its life ; and of varieties of Erythronium Dens Canis, from 
 the same gardens, the plants of which, growing side by side 
 in the same bed, always present a similar difference in their 
 times of flowering, &c., though in all other respects alike.] 
 It would be difficult to imagine a variety thus marked only 
 by a peculiarity in rate of living, if temperature, or the influ- 
 ence of the seasons, alone determined the rate of life in the 
 species. The simplest explanation seemed to be that, as there 
 may be varieties in size and number of organs, and almost all 
 those other properties of a species which together make up 
 its specific character, so there may be also varieties in regard 
 to that time-rate of the processes of organic life which, even 
 by this variability, is indicated as essentially dependent on 
 the properties of the organism itself. 
 
 Again, there are some species in which there seems to 
 exist a singular independence of external conditions. Instances 
 of this are found in the Eriogaster lanestris, and the other 
 moths mentioned by Kirby and Spence. If pupae, formed in 
 June or July, be ' selected of the same size, and exposed to the 
 same temperature, the greater number of them will disclose 
 the perfect insect in the February following ; some not till 
 the February of the year ensuing, and the remainder not 
 before the same month in the third year.' (Vol. iii. p. 264.) 
 The design of so singular an arrangement is, as they observe,
 
 ERKOIIS IX THE CIIKOXOMETRY OF LIFE 79 
 
 to secure that insects, coming into active life in February 
 or March, may not be utterly exterminated by the ungenial 
 weather of a single season, or of two such seasons in succes- 
 sion : but the very cause of the differences among the pupas, 
 in their relations to the same external conditions, must be in 
 their own properties. 
 
 A somewhat similar instance of apparent complete like- 
 ness among seeds in all respects except that of time, is in 
 those of a Begonia, which, if taken from the same pod, and 
 all planted together, and all kept in the same conditions, will 
 germinate, some in a day, some at the end of a year, and 
 some at various intermediate times. 
 
 To these indications of self-dependent time-rates in the 
 lower organisms, might be added all the facts of another 
 class, which show punctuality in the adjustment of several 
 distinct processes. Scarcely an event of life could be watched 
 which would not show it. 
 
 [The instance by which it was illustrated, was that of a 
 Saxifraga, whose stamens, like those of Parnassia, arrive at 
 their very maturity, not all together, but in pairs, and in 
 pairs bend upon the pistil, each pair rising again before 
 another pair bends down.] 
 
 And, lastly, the influence of temperature on the rate of 
 the formative processes in the lower organisms is scarcely, or 
 not always, greater than that of nutriment and other external 
 conditions, is on their quantity. The occurrence of ' good ' 
 and ' bad ' seasons indicates the latter influence, as that of 
 ' early ' and ' late ' seasons does the former. Plants of the 
 same species growing, some in an arid, others in a rich soil, 
 differ exceedingly in size ; the one are stunted, the others 
 exuberant ; here nutriment modifies the quantity of forma- 
 tion as, in other instances, varieties of heat will modify its 
 time-rate. But this being so, it may be held that as a cer-
 
 SO KKKORS IX THE CI1KOXOMETKY OF LIFK 
 
 tain average size or quantity of growth is a characteristic of 
 each species, and an issue of its very nature, so is a certain 
 average time or rate of growth. Quantity and rate may 
 alike be varied by external circumstances, but the standard 
 or medium of both, as well as the limits of variation com- 
 patible with life, are determined by the natural and inherent 
 properties of the species. 
 
 Whatever evidence these and the like facts might supply, 
 that, in connection with the seasons, the time-rates of the 
 organic processes in the lower organisms are essentially de- 
 pendent on the inherent properties of each organism, similar 
 evidence might be adduced for the case of the higher, and 
 especially the warm-blooded animals. In these the varieties 
 of seasons have less influence in modifying the time-rate, as 
 well as all the other measures, of life ; and the less influence, 
 the higher the species, or the degree 'of development of the 
 individual. Moreover, there are in birds' some instances in 
 which organic processes have a tendency to observe certain 
 times of the year even when the seasons are changed. Thus 
 among those brought from Australia to this country, some of 
 the parakeets breed here in December ; the black swan some- 
 times breeds in November as well as in May ; the New 
 Holland Cereopsis-goose has bred at the Zoological Gardens 
 every February for five or six years. 1 Among migratory 
 birds, also, it has been observed that when they are kept in 
 confinement, and removed from all the circumstances that 
 
 1 Mr. Sclater, to whom the speaker was indebted for this fact, 
 supplied also dates which tend to prove that the Australian parakeets, 
 in this country, breed less often in December than in the months from 
 May to September, inclusive ; but even a minority of instances of the 
 observance of times, and a general tendency towards it, when the force 
 of such external conditions as those of the seasons is strong against 
 it. is good evidence that inherent properties are the mainspriugs 
 determining the rates of life.
 
 ERRORS IX THE CIIROXOMETRY OF LIFE 81 
 
 might be supposed to induce or necessitate their journeys, 
 they yet become restless at the return of the season for their 
 migration. 
 
 In these and the like facts there appear indications of a 
 chronometry in the organic processes of warm-blooded ani- 
 mals, which corresponds with that of the seasons, but is 
 essentially independent. And, if it be so, these might form 
 a group of facts, in addition to those of the diurnal variations 
 of the organis processes, in which vital changes are set to the 
 same rules of time as changes of the surface of the earth, yet 
 have their own proper laws ; and concerning which it might 
 be said, that the cycles of life, and of the earth, do, indeed, 
 correspond, but only as concentric circles do, which are drawn 
 round one centre, but are not connected, except in design 
 and mutual fitness. 
 
 But, however this might be, all the instances of time- 
 regulation cited in the discourse (all being examples of large 
 groups of facts), would seem sufficient to prove, that the 
 observance of time in organic processes is as exact and as 
 universal as that of any other measure ; that each species has 
 a certain time-rate for the processes of its life, variable, but 
 not determined, by external conditions ; and that the several 
 phenomena commonly studied as the periodicities of organic 
 life, are only prominent instances of the law which it was 
 the object of the discourse to illustrate. 
 
 G
 
 Sl> ERRORS IX THE CIIROXOUETRY OF LIFE 
 
 Before speaking of the errors of chronometry in 
 relation to disease, I wish to point to the probability 
 that in many of the instances which I cited of the 
 observance of time in disease, the time-rates may 
 be determined chiefly by the events in the lives of 
 microbes, which were scarcely subjects of stud}' when 
 the lecture was given. 
 
 And I may suggest an inquiry, which I have 
 often wished that I could pursue, into the influence 
 of the variability of a time-rate, as of one of the 
 conditions on which may have depended the ' selec- 
 tion of species.' The subject was hardly within the 
 general range of study thirty years ago. 
 
 It is not difficult to imagine many terrestrial 
 events in which the ' survival of the fittest ' amono- 
 
 o 
 
 species or individuals might depend, chiefly, on the 
 possibility of adjustment of a time-rate in one or 
 more processes. In the ordinary course of nature 
 the time-rates in each creature are adjusted to those 
 of the external conditions most necessary to its life. 
 The development and hatching of the young pigeon 
 keep time with the development of its parent's 
 crop ; the development of the mammalian foetus with 
 that of the mother's mammary glands. Such adapted
 
 ERRORS IN THE CIIROXOMETRY OF LIFE 83 
 
 changes in parents for the sake of their offspring are 
 everywhere to be seen ; and so are the instances in 
 which the developments of animals of all kinds keep 
 time with those of the plants or other animals on 
 which they live. 
 
 It is hardly too much to say that the whole 
 course of nature among living things thus depends 
 on their mutual adjustment in time as well as in all 
 the other conditions of their lives. And if this be 
 so, then, any alteration of the time-rate of life in 
 any species might gravely affect its fitness for an un- 
 changing environment, or might lead to the natural 
 selection of a few of the species whose differences 
 from the rest would be transmitted to some of their 
 offspring. Or, in the other direction, a considerable 
 change in the time-rates of any of those things such 
 as a vegetable or other food on which a species 
 depends for its continuance, might lead to the extinc- 
 tion of that species, unless the time-rates of some of 
 its members and their offspring could be adjusted to 
 the change. It cannot reasonably be supposed that 
 the time-rate is the only characteristic of the pro- 
 cesses of life which is not liable to variation ; the 
 ' late ' and the ' early ' varieties of a species are 
 instances of its occurrence ; and whenever a change 
 of time-rate occurs there must arise an opportunity 
 for 'natural selection,' just as there does on the 
 
 G 2
 
 84 ERRORS IX THE CIIROXOMETRY OF LIFE 
 
 occurrence of any variation in the form of a limb 
 or of any other part. 
 
 But I can only wish that I could work at this : it 
 is too far beyond the range of both my knowledge 
 and my opportunities. I commend it to younger 
 and more learned students of evolution. 
 
 This subject of chronometry in life has, naturally, 
 been very often in my mind, and facts illustrating it 
 have often seemed as if they might be arranged in 
 some systematic manner useful for the evidence of 
 general principles in physiology. Through want of 
 ability or want of time I have been unable to do 
 this ; but I may mention one instance in which the 
 time observed in processes in living structures may 
 show a general principle which, I think, can hardly 
 otherwise be established, namely, that none of what 
 we may regard as the component parts of any or- 
 ganised structure are exactly alike. For example, 
 no two or more minute structures can appear more 
 exactly alike than do the adjoining cells of a leaf; yet, 
 if we watch them in the unfolding or other expansion 
 of the leaf, they do not all at the same time attain 
 the same size or the same colour ; and yet more 
 evidently in their decay, we see the yellow or other 
 tint gradually extending in different shades of inten- 
 sity from one part to another of the same leaf. The
 
 EltllORS IX THE C1IUOXOMETI1Y OF LIFE 85 
 
 external conditions of the whole leaf may be the 
 same : if all or any of its cells were exactly alike, they 
 would pass through changes of colour in exactly the 
 same time ; but they do not so change unless, per- 
 haps, it be the cells placed in exact symmetry on two 
 parts of the leaf. Now, the fact that different lengths 
 or periods of time are required for producing similar 
 changes in two or more structures, is sure evidence 
 that those structures are not exactly alike. I know 
 no other test than this that could detect a difference 
 among, say, the cells most near to one another. 
 
 Similar illustrations may be found in so many 
 structures for instance, in two parts of the same 
 tooth, the same hair, the same cornea that I think 
 the rule may be deemed general and constant ; and 
 it may be useful to bear it in mind as evidence of 
 differences among structures in which no difference 
 can be detected by even the finest chemical or physi- 
 cal test yet within our power. It is often said that 
 no two cases of disease are alike ; we cannot expect 
 them to be so if no two elementary structures in the 
 same person are.
 
 86 ERRORS IN THE CHROXOMETI1Y OF LIFE 
 
 The errors of clironometry unpunctualities in 
 life, as they may be called may be studied in two 
 different, though often mingled, forms. In one, an 
 unusual time-rate is maintained in all parts, or, at 
 least, in all important parts, but is maintained alike 
 and uniformly in all ; in the other the time-rate is 
 erroneous in only one or a few parts. To use an 
 illustration from what may happen in an orchestra, 
 in the one case the error is like that of music which 
 is played too fast or too slow, but in which all the 
 musicians keep the same time ; the music is not good, 
 but there is no discord. In the other case it is like 
 the music in which one or more of the musicians 
 play too fast or too slow, and are as constant sources 
 of discord as if their instruments were out of tune. 
 
 The most frequent and obvious instances of the 
 first class in which the time-rate is erroneous, but is 
 uniform in all parts, may be observed in the earlier 
 and in the later periods of life. It is matter of com- 
 mon observation that some young people look older 
 and some look younger than they are, and the former 
 are generally deemed stronger and healthier than the 
 latter. In later life, also, some people look older and 
 some look younger than they are ; but the judgment
 
 KI;I;OI;S IN Tin: CIIIIONO.MKTIJY OF LIFE 87 
 
 is reversed, and the latter are deemed stronger and 
 healthier than the former. The judgments are so 
 often right that one is often prone to think that looks 
 are better evidence of the probabilities of life than 
 are the registers of births ; for a register can only tell 
 the time since birth, but looks i.e., the appearance 
 not only of the features in the face but of the size, 
 shape, and manner can often indicate accurately 
 the rate at which the vital processes have been 
 carried-on, and at which they may be moving to 
 their end. 
 
 But, although this may be generally true, there 
 are very many exceptions to the rule, and it may be 
 that in this as in all pathology, more truth may issue 
 from the study of exceptions than from the ready 
 acceptance of general rules. 
 
 The young persons who look older than they are, 
 and who have had in all their structures more than 
 the mean time-rate of development and growth, are 
 usually healthy and potent in resistance of disease, 
 but exceptions are not rare ; scrofula may be seen 
 well marked in some whose stature, muscular power, 
 and sexual development are three or four years in 
 advance of the mean at their registered ages. Still, 
 if there be no evident marks of defective health, they 
 who, when they are less than twenty, look older than 
 they are, may be deemed healthy above the average.
 
 88 i:i;i!(;i:s ix THE CIIRONOMKTKY OF LIFE 
 
 I think that the greater time-rate does not, in this 
 class, continue in later life ; that they are not com- 
 monly among those who at all ages, especially when 
 in or near old age, look older than they are. But 
 this needs more accurate inquiry. 
 
 On the other hand a large majority of those young 
 persons who look much younger than they are, are 
 weakly and have what is called delicate health. 
 Some are evidently scrofulous, having clear signs of 
 such diseases of the glands, or joints, or other parts ; 
 and some are as evidently syphilitic by inheritance, 
 or rickety ; and many more, though not plainly 
 thus diseased, are certainly prone to scrofula, tuber- 
 culosis, acute rheumatism, and other diseases of this 
 class. They have large tonsils, granular pharynx, 
 swollen nasal mucous membrane, and other minor 
 signs of such diseases. Thus, together with their chro- 
 nometric errors, they have coincident or, perhaps, in 
 some measure, consequent errors of structure or com- 
 position in this or that part or group of parts. 
 
 It may seem probable that the ' delicacy ' of the 
 young who look younger is generally due to this 
 qualitative error rather than to the error in their 
 time-rate. For in a numerous minority of them there 
 is no such delicacy ; all their functions are discharged 
 in right mutual adjustment, and in quantity befitting 
 their apparent, though not their registered, age ; and
 
 ERRORS IN THE CIIRONOMETRY OF LIFE 80 
 
 after what may seem a long time they acquire a manly, 
 robust health and full power, though rarely a full 
 stature. Still, it is very often useful when elderly or 
 old people are ill, especially if they are ill with ob- 
 scure chronic disease, to ask them about their looks 
 in early life. Facts helping to a right diagnosis may 
 often be thus learned ; many of the subjects of senile 
 scrofula will tell that they were small and delicate 
 while young, though not evidently unhealthy, and 
 that after their youth they were hearty and strong- 
 till their old age began. They may be examples of 
 a second childishness in bodily though not in mental 
 defect. 
 
 I have often tried, but often in vain, to learn the 
 conditions which have retarded the time-rate of 
 development and growth in the young. I have not 
 found that the health, good or bad, of parents has 
 any clear influence on the time-rate of their children 
 in early life, nor that the children of the old are 
 different in this respect from those of the younger. 
 Yet various time-rates are often characteristic of 
 families, and examples may easily be found of two 
 or more families in the same conditions of life, and 
 equally good general health, in which the young 
 people of one family look much younger than those 
 of the same ages in the other, and are really younger 
 in all reckonings but that of the times since birth. I
 
 90 ERRORS IX THE CIIHONOMETRY OF LIFE 
 
 have notes of an example of eight children of the 
 same family living to middle age, small and always 
 looking young, and with one exception always 
 healthy. Their parents, this exceptional one told me, 
 ' looked their age/ 
 
 The most frequent cause of delayed growth, when 
 any cause for it can be assigned, is an acute illness, 
 such as scarlet fever, diphtheria, or whooping cough. 
 Mr. Galton 1 relates a striking instance of retarded 
 growth of children's heads during and for a time 
 after each of their occasional illnesses. A less con- 
 siderable fact is in the checked growth of the nails 
 during illness.' 2 Mr. Galton's fact was ascertained 
 by very careful measurements. Often, though less 
 accurately, one sees that after apparently complete 
 recovery from scarlet fever, pneumonia, whooping 
 cough, or other acute illness in early life, growth is so 
 retarded that two, three, or more years seem to have 
 been lost, and young people of fifteen or eighteen 
 look, and are, as if not more than twelve or fourteen 
 years old. They may be, for their apparent age, 
 quite healthy, but more often they are not, and they 
 
 1 Inquiries into Human Faculties, p. 235. I have heard also from 
 Mr. Galton that, in the growth of cereal crops, a check at any period 
 of their progress is followed by long-continued delay in growth, 
 imitating the consequence of an acute illness. 
 
 2 Dr. "Wilkes has related a case in which this occurred in the sea- 
 sickness of two voyages across the Atlantic of only seven or eight 
 days each.
 
 ERRORS IN THE CHRONOMETRY OF LIFE 91 
 
 are among those who will prove the value of a general 
 rule in both practice and education, that both lessons 
 and the rules of living should be adjusted to the 
 apparent rather than to the registered age. 
 
 It is often said that during and after acute illness 
 some young people increase in height very rapidly. 
 This may be true, but I think that such growth in 
 height is seldom, if ever, associated with equivalent 
 growth and development of organs whose size is more 
 important than is the length of the lower limbs and 
 spine. Length thus attained is not significant of high 
 development ; 1 it may no more be so than is that 
 strange increase of fatness sometimes occurring in 
 young people after illness. I have seen this espe- 
 cially in some when convalescent after acute scrofu- 
 lous joint-disease ; they have become big, round, fat, 
 and dull, yet they looked too young. 
 
 What is true of these general illnesses in respect 
 of the general time-rate may be true of the influence 
 of local disease or severe injury on the time-rate of 
 
 1 I say ' thus attained ' because more generally stature and 
 development may seem in some measure correlative. Mr. Roberts 
 (Report of the Anthropological Committee of the British Association, 
 1883) reports that, ' Compared with the general [adult] population, 
 lunatics show a deficiency of stature of 1'9G inch, and of weight of 
 10-3 pounds, and criminals of 2-06 inches and 17*8 pounds.' Nation- 
 ality also must here be taken into account. ' In this country shortness 
 and lightness are deemed signs of degeneracy; in America and the 
 older Australian colonies excess of stature is so regarded.' Roberts, 
 St. George's Hospital Beports, vol. viii. 1874-6.
 
 92 KRHOKS IX THE CHROXOMETRY OF LIFE 
 
 the one part affected : it may be made or may become 
 comparatively old or young ; almost certainly it \s ill 
 be out of time, as well as out of harmony, in structure. 
 And, as all parts do not grow at the same rate at all 
 times, so various disproportions may be determined 
 in different persons by the time in early life in which 
 any general illness may have occurred. 
 
 A slow time-rate is often observed in children 
 who were prematurely born. They seem behind 
 time till their growth is nearly complete, but some of 
 these continue to grow longer than usual, and some 
 attain, in time, great stature. 
 
 The foregoing facts relate chiefly to delayed 
 growth, and it is, of course, in early life that such 
 chronometric errors are most frequent ; but delays, or 
 slow time-rates, may also be noted in later years. 
 Then, the looking young, in which is often expressed 
 the fact of being comparatively young in all but years, 
 is probably due to slowness in the degenerative pro- 
 cesses of life ; and we may fairly guess that this may 
 also explain the many instances of great longevity in 
 persons who, when they are very old, say that they 
 never were strong, never vigorous in health. Their 
 whole time-rate has been slow, and they have, there- 
 fore, lived long ; as among several clocks of similar 
 construction, those which go slowest will go longest. 
 The contrast with these may be found in some
 
 ERRORS IN THE CIIROXOMETRY OF LIFE 93 
 
 who look prematurely old ; but it is hard to judge of 
 these, because so few have lived long without having 
 some disease or disturbance of this or that part which 
 has destroyed the uniformity of the time-rate at 
 which all the organs began to live, and which may 
 have been necessary to healthy life."^ Hence it is that 
 natural death that is, death through uniform and 
 exactly contemporary decay of all the structures is 
 very rare.ySThe few cases in which it is observed do 
 not prove more than that there is no fixed time at 
 which it should occur. 
 
 The foregoing facts, incomplete as they are, may 
 be enough to show that important and useful know- 
 ledge may be gained by a careful study of those 
 deviations from the usual time-rates of life in which 
 all parts deviate alike, the rate being in all parts 
 equally too fast or too slow. A still larger field for 
 study is in what may be deemed the premature 
 development or degeneration of one or more parts ; 
 the rate of life being not uniform in all. But on this 
 I can scarcely do more than recommend it for the 
 study of younger men, for I have no clear facts con- 
 cerning it in relation to any of the most important 
 parts. 
 
 The best illustrations are in some of the least 
 important parts, but these may suffice as suggestions 
 for seeking similar facts in the most important.
 
 04 ERRORS IN THE CI1ROXOMETRY OF LIFE 
 
 Premature development is only too commonly 
 seen in the teeth. Their time-rate may be faster than 
 that of the jaws, with which it ought to coincide 
 exactly ; and in this case they come out crowded, and 
 the more so the more exactly they keep time with 
 one another. Often, however, they do not keep time 
 either with one another or with the jaws ; they come 
 out both crowded and disorderly. I have seen a 
 young gentleman who, at eighteen, had cut all his 
 wisdom-teeth, and his teeth were in advance of every- 
 thing, for his jaws were small and had not room for 
 them ; he had no appearance of hair on his face, and 
 he was altogether boyish in build arid mind. The 
 opposite error in time, shown in delayed tooth-cutting, 
 is nearly as common, and cases are not rare in which 
 the eruption of the wisdom-teeth, which signalises 
 their complete development, is delayed till middle 
 age or later. 
 
 Errors in time such as these are very troublesome, 
 not gravely important. But surely it is very probable 
 that similar errors occur in other more important 
 parts. Premature puberty may be cited ; and it may 
 at least be suggested that grave trouble may ensue 
 if, for example, a heart should be acquiring its full 
 power more quickly than the lungs or arteries. And 
 let it be remembered that even the smallest defect 
 in chronometry, beginning in early life and continued,
 
 KRRORS IX THE CIIROXOMETRY OF LIFF 95 
 
 will become constantly more serious in its effect's ; 
 just as an inaccurate clock becomes more wrong the 
 longer it goes. 
 
 The premature degeneration of this or that part, 
 whether with mere wasting or with fatty or other 
 change of structure, while the other parts go-on at 
 their usual time-rate, is, no doubt, often due to 
 disease of the part ; but it is not always so. The 
 changes which are natural in old age, and which when 
 uniform end in natural death, often begin at different 
 times in different parts and make unequal progress. 
 Here again the plainest illustrations may be found 
 in the teeth and in the hair. We are apt to think 
 lightly of premature grey hairs because they are 
 common and may be seen in many who are in good 
 general health ; but it had better be believed that 
 analogous untimely degenerations may occur, without 
 disease, in much more important parts. All parts do 
 not often grow old at the same rate ; and as people 
 of the same age according to the register are, in 
 many instances, of widely different ages by every 
 other test, so is it with the several organs of the same 
 body. For all the purposes of life some parts may 
 have grown old much faster than others ; some may 
 even be dying as of old age while others are still fit 
 for active life ; and these dying parts may never have 
 been the seats of any morbid process ; their errors
 
 9G ERRORS IX THE CIIROXOMETRY OF LIFE 
 
 may have been only clironometric ; they have not 
 kept time ; they have too quickly become ' grey.' 
 
 I think that we may thus explain, or, at least, 
 may thus express, some of what are deemed diseases 
 of old age. One sees people with scarcely a grey 
 hair at seventy whose stomachs are simply incapable 
 of digesting, as feeble and as quiet as in those who 
 are dying of old age. And so, one sees some with 
 shuffling tottering gait, and with such weak and 
 shrivelled limbs, as might be deemed natural in 
 people of ninety, and who yet say that they can eat 
 and drink and digest as well as ever. Similar illus- 
 trations of different time-rates observed in different 
 organs in the same person may be found, I suspect, 
 in some weak dilated hearts, and some wasted em- 
 physematous lungs and inelastic arteries. Certainly, 
 I think we may thus explain many cases of distended 
 urinary bladders in men of sixty or but little older, 
 who in general health show no signs of old age. 
 Their bladders become distended with gradually ac- 
 cumulated urine, which they are too weak to dis- 
 charge, though there be no hindrance in the urethra 
 or prostate. The patients, themselves, are often 
 unaware of the distension, the bladder being alike 
 insensible and inactive ; and the urine may be quite 
 healthy, unless, as in some cases, it be of very low 
 specific gravity. Similarly, the rectum may be found
 
 ERRORS IN THE CHRONOMETRY OF LIFE 97 
 
 weak, dilated, and irritable, with detained solid faeces, 
 in elderly people who are sturdy and active, and in 
 whom all other organs seem naturally strong. The 
 rectum alone in them is old-aged. 
 
 I venture to think that our pathology and, some- 
 times, our practice would be improved if local defects 
 of working power were more often thought of as 
 errors in the time-rate of life in the defective parts ; 
 if we would think of the ' age ' of each part as not 
 always wholly or exactly expressed by the time that 
 has elapsed since it was first formed ; if we would 
 bear in mind that any internal organ may deviate 
 from the general time-rate of the body as much as 
 the teeth, and the hair, and the skin, which we so 
 commonly think of as old before their time. We 
 should not be content with asking a patient how old 
 he is ; we should ask ourselves, how old is his heart, 
 or his brain, or any other part which seems now less 
 healthy than the rest. 
 
 H
 
 98 RESIDUAL DISEASES 
 
 CHAPTEE IX 
 
 KESIDUAL DISEASES 
 
 THE last essay may show that as we grow old we are 
 apt to believe that we can see lines of enquiry which 
 ought to be pursued, and which we would ourselves 
 pursue if we were likely to have time and oppor- 
 tunity sufficient for such work. Among the enquiries 
 of which I have often thus thought is that which 
 might decide whether each disease does not leave, 
 after it has ceased, certain conditions of blood or 
 structure which, sooner or later, may manifest them- 
 selves in what may be named a residual disease. 
 When a patient after illness feels well and shows no 
 definite sign of disease, we are ready to think that 
 he has recovered his former health : but often it is 
 not so ; and I always remind myself of what my 
 admirably wise friend and colleague Dr. Baly used 
 to say, that among the most useful books might be 
 one ' On the Diseases of Convalescents.' 
 
 Of the soon occurring sequels l of diseases we 
 
 1 I use this word rather than ' sequelae,' of which the sound is as 
 ngly as itself is un-English, and rather than ' consequence ' because the
 
 RESIDUAL DISEASES 99 
 
 know many ; of the later, comparatively few. Yet, 
 for an example, I have notes of cases which seem to 
 make it nearly certain that the periostitis which is 
 often observed soon after recovery from typhoid fever 
 may not appear till one or even two years after. 
 And I have heard of cases in which paralyses, such 
 as are often seen after diphtheria, have not occurred, 
 till three months after apparently complete recovery. 
 It is, of course, impossible to prove that the sequence 
 was a consequence of the previous disease ; some 
 other cause may, possibly, have intervened and es- 
 caped notice. But I am sure that these cases were 
 sufficient to suggest, as I have said, that it may be 
 very useful to ascertain whether many diseases do 
 not leave behind them residual conditions which, after 
 long intervals of apparently good health, may mani- 
 fest themselves in characteristic signs. It is a well- 
 known part of the natural history of ague and of 
 syphilis that such residual conditions remain after 
 their primary attacks, and show themselves, in the 
 one, in recurrences of similar periodic signs, in the 
 other, in a succession of diseases regular enough to 
 be regarded as specific secondary and tertiary con- 
 sequences of an infection. And, as these among 
 general diseases, so among local diseases residual 
 
 ' sequel ' is not nearly constant, and may depend on many conditions 
 not yet nearly ascertained. 
 
 H 2
 
 100 RESIDUAL DISEASES 
 
 abscesses, 1 or any recurrent inflammation in an injured 
 part, may be taken as the guides by which to look 
 for similar events in other instances, and to study 
 whether other diseases leave similar residues and 
 how these residues may be known. 
 
 Nearly all diseases leave what is commonly called 
 weakness, and, in this weakness, many diseases to 
 which there were previously only the ordinary per- 
 sonal liabilities are likely to appear. Thus, scrofula 
 or tuberculosis or gout may become evident in the 
 weakness following fever or any severe injury. And 
 often the ' weakness ' is shown to be local as well as 
 general ; for the disease is especially likely to appear 
 in the part which has been injured. Thus gout is 
 apt to attack a strained joint ; or a joint may first be 
 gouty and then scrofulous. But these are not such 
 residual diseases as are characteristic of those which 
 preceded ; they are in no such definite relation to the 
 preceding disease as secondary sj-philis is to primary, 
 or as periostitis or phlebitis is to typhoid fever, or 
 diabetes to ague. These do not occur indifferently 
 in the weakness that may follow any acute or pro- 
 longed illness ; each of these follows one disease alone 
 or much more frequently than it follows others, and 
 each may be fairly suspected to be due to some 
 
 1 Such as I described in St. Bartholomew's Hospital Reports, 
 I860, and in Clinical Lectures and Essays.
 
 RESIDUAL DISEASES 101 
 
 residual material left in the blood or in one or 
 more of the tissues. 
 
 A residual disease may appear very soon after 
 the primary disease from which it is derived, as 
 secondary syphilis commonly does after primary, or 
 as paralysis after diphtheria. Or it may be long de- 
 layed, as in the cases of periostitis already cited ; 
 and after this delay its outcoming may be due to 
 some casual disturbance of the general health. Thus, 
 after any number of years, ague may reappear in 
 those who have lately undergone operations and, 
 with its shiverings and high temperature, may excite 
 alarms of septic infection ; alarms which may be 
 quieted with the quinine, which is thus at once 
 diagnostic and curative. Or, more than this, ague 
 may appear for the first time, after an operation, 
 in some who lately, or even many years previously, 
 were exposed to malaria. 
 
 A clergyman whom I cut for stone had a fierce 
 rigor, followed by intense heat and sweating, on the 
 third or fourth day after the operation. It was not 
 associated with any passage of urine along the 
 urethra ; it was very like the beginning of pyaemia. 
 Of course I asked about ague, and he told me that 
 he had never had it, but had given away ' pounds 
 of quinine ' to his parishioners. He had lived in an 
 ague district, the ' poison,' whether microbe or any
 
 102 RESIDUAL DISEASES 
 
 other evil thing, was in him ; but it was harmless 
 till, we may suppose, his blood was made fit for its 
 multiplication or diffusion by the changes following 
 the operation. In another case, a middle-aged lady, 
 whose breast I had removed, had regularly periodical 
 attacks of chilliness, followed by heat and sweating. 
 She had never had ague, but her early life had been 
 passed in a place where it was frequent, and her 
 mother was ' always giving her quinine.' And now 
 quinine cured her. 
 
 The residues of diseases manifested in such cases 
 of ague show characters unchanged through years, 
 or even in the whole of a long life. I have known 
 well-marked ague in one who had first incurred it 
 sixty years before. Similarly, a chronic pyaemia may 
 go on for many years after septic poisoning, with 
 repeated abscesses in similar textures, and with long 
 intervals of apparently good health. 1 More commonly, 
 in course of time, the residues change and other 
 characteristic signs appear ; as tertiary syphilitic 
 diseases may follow secondary, or, without the inter- 
 vention of secondary disease, may appear long after 
 the primary disease. But there is no constant rule 
 for these events ; the usual secondary symptoms are 
 sometimes, however rarely, delayed for many years. 
 
 1 Or, as in one case, with complete freedom from suppuration 
 during three periods of pregnancy and lactation. Clinical Lectures 
 and Essays, p. 171.
 
 RESIDUAL DISEASES 103 
 
 A man when eighteen years old had a primary sore, 
 and he had no other primary affection or any signs of 
 secondary disease till seventeen years later, when I 
 first saw him. Then, after a great fright and grief, 
 he had been ill for a month, and had lost much 
 in strength and weight, and now a copper-coloured 
 eruption, like the most ordinary secondary syphilitic 
 psoriasis, appeared on the scrotum, and soon after on 
 the scalp. Two weeks later he had small superficial 
 ulcers on the tonsils and the glans. He got much 
 better while taking mercury, but had a small ulcer 
 on the side of his tongue. 
 
 Many such cases might be cited, and still many 
 more showing that, at any time, the residues of 
 syphilis may appear modifying the signs of scrofula, 
 or of gout, or of any other disease with which syphilis 
 may combine. 
 
 But I can only cite these facts as encouragements 
 for the study which I have suggested, the study of 
 the probability that many other diseases do, like 
 syphilis and ague, leave certain residues in some part 
 of the system, which, long after apparent recovery of 
 health, may show themselves in distinctive morbid 
 processes or in modifications of those due to other 
 diseases. This study may give more definite design to 
 the records of the history of each case, and I am sure 
 that, in private practice, I have found it much more
 
 104 RESIDUAL DISEASES 
 
 useful than my case-books would prove it to have 
 been. We should in nearly all cases ask, Have you 
 ever had a serious disease ? Were you healthy in 
 childhood ? The answers will often help to accurate 
 diagnosis.
 
 105 
 
 CHAPTER X 
 
 DISEASES OF STRUCTURE DUE TO DISTURBANCE OF 
 NERVE-FORCE 
 
 IT seems possible that it may be useful to record 
 some of the least common-place of my cases of struc- 
 tural disease having its origin chiefly or solely in 
 nerve-disturbance. They may be useful as additions 
 to any collections being made by others, just as spe- 
 cimens of varieties are useful in herbaria destined 
 chiefly for the study of species. 
 
 .Among the cases are several of rapid wasting of 
 parts after injury of their nerves, including especially 
 some in which nerves and the parts round them were 
 severely crushed. 
 
 The most remarkable was observed in a gentle- 
 man, about twenty-five years old, very strong and 
 muscular, who had been for two years subject to 
 epileptic attacks, some of which were preceded by 
 half-a-minute's mania. In one of these attacks with 
 mania, a month before I saw him, he was seized by
 
 106 DISEASES OF STRUCTURE 
 
 six workmen, who, in their fright and against his 
 violent resistance, tied his feet and hands and arms 
 with strong thin cords. The cords on his feet gave 
 him only temporary trouble, but those on his arms 
 and wrists did greater damage. They were twisted 
 and tied as tightly as possible and kept on, I think, 
 for some hours, and the marks of their coils were 
 still distinct in bands of bruised and brownish 
 skin. 
 
 When he was set free his hands and wrists were 
 powerless and insensible ; he described them as * drop- 
 ping ' like those of one with lead-palsy. Soon after, 
 the arms began to swell, and in the next four or five 
 days they were in such a state of inflammatory oedema 
 that it was expected that portions of them would 
 slough, or that there would be extensive suppuration. 
 The pain was extreme, with burning and tingling and 
 aching in the hands and fore-arms, though to the 
 touch they were insensible; and this pain continued 
 much longer than the swelling. After the swelling 
 subsided, which it did without suppuration, he began 
 to regain some sensibility and some slight power over 
 the muscles, but they were found to be exceedingly 
 wasted ; they had been very robust, and they had 
 become quite slender and puny. In the fourth week 
 after the injury the whole condition improved ; the 
 pain decreased, the muscles became rather more
 
 WE TO DISTURBANCE OF NERVE-FORCE 107 
 
 active and increased a little in size, but still they 
 showed signs of having wasted, more rapidly than 
 any I had ever seen. The pulse was natural, there 
 was no sign of injury to bone or joint, or of any 
 deep-seated disease ; the skin remained in some parts 
 completely, in others partially, insensible to touch. 
 Slowly recovery ensued, and I believe that, in time, 
 the muscles regained their size and power. 
 
 It is by the rapidity rather than by the degree of 
 the wasting that this and similar cases are distin- 
 guished, and such rapidity, far greater than that with 
 which muscles waste through mere inaction or after 
 division of their nerves, is, I think, indicative of in- 
 flammation in the nerve-fibres, or, perhaps, in some 
 cases in a nerve-centre. Such rapid wasting of the 
 muscles, and, probably, of other structures in the 
 limb, is seen in cases of what may be considered 
 acute sciatica, and, I think, it may distinguish the 
 cases due to neuritis from those which may be 
 ascribed to neuralgia. A similar condition is some- 
 times, though rarely, observed in association with 
 herpes zona. I have seen two examples of this in 
 middle-aged men in whom the herpes was in the 
 range of distribution of part of the brachial plexus, 
 especially on the shoulder. The pain was intense, 
 and the wasting rapid and excessive; the muscles 
 were reduced to an extreme emaciation within a
 
 108 DISEASES OF STRUCTURE 
 
 month, and were for some time powerless. But the 
 pain was not unusually prolonged, and the wasted 
 parts recovered, in one of the cases I know, and in 
 the other I believe, completely. 
 
 I do not pretend, for, indeed, I am quite unable, 
 to express what may be the difference between these 
 disturbances of nerve-force which are attended with 
 similarity of pain, but of which some are, and some 
 are not, productive of wasting or structural change 
 in the parts in which the nerves are distributed. 
 There are singularly intermediate or mingled illustra- 
 tions in different cases of herpes zona. Ordinarily, 
 with considerable preceding or associated pain there 
 is only so much local necrosis as is expressed in 
 the death and separation of the epidermis of the 
 minute vesicles and the shallow ulceration indicated 
 "by the little scars ; but this ulceration may be deep, 
 and I have seen one case in which, with herpes 
 in the range of the second division of the right fifth 
 nerve, there was necrosis of the portion of the alveo- 
 lar border of the upper jaw and of all the teeth re- 
 ceiving branches from that nerve. In the cases which 
 are most severe as to the structural changes, there 
 is not always more than ordinary pain ; and, on the 
 other hand, there are the usual cases in old persons, 
 in whom the pain continues during and long after the 
 eruption, but neither hinders the healing nor is asso-
 
 DUE TO DISTURBANCE OF NERVE-FORCE 109 
 
 elated with considerable wasting. Earely, also, one 
 meets with cases of long-abiding and intense pain in 
 one of the ordinary seats of herpes zona, but with- 
 out either eruption or any other apparent structural 
 change. 
 
 Among the cases of inflammation due to nerve- 
 disturbance, I find one in which parotitis was conse- 
 quent on the sight of acid food. A gentleman, sixty- 
 nine years old, thin, feeble and gouty, had become 
 unusually weak through over-work. Eight days 
 before I saw him he was just going to eat some 
 acid fruit, when he felt, as he had often felt at the 
 sight of acids, a painful tightness or soreness behind 
 his lower jaw. 1 It was as severe as any of the kind 
 that he had ever felt, and he could not take the fruit. 
 Soon after, one of his parotid glands began to swell ; 
 and from that time it had been swollen, hard, tender 
 
 to the touch, and, at times, intensely painful, and the 
 
 
 skin over it was ruddy. His pulse was quickened 
 
 and full ; he had little appetite and felt ' ill all over,' 
 but he slowly recovered, and no permanent harm was 
 done. 
 
 Somewhat similar to this, but much more fre- 
 
 . 
 quent, are the inflammation of the prepuce and glans 
 
 1 He could remember being, in his boyhood, sometimes obliged to 
 leave a room at the sight of some drops of vinegar.
 
 HO DISEASES OF STRUCTURE 
 
 consequent on sexual excitement. The inflammation, 
 which is often like a preputial herpes, commonly 
 appears a few hours after copulation ; and I have 
 seen one who, abstaining from sexual intercourse 
 because of this consequent annoyance, had similar 
 inflammation after an involuntary seminal emission. 
 I think that cases of this kind are most apt to occur 
 in men with too acid urine ; but the inflammation is 
 never harmful, never more than troublesome, and 
 washing and correction of the urine will cure it. 
 
 I may refer to one more case of transient inflam- 
 mation consequent on nerve-disturbance. A lady 
 had some congestion and toughening of part of her 
 left mammary gland, and with this a fear of cancer 
 and intense neuralgia in the breast and along the 
 branches of the brachial plexus in the upper arm. 
 Within the range of the neuralgia were many patches 
 of erythema. 
 
 Cases of 'glossy fingers' after injury of nerves 
 have been so often recorded since I ventured to 
 suggest the name for them, that I can add nothing 
 useful on them. Neither can I concerning the gan- 
 grene of fingers following intense neuralgia in ' Eay- 
 naud's disease,' unless it be that in one case, in a 
 lady, about thirty-five, together with the ' deadness,' 
 coldness, and excessive pain in the fingers which pre-
 
 DUE TO DISTURBANCE Of NERVE-FORCE 111 
 
 ceded their partial patchy gangrene, there was un- 
 natural heat of the scalp, and with this a profuse 
 growth of strong black hair, and free perspiration, 
 while from other parts she perspired little. The 
 growth of hair might be compared with that which 
 one sees on limbs with disease of a joint or other 
 structure associated with abnormal afflux of blood 
 and high temperature. 
 
 In the following case of local death associated 
 with intense pain one may believe that there was 
 some affinity with Eaynaud's disease. 
 
 A healthy-looking young man of nineteen was in 
 St. Bartholomew's with extreme pain in the fore- 
 finger of his left hand pain so severe that it often 
 kept him awake all night and made him beg that his 
 finger might be amputated. Its chief seat was at the 
 joint between the first and second phalanges, and at 
 this part there was slight enlargement with thicken- 
 ing and induration of the tissues ; but there neither 
 was nor ever had been any open suppuration. The 
 pain had existed three years with scarcely any inter- 
 mission ; he could not assign any cause for it, and 
 of many treatments none had alleviated it. 
 
 I amputated the finger and found that all the 
 visible disease was in an ulceration, which had formed 
 a cavity, about one-sixth of an inch in diameter, on 
 the palmar surface of the first phalanx close to its
 
 112 DISEASES OF STRUCTURE 
 
 distal articulation, but not involving or affecting the 
 joint. This cavity was filled with a firm substance, 
 like firm granulation tissue, projecting a little beyond 
 the level of the surrounding bone, but without any 
 appearance of abscess formation. All the adjacent 
 parts looked quite healthy. 
 
 The case went on well after the operation, but 
 the subjective sensations, as if there were still a very 
 painful finger, remained long after, and seemed to 
 indicate, as did the previous pain, that the origin of 
 the disease was in some nerve-disturbance. 
 
 The indications that the wasting and other de- 
 generations, including those of acute inflammations, 
 are associated with neuritis, not with mere neuralgia, 
 are confirmed by the frequent cases of rapid and wide- 
 spreading bed-sores and other sloughings in some 
 cases of acute myelitis, especially in those which 
 follow injury of the spine. But I think that the 
 most remarkable facts illustrated in these cases are 
 those which show that structures which, having their 
 nerve-supply cut-off or hindered, are unable to main- 
 tain themselves in size and texture, or to endure un 
 usual pressure or any other continued hindrance of 
 nutrition, are yet able to repair the injuries which 
 may happen by accident, or may be caused by 
 sloughing or ulceration. In other words they can,
 
 DUE TO DISTURBANCE OF NERVE-FORCE 113 
 
 in a measure, repair the losses of some of the struc- 
 tures which they could not maintain. 
 
 Of many cases one may serve for evidence of 
 this : 
 
 A man, about thirty-eight years old, was in St. 
 Bartholomew's with paraplegia, the consequence of 
 injury of his spine about two years previously. He 
 was very slowly regaining some power in his lower 
 limbs, and in the course of a year's treatment had 
 acquired slight sensation in his feet and more in his 
 legs and thighs, and some power of movement suffi- 
 cient for crawling about the ward. But his feet and 
 toes were so shrivelled and incurved that they pre- 
 vented all attempts at walking. To remedy this his 
 surgeon divided his Achilles' tendons and the tendons 
 of his toes. No immediate harm ensued ; but, three 
 or four days afterwards, his limbs were put on splints 
 and bandaged to them, and then, though the ban- 
 dages were not very tight, sloughing quickly ensued 
 on and around both the insteps. The sloughs at first 
 included a large portion of the integuments of these 
 parts and, for a time, they seemed separating in an 
 ordinary and healthy manner ; but when the dead 
 skin was separated, the sloughing again extended, 
 and it laid open the dorsal arteries of both feet, 
 permitting severe hemorrhages. Then, again, it ex- 
 tended, and both ankle-joints were laid open ; and
 
 114 DISEASES OF STRUCTURE 
 
 yet, with all this, the process of granulation on ad- 
 jacent parts seemed to go on healthily, and the 
 patient's general condition was good, except in so far 
 as he was weakened by the loss of blood. 
 
 For some time, however, it seemed as if the repair 
 would not go beyond the granulation-process ; the 
 granulations were well formed, florid and firm, but 
 they did not appear to develope epidermis or, perhaps, 
 connective tissue. Production was active ; complete 
 repair was delayed. It was only after a long time that 
 the granulations began to be covered with epidermis 
 extending over them, as usual, from the circumfer- 
 ence, but from this time the healing went on steadily, 
 and in three months from the beginning of the slough- 
 ing the scar was complete, even the opened ankle-joints 
 being completely covered-in by it. During the heal- 
 ing the feet became rather more sensitive, and at 
 last he could just feel when touched as low down 
 as the ankles. 
 
 No case could better show that parts incapable 
 of maintaining themselves during even slight dis- 
 turbances of their ordinary conditions may yet re- 
 pair themselves after severe injury. It is as if we 
 might say that repair costs less than common main- 
 tenance, and indeed many other facts show that 
 such an expression might be justly used ; for, not 
 rarely, the repair of an injured part will go on while
 
 DUE TO DISTURBANCE OF NERVE-FORCE 115 
 
 the rest of the body is dying, whether of old age 
 or of premature decay or of some general disease. 
 The explanation may be that the substance by which 
 the injury is repaired is a less complex or less de- 
 veloped structure than that which was injured or 
 removed, and that much less power is needed for 
 the production than for the higher development of 
 organic structures. 
 
 i 2
 
 116 DIABETIC GANGRENE 
 
 CHAPTER XI 
 
 DIABETIC GANGRENE ] 
 
 IN spite of all that M. Marchal (de Calvi) 2 and 
 others have written on diabetic gangrene, I feel sure 
 that the liability of diabetic old people to gangrene 
 is not sufficiently estimated. I have seen so many 
 instances proving this liability that I am disposed 
 to think that diabetes has a share in fully half the 
 cases of senile gangrene that occur in the well-to- 
 do classes of English people. It may be the same 
 among the poor ; but I have not been able to study 
 in workhouses where the majority of the cases would 
 be found. 
 
 I hoped that in looking through my cases, briefly 
 
 1 This paper was written before I received one on the same subject 
 by Dr. William Hunt, published in the Transactions of the Phila- 
 delphia County Medical Society, vol. ii. 1888. If he had published 
 it in a book likely to be found in any but our largest libraries, I should 
 not have printed this, for his study of the subject is complete, and its 
 results are admirably told. I can only hope that my paper may be 
 auxiliary to his. 
 
 2 Sur Ics Accidents diabetiqucs, 8vo. Paris, 1864.
 
 DIABETIC GANGRENE 117 
 
 as they are recorded, I might have found facts 
 enough to show how the diabetic might, by its own 
 characters, be distinguished from other forms of gan- 
 grene. But I have failed, chiefly, I think, because 
 so few people who are diabetic after middle age are 
 in all other respects sound, and the various unsound- 
 nesses variously affect the characters of the gangrene 
 in each of those in whom it occurs. Still it may 
 be useful to state some of the facts that I have 
 observed. 
 
 I have only once seen a case in a person under 
 fifty ; but though he was less than fifty years old 
 by the register, he was much more by the tests of 
 health. The cases in men are far more numerous 
 than those in women ; but probably in not larger 
 proportion than diabetes itself is. 
 
 The diabetes had been in some cases observed 
 long before the gangrene began ; in one instance as 
 much as fifteen years. In others it was unsuspected, 
 though its existence was made probable by failing 
 health, thinning, and other signs remembered when 
 asked for. In some it had been intermittent, and 
 in one there was reason enough to believe that 
 the gangrene began during an intermission. The 
 quantity of sugar found in the urine in different 
 cases was, I think, various ; the quantity of urine 
 was rarely very large ; in a few cases it was albu-
 
 118 DIABETIC GANGRENE 
 
 minous as well as saccharine ; in some overcharged 
 with uric acid. 
 
 I have not seen a case of gangrene during a 
 'diabetes insipidus,' and only one in a very corpu- 
 lent person. 
 
 The gangrene has not in any case of which I 
 have a record begun suddenly, as it usually does in 
 cases of embolism or rapid obstruction of main 
 arteries. Neither has it been so often threatened 
 and not come to pass as one observes in the cases in 
 which it follows the repeated local chills and flush- 
 ings, the signs of local syncope or of local asphyxia, 
 which seem chiefly due to nerve-disturbance. Its 
 most frequent preceding signs are swelling, duski- 
 ness, oedema, and over-heating, of one or both feet ; 
 with pain the pain of ' local dying,' which is often 
 severe, but not, I think, accompanied by fever. 
 
 It is common for the diabetic gangrene to begin 
 after injury, often very slight injury, such as the 
 cutting of a corn, or anything that produces inflam- 
 mation of a toe or other part of a foot. It is rarely 
 dry or shrivelling as the typical gangrena sicca of 
 old age or of Eaynaud's disease is. Usually it sets 
 in with increasing heat and cedematous swelling and 
 flushing, and the dead parts remain warm longer, I 
 think, than in other forms of senile gangrene, and 
 even long after they have become deeply discoloured.
 
 DIABETIC GANGRENE 119 
 
 The extent of the gangrene at its beginning is 
 very various. It may be one toe, or even a small 
 portion of the skin of one, and here it may end, and 
 healing may follow. But more often it extends 
 and invades other toes, and they die in their whole 
 thickness, and portions of the foot or leg perish ; 
 all after the same manner, with pain and heat and 
 4 moist sloughing.' 
 
 Two things are, I think, more frequent in the 
 diabetic than in any other form of senile gangrene : 
 namely, a tendency to occur in places at some dis- 
 tance from its first seat, and a frequent extension 
 along subcutaneous tissue, leaving the skin unaffected. 
 Thus, soon after it has begun at one or more toes, we 
 may find separate patches of skin discoloured, and 
 quickly dying on the foot or even high on the leg. 
 And often, when it seems limited to the toes, one 
 finds suppuration extending along the sole of the 
 foot, with sloughing of the connective tissue, or even 
 of the plantar fascia and parts of the flexor tendons. 
 
 The speed of progress and the termination of the 
 cases I have seen have been widely various. Most of 
 them have ended fatally ; some rapidly, with coma or 
 exhaustion, or, I suppose, blood-poisoning. But the 
 rate and manner of dying have depended much less 
 on the gangrene than on the general conditions of 
 disease to which itself was chiefly due.
 
 120 DIABETIC GANGRENE 
 
 On the other hand, recovery has not been rare. 
 The dead parts have been separated, and rapid heal- 
 ing has ensued, following step by step the process of 
 separation and forming good sound scars. Healing 
 may thus go-on in one part while gangrene is extend- 
 ing in another. 
 
 What may ensue after healing is uncertain, but 
 depends, I suppose, on the degree in which the dia- 
 betes and other morbid conditions are maintained. 
 I have known survivals of three years, five years, 
 and, after a diabetic necrosis of the jaw, of at least 
 ten years ; but I do not know how those patients 
 died at last. In other cases the healing has been 
 partial or of short duration, and gangrene has soon 
 recurred. 
 
 Respecting treatment, it must be so varied 
 according to the conditions with which the gangrene 
 and the diabetes are complicated that it would be 
 unreasonable to think of many simple rules. But 
 there are two which may generally be observed : 
 first, that the diet must be much more various and 
 less exclusive than it should be in the usual diabetic 
 state ; and that opium should be given in frequent 
 doses and in larger quantity than may be necessary 
 for the mere alleviation of pain. Albumen in the 
 urine may forbid or much limit the use of opium, but 
 if this be not necessary it should be given freely in
 
 DIABETIC GANGRENE 121 
 
 any form in which it can best be tolerated ; and it is 
 a good rule to give with it, occasionally, a small dose 
 of calomel, or other preparation of mercury. 
 
 For local treatment, the chief good things are 
 warm, soft, and dry coverings, such as thick wrap- 
 pings of cotton- wool around the whole limb, and 
 deodorant stimulant ointments. The less of local 
 interference, in the way of picking off bits of slough 
 and the like, the better ; but of the larger proceeding 
 by amputation far above the gangrene I have seen 
 too little to write with any confidence. Mr. Hutchin- 
 son 1 has published a very remarkable case of suc- 
 cess ; and one of my patients, sixty-three years old, 
 who died quickly with diabetic gangrene of a foot, 
 had undergone amputation of the other foot for 
 similar gangrene three years previously, and had 
 recovered well with a good stump. 
 
 The cases thus far referred to have been so closely 
 in accordance with the general descriptions of senile 
 gangrene that they, and others like them, may justify 
 the practical rule of always thinking that an elderly 
 person with gangrene of any part of an extremity 
 maybe diabetic. But the rule had better be extended 
 far beyond this, even to all cases of local death 
 not due to adequate local injury. The frequent 
 association of boils and carbuncles with diabetes is 
 
 1 Medico -Cliirurgical Transactions, vol. Ixv. p. 97.
 
 122 DIABETIC GANGRENE 
 
 well known ; and the formation of vesicles and blis- 
 ters in some of the eruptions that are common in the 
 diabetic may justly be regarded as due to the death, 
 and consequent separation, of small portions of 
 epidermis. They are like the blistering due to burns 
 and scalds which, in one degree of severity, kill only 
 epidermis ; in other and greater severities, kill skin 
 and yet deeper structures. I saw a good illustration 
 of such apparently insignificant local dying in an 
 elderly lady from whom the nails of both little 
 fingers came off quietly, without pain or inflamma- 
 tion. She had long been diabetic. The nails were 
 replaced by healthy ones ; but a few years later, 
 remaining still diabetic, she had small sloughing 
 sores on one heel. These also healed, but within a 
 year afterwards she died. 
 
 It may be well to mention a form of diabetic 
 necrosis of which I have seen three examples, two in 
 the upper and one in the lower jaw. 1 They were all 
 in elderly men, in whom, after tedious ill-smelling 
 suppuration under the gums, with decay or falling 
 of teeth, portions of decayed and dead bone separated 
 and were removed. One of them died before the 
 diseased part healed died as if finally exhausted by 
 
 1 M. Magitot, in the Bulletin de I' Academic de Medecine de Paris, 
 1881, mentions as signs of the beginning and progress of diabetes an 
 inflammatory condition of the gums indicating an alveolar periostitis 
 which tends to loosening and loss of teeth.
 
 DIABETIC GAXGREXE 123 
 
 the diabetes ; in the others the parts healed soundly, 
 and one of them, as I have already said, lived for at 
 least ten years. 
 
 And there is a remarkable form of diabetic 
 disease of the scalp in which portions of the subcu- 
 taneous tissue slough, and are discharged or removed 
 through large sloughs or ulcers in the skin, which 
 may then heal with round or irregular deep tough 
 scars. They are not like carbuncles ; they are very 
 slow in progress, not attended with much pain or, 
 I think, with any acute illness. When the sloughs 
 are separated the ulcers remaining are very like 
 those of some cases of tertiary syphilis. They may 
 -heal and be long survived, and the scars remaining 
 are very characteristic. Nearly similar shapes of 
 ulcers and of scars may be seen in and after some 
 kinds of Indian ulcers. And I think that this like- 
 ness between the diabetic and the syphilitic ulcers 
 and scars especially in their crescentic, horse-shoe, 
 or nearly annular shapes and well-defined borders- 
 may be very much worth studying. Differences of 
 plainly visible shape are commonly significant and 
 characteristic of differences in the most intimate 
 composition of organic as well as of inorganic 
 bodies. 
 
 Dr. Hunt, in the paper already referred to, gives
 
 1'24 DIABETIC GANGRENE 
 
 references to all the cases of diabetic gangrene re- 
 corded previously to its publication ; and they in- 
 clude examples of gangrene in lungs, pleura, and some 
 other parts. The rule of suspecting diabetes in cases 
 of local death may therefore be a very general one. 
 The suspicion may be much greater in the cases of 
 the old than in those of the young, if the estimate 
 of age be made by the personal characteristics, not 
 by the birth-register. I should, indeed, have given 
 the title of Diabetic Senile Gangrene to this chapter 
 if Dr. Hunt had not cited two cases occurring in 
 young persons. I have not seen a case in anyone 
 whom I could not regard as ' old,' and I have always 
 counted this fact among many that may make it 
 probable that the diabetes of the old and that of the 
 young are widely different diseases, though they are 
 alike in what seems, at present, their most character- 
 istic symptom.
 
 125 
 
 CHAPTER XII 
 
 SUBCUTANEOUS ULCERATION 
 
 MR. TEALE l has given this very appropriate name to 
 cases very similar to those on which I had written the 
 following paper. They are not rare, but they are, I 
 believe, too often overlooked because they are not 
 described in the surgical works most often referred 
 to. Probably, now that they can have a distinctive 
 name, even though it be a plain one, they will be 
 more generally described and studied. 
 
 I will not report the cases I have seen, but will 
 give a general account of the disease as observed in 
 them, and will illustrate its likeness to others to which 
 it appears nearly related. 
 
 Among the frequent effects of inflammation are 
 separations of adjacent layers of dissimilar tissues. 
 Some of the simplest examples of this dissevering 
 
 1 Liverpool Medical and Surgical Journal, vol. vii. p. 87, 1887. 
 The name had occurred to myself as a fitting one, and is certainly 
 much better than 'necrosis of fascia.'
 
 126 SUBCUTANEOUS ULCERATION 
 
 process are those in which one finds the capsule of 
 the kidney more than usually separable, or the peri- 
 osteum separated or too easily separable from a bone, 
 even though there be no evident effusion between 
 them. In these cases there may be no more morbid 
 change than that of softening of the walls of the 
 vessels and of the small quantity of connective tissue 
 which naturally hold together the two parts. A 
 greater change is effected when articular cartilage 
 is separated or can be stripped from bone ; for here 
 the separation is not possible till after ulceration or 
 extreme softening of one or both of the adjacent 
 layers. In some of these cases it is observable that 
 the disseverance of the bone and cartilage is without 
 apparent formation of pus or other morbid fluid. The 
 cartilage, usually ulcerated on its under surface, 
 can be raised from contact with the bone, and the 
 bone either appears roughened as by ulceration or 
 is covered with a thin layer of granulations ; but 
 between the two there may be, at least to the naked 
 eye, no appearance of pus, even though there be pus 
 in the cavity of the joint. 
 
 This method of separation by ulceration of bone 
 and cartilage is a common and well-known result of 
 acute inflammation in joints ; its effects are shown in 
 all good pathological museums, and it may help to 
 the understanding of the similar subcutaneous ulcera-
 
 SUBCUTANEOUS ULCERATION 127 
 
 tion. In this the subcutaneous fat is separated from 
 the subjacent fascia, and when, after incision, the 
 skin and fat are lifted up and everted, so as to expose 
 the space beneath them, they are usually found 
 covered with rather dusky granulations like those 
 which may be found on the surface of a wound not 
 prone to heal. The change may seem just like the 
 more frequent change in the diffuse inflammation of 
 phlegmonous erysipelas (so-called) ; but there is this 
 among several differences, that in the one the ulcera- 
 tion, in the other the suppuration, greatly predomi- 
 nates : in the one there may be widespread dissever- 
 ance of the layers of tissue without much, if any, pus 
 between them ; in the other there is abundant pus 
 diffused between the layers and in at least one of 
 them. Besides, in the one there is only severance by 
 ulceration, in the other there may be sloughing. 
 
 I believe that subcutaneous ulceration is most 
 frequent in the thigh or leg, especially in the parts 
 near to the knee. It is commonly indicated, at first, 
 by an ill-defined patch of mottled dusky redness of 
 the skin, which feels warm, firm and brawny, but is 
 scarcely raised above the level of the surrounding 
 healthy skin. The brawny, firm feeling of the skin 
 usually precedes and extends far beyond the redness, 
 but has no marked boundary and is not very painful, 
 if at all so. After a time some of it usually feels
 
 128 SUBCUTANEOUS ULCERATIOX 
 
 tender and more yielding to pressure, as if it were soft- 
 ening, and, sometimes, at these soft places it opens 
 by ulceration, and this ulceration may extend rather 
 widely. There is seldom any fever or other acute 
 general symptom, and I have never known this dis- 
 ease associated with rigors or hectic. 
 
 The most frequent subjects of the disease are 
 young persons of pallid complexion, with feeble 
 general health, thin, and with very little muscular 
 power. They might be called scrofulous ; but I have 
 not observed in them any special enlargement of the 
 lymph-glands or other of the more distinctive signs 
 of that condition. Neither have I noted any sugges- 
 tion of syphilis, either acquired or inherited. I think 
 the disease is most common among the poor and ill- 
 fed ; but I have seen it among those living in all 
 comfort, and in these it had just the same characters 
 as in the hospital-patients. 
 
 I have never seen a case of this disease cured by 
 any medicinal treatment, whether general or local. 
 The only useful method has been the puncture at one 
 or more of the softened portions of the skin, and then, 
 from this opening, or from any ulcerated openings 
 already formed, the free laying open of all the space 
 in which the skin and the subjacent tissues have been 
 dissevered. And this space has generally been much 
 wider than the outer appearance of the part led one to
 
 SUBCUTANEOUS ULCERATIOX 120 
 
 believe, extending to parts over which the skin seemed 
 healthy, neither ruddy, nor tough nor softened, and, 
 indeed, only just separated from the layer beneath it, 
 separated by an ulceration with scarcely any trace of 
 pus visible to the naked eye. 
 
 After this free laying open, and with cleanly 
 dressing, healing has been slowly completed in all the 
 cases that I have seen. And the healing has been 
 with ordinary production of pus, without any slough- 
 ing or ulceration of the skin, and with no other defect 
 than that of large thin scars, apt, for some short time 
 after their formation, to ' break-down ' and to need 
 rest and soft coverings to heal them again. The 
 patient's general health, too, needs repair and strength- 
 ening with tonics, good food, good air, and light. I 
 have never seen the disease in one who could be 
 deemed of sound constitution. 
 
 Mr. Teale recommends the thorough scraping- 
 away of the granulations exposed by the laying open 
 of the cavities, and I do not doubt that the healing 
 may thus be hastened. He gives, also, good reasons 
 for regarding these cases as really scrofulous. 
 
 K
 
 130 UNUXITED FRACTL'RES IX CHILDREN 
 
 CHAPTER XIII 
 
 UNUXITED FRACTURES IX CHILDREN 
 
 I HAVE seen only three cases of ummited fractures in 
 young children, and the measures which are usually 
 sufficient for the cure of this defect in adults were 
 in all these cases completely useless. Similar cases 
 have occurred to others ; and, so far as I know, 
 they have not been explained. I can only guess 
 at a possible explanation, but it may help others 
 to do more than guess if I tell at least one of my 
 cases. 
 
 A little girl, three and a half years old, was 
 brought from Australia, and I saw her with Sir 
 William Fergusson and Dr. Protheroe Smith. She 
 was fair, light-haired, healthy-looking, well-formed, 
 and full-sized. When she was five months old her 
 left tibia and fibula were broken at the junction 
 of the middle and lower thirds. She was in her 
 mother's arms at the time, and the force that broke 
 them was very slight, Probably there was little, if
 
 UNUNITED FRACTURES IX CHILDREN lol 
 
 any, displacement of the fragments, for the fracture 
 was not detected and was not carefully treated for 
 nine weeks. Then, the fracture having become 
 evident, the limb was put-up in gum and chalk- 
 splints and was thus kept long in good position ; but 
 no union took place. In the course of the next year 
 a seton was put between the ends of the broken 
 bones, but it did no good. After this, when the child 
 was two years old, the ends of the bones were ex- 
 posed and ivory-pegs were put in them. The pro- 
 gress of the case after this seemed good ; but after 
 eight weeks erysipelas attacked the limb and no 
 union took place. Since this failure the child had 
 learned to walk and run, and did so actively, with a 
 strapped boot that reached high up the leg and kept 
 the fragments well together. 
 
 When I first saw this child, at three and a half 
 years old, the ends of the bones overlapped between 
 half and three-quarters of an inch, and there seemed 
 no kind of union. Their ends were about a quarter 
 of an inch apart and moved freely upon one another ; 
 they felt smoothly rounded and tapering, and tin- 
 upper were in front and to the inner side of tin- 
 lower. The leg was rather more than an inch 
 shorter than the other, and its muscles were small 
 and soft. The shortening was due partly to the 
 overlapping of the bones and partly to defective 
 
 K -2
 
 132 UNUNITED FRACTURES IX CHILDREN 
 
 growth. The foot was large and heavy as if with 
 residues of oedema. 
 
 None of us had known of any good ensuing from 
 operations in such cases, and we recommended only 
 an improved support for the limb. With this the 
 child could run and walk actively, and in six months 
 the leg grew seven-eighths of an inch and she re- 
 turned to Australia. 
 
 I did not see her till thirty years afterwards, and 
 then she told me that the limb had become every 
 year more troublesome and, when she was fifteen, 
 was so intolerable that it was amputated ; and she 
 had been in comparative comfort and completely 
 good health ever since. 
 
 I believe that this case may be regarded as a 
 good example of the group which it illustrates, and 
 that the general course of events begins with a frac- 
 ture produced by what may seem an inadequate 
 cause, proceeds through a series of vain attempts to 
 obtain reunion, and ends with amputation of the 
 limb. Thus it was in another case which I often 
 saw, and in which I assisted Sir Prescott Hewett at 
 some of the failures and at the final remedy. 
 
 A baby, the child of rich parents and apparently 
 healthy, beginning to run about, fell and broke his 
 tibia and fibula just below the middle of the leg. 
 The fracture was at once well set, and every care was
 
 FXUXITED FRACTURES IX CHILDREN 133 
 
 taken of it in respect of surgery, food and nursing. 
 Good union seemed complete ; but some weeks after- 
 wards, without any force applied, the union gave 
 way, and the fragments moved freely on one another. 
 What may fairly be called ' everything ' was done to 
 promote repair : absolute fixity, friction, scraping, 
 excision, wiring, everything ; but it was all useless, 
 and when the wish for public school-life came the 
 limb was amputated. The patient is still active and 
 healthy. 
 
 It may be only a chance-coincidence that in the 
 three cases that I have seen of fractures in children, 
 which were not repaired in the usual time and man- 
 ner, the repair appeared to be impossible. But I 
 think that other similar cases may have occurred l 
 and that the subject may deserve careful study. At 
 the least the cases are enough to urge that when, in 
 a young child, a fracture is caused by what would 
 generally be regarded as an inadequate force, no 
 pains should be spared to insure, if possible, its 
 direct repair. 
 
 So far as I know, nothing has been ascertained as 
 
 1 Among 484 cases ofununited fractures collected by Gurlt, Hand- 
 buch . . . v. d. Knochenbriichen, Th. i. 1862, there are seven which 
 occurred in children not more than four years old. In three of the 
 seven union was not obtained by the treatment to which they were 
 submitted ; in another it was only reported as ' beginning.' In adults 
 the proportion in which treatment failed was far less.
 
 134 UXUNITED FRACTURES IX CHILDREN 
 
 to the condition of the bones at the time of fracture 
 in any of these cases. When they have been seen 
 in or after operations for inducing repair, they have 
 been so changed by inflammatory and degenerative 
 processes which may all have occurred after the 
 fracture, that it has been impossible to find how, if 
 at all, they were changed before it. They can hardly 
 have resembled the bones in ordinary cases of the 
 so-called ' fragilitas ossium ; ' for in these cases there 
 are fractures of more than one bone, and union is 
 as sure to happen as in any broken healthy bones. 
 Neither was there in any of them any characteristic 
 appearance of rickets or of syphilis or any other 
 general defect of health. 
 
 The only disease to which I can think they have 
 borne near resemblance is that described by Professor 
 Czerny under the name of Ostitis deformans. 1 In these 
 a morbid condition, which appears to have been 
 like the ordinary Osteomalacia (Mollities Ossium) 
 which commonly affects many bones, was found in 
 only the tibia, or the tibia and fibula, or, in one case, 
 the femur. In each case the affected bone was bent 
 to an angle in only one part of its shaft ; and one 
 may believe that a little less or more of the disease 
 
 1 In the Wiener medizinische Zeitschrift, September 27, 1873. I 
 had not seen this paper when I gave the same name to the disease 
 which I described in the Medico-Chirurgical Transactions, vol. xlii. 
 1877. A specimen of Czerny's disease is in the College Museum.
 
 UNUNITED FRACTURES IN CHILDREN 135 
 
 would make this one part either bend or break ac- 
 cording to the force applied to it. But I can only 
 
 guess. 
 
 Since that was written the guess has been in some 
 measure justified by a case which I saw with Dr. 
 Scowcroft, of Bolton, and of which he has kindly 
 given me notes. 
 
 The patient was a girl, eight years old, appar- 
 ently quite healthy, as, indeed, she always had ap- 
 peared. When she was four days old it was observed 
 that her right leg was bent to an obtuse angle just 
 below its middle ; it may have been so at or before 
 birth. The bones were entire, but when she was 
 three years old a bone-setter broke them, made the 
 leg straight, and so fixed it and kept it steady for 
 some long time. But the fracture was not repaired ; 
 and all the means employed to obtain union com 
 pletely failed. Among these were long-continued 
 pressure and absolute fixity, resection of the ends of 
 the fragments and accurate wiring ; and this was re- 
 peated ; but nothing did good. The whole limb 
 wasted, and the leg could be bent in every direction. 
 Dr. Scowcroft amputated below the knee, and the 
 child recovered well, and the muscles of the thigh 
 grew quickly. There was no appearance of any pro- 
 cess of union at the fracture.
 
 136 SPELLINGS ABOVE THE CLAVICLE 
 
 CHAPTER XIV 
 
 SWELLINGS ABOVE THE CLAVICLE. 
 
 I WISH to draw attention to a kind of swellings above 
 the clavicle, of which I have many short notes, and 
 in which I believe that some good observer may 
 discern facts of pathological as well as of practical 
 importance. Practically, they are of interest as 
 being sometimes regarded as fatty tumours ; patho- 
 
 I 
 
 logically, I think they may be considered examples 
 of a localised myxoedema. 
 
 They are found in the hollow just above the 
 clavicle ; sometimes on both sides and symmetrically, 
 sometimes on only one side, and, I think, more often 
 on the left than on the right. They fill the hollow 
 space and may extend some short way above it on 
 the side of the neck. Thev are oval, with their 
 
 / 
 
 longer diameter transverse, lowly convex and usually 
 rather less than an inch in thickness. To the sight 
 they may appear well defined, but to the touch they 
 are not so ; their borders appear to be lost in the
 
 SWELLINGS ABOVE THE CLAVICLE 137 
 
 adjacent fat or connective tissue. The skin moves 
 freely over them, and they feel as if they could be 
 moved freely on the deeper parts ; but their substance 
 is so pliant that this test cannot be relied T on. They 
 may at first feel like soft fatty tumours, or like the 
 softer fatty overgrowths which one finds symmetri- 
 cally placed at the back of the neck or under the chin. 
 But these swellings above the clavicles are still softer 
 and more pliant, more easily pressed up and folded, 
 than any kind of fat, unless it be that which has 
 wasted and become soft and flabby like that of the 
 pendent part of the nates in one who is much, emaci- 
 ated. They are just like portions of soft myxcede- 
 matous tissue, and such I think they would be found 
 if they could be examined ; but I have never had an 
 opportunity of examining one, having not yet re- 
 moved one in the suspicion of its being a fatty or 
 other tumour. 
 
 I have seen some ten or twelve cases of this con- 
 dition, but have not seen one in which the growth 
 increased to such an extent as could be deemed un- 
 sightly, or could give any serious trouble other than 
 that of the fear of disease. I think that they have 
 all been in women in adult life, many of whom were 
 such as might be called neurotic and had heavy 
 aching pain in the swellings. In other respects 
 they were healthy, and in some they became less
 
 Io8 SWELLINGS ABOVE THE CLAVICLE 
 
 and so remained ; but it was observed in all that the 
 swellings often varied in size, ' puffing up ' at times 
 with increase of pain. 
 
 I should be ashamed of so incomplete a narra- 
 tive as this if it had any other purpose than that 
 of helping to diagnosis and of indicating what I 
 believe to be a good subject for study, localised 
 myxoedenia perhaps associated with disturbance of 
 some nervous centre. But, when writing on the 
 diagnosis of swellings above the clavicle, I may as 
 well add that the explanation of some of them is to be 
 found in the existence of cervical ribs. I remember 
 consultations on two such cases, in which the uplifted 
 and flattened subclavian arteries caused serious fears 
 of aneurism ; and more in which the rather enlarged 
 free ends of the ribs suggested exostosis. The 
 diagnosis will not be difficult to anyone who will 
 remember that cervical ribs are not very rare.
 
 AX IRREGULAR PULSE 139 
 
 CHAPTEE XV 
 
 AN IRREGULAR PULSE 
 
 IN the early part of July 1886, I chanced to find 
 that my pulse beat irregularly. It may have done so 
 before I observed it, for I was not in the habit of feel- 
 ing it, and only by chance did so now, while sitting 
 with my hands clasped, so that the beating of the 
 digital arteries could be felt in the mutually com- 
 pressed fingers. The irregularity was in the frequent 
 missing of one beat. Three or four or more would 
 follow regularly ; then, one would be missing ; and 
 then, in exactly the due time, the regular beats 
 would again follow. There was no order in the 
 times at which the missing of the beats occurred ; 
 the irregularity was quite irregular. Three beats 
 might be regular ; then one would be missed ; then 
 there might be six regular and a miss ; then ten or 
 fourteen or twenty ; then, again, four or five and so 
 on. I could neither then nor at any time after find 
 any rule or order in the method of irregularity.
 
 140 AX IRREGULAR PULSE 
 
 The defect was almost wholly in respect of the 
 time of the beats. At the most I could feel that the 
 beat which followed next after an intermission was 
 a little stronger than the others, as if during the 
 longer rest the ventricle gained rather more power 
 for contraction ; but the difference was not very 
 marked. I think, too, that the pulse became, gene- 
 rally, rather slower. For the last two or three years 
 it had been about eighty in the minute ; before this 
 time it had generally been from seventy to seventy- 
 five ; now again it was commonly, I think, not more 
 than seventy-two, even when one counted the inter- 
 missions as if they had been pulse-beats. And I 
 think it had for some time been becoming a little 
 harder, as if with an increase of arterial tension or 
 an increase in the toughness of the arterial walls. 
 
 With this irregularity of pulse I was not con- 
 scious of any change in my feelings of health. I 
 was rather tired with the year's work, but not more 
 than I usually had been in July ; and on the day on 
 which I detected the irregularity I felt very fatigued 
 
 O v / 
 
 by unusually hot weather ; but neither then nor at 
 any other time could I observe any change whatever 
 in any function except this of the heart, and in 
 this the only change was in its loss of rhythm. I 
 sometimes watched closely; but I could find no 
 change in breathing or digestion, in renal or intes-
 
 AN IRREGULAR PULSE 141 
 
 tinal action ; and Dr. Andrew found nothino- wrono- 
 
 o o 
 
 in the heart's sounds. In everything I seemed just as 
 usual, and my usual condition was that of quite good 
 health. There was one apparently slight change ; 
 and it seemed possible, not more, that the heart's 
 error was associated with this. For about two years 
 I had had on each leg a small patch of eczema, dry 
 and very thinly scaly, and sometimes at night irrit- 
 able and itching. They were such as I had often 
 had before on the legs or other parts, and I deemed 
 them ' gouty,' and took no measures to get rid of 
 them ; I rather preferred to have them as, probably, 
 averting some of those worse issues from the same 
 inherited malady as I had at times suffered with. 
 But a few weeks before I first observed the irregu- 
 larity of the heart's action these spots had begun to 
 grow paler, and less scaly and less irritable ; and 
 about ten days or a fortnight before the heart's error 
 was detected they wholly disappeared, and none 
 formed in any other place. 
 
 After the irregularity had been observed for two 
 months, during which I had never felt so many as 
 fifty beats, and seldom as many as fifteen, without an 
 intermission, my holiday-time came, and I went to 
 the Pyrenees, and some of the Proven9al towns. I 
 took no special care of myself, but ate and drank 
 the usual foods and wine of each place in the
 
 142 AX IRREGULAR TULSE 
 
 country, and travelled and walked and amused my- 
 self in any way that chanced. I could walk much 
 more and better than I expected ; as much as, at 
 least, twelve to fifteen miles, including 2,500 feet of 
 rather steep and very rough ascent and descent. 
 Still, the irregularity of pulse continued, and nothing 
 seemed to change it, except that in long walking up- 
 hill, the beats became quicker and fuller, and the 
 intermissions were less frequent. There were some- 
 times twenty or thirty regular beats, then one was 
 missing, then a succession of from five to ten or 
 fifteen, but never was there complete regularity, or 
 any order in the irregularity. 
 
 At the end of five weeks of thorough enjoyment 
 in which I had never once felt ill, or been conscious, 
 except by feeling my pulse, of any change in the 
 action of my heart, I came home quite refreshed. I 
 had never from any holiday felt greater advantages : 
 I could work harder, walk further and faster, and 
 digest and sleep, if possible, better than -before I 
 went abroad. 
 
 In the first ten days abroad I lost ten pounds in 
 weight; chiefly, I think, through much more than 
 usual sweating ; for there were two intensely hot days 
 in Paris ; and then followed active exercise in bright 
 
 o 
 
 clear air. In the five weeks I lost twelve pounds ; 
 but soon began to regain them in the conditions of
 
 AX IRREGULAR PULSE 143 
 
 home-life, when I had returned to the same diet and 
 manner of life as I had when the irregularity of the 
 pulse began, 1 and it still continued exactly as it had 
 been : or, if there were any alteration at all, it was 
 only in the intermissions being rather less frequent. 
 It was not till three weeks after my return home 
 that any change occurred ; and then I unexpectedly 
 found my pulse quite regular again, and just such as 
 it had been three months previously. I do not know 
 whether the change were accomplished suddenly or 
 gradually ; it must have been within two days ; and 
 the first time I observed it, it was complete. 
 
 Now, this irregularity of pulse had continued 
 unchanged in all the variety of home-life, and all the 
 different varieties of holiday-life. I tried in vain to 
 find anything materially affecting it. Heat or cool- 
 ness ; hard work or light ; exercise or rest ; full meals 
 or spare ; near sleeping or when waking, it was always 
 alike, unless in being made rather less irregular, and 
 more frequent and forcible during very active exer- 
 cise, or sometimes after a full dinner with wine. 
 Only one change could I observe about the time of 
 the pulse becoming regular again ; namely, that, in 
 the fortnight previously, the eczema on the legs, 
 
 1 For many years and, perhaps, for many more than those in 
 which I have observed it, I have always thus lost weight in holidays 
 abroad, always coming down from near 11 stone to scarcely more than 
 10 stone- I suspect that many others do the same.
 
 144 AN IliREGULAR PULSE 
 
 which, had disappeared just before the irregularity 
 began, now reappeared. At least, there were small 
 scattered papulas in and near the seats of the former 
 eczema, and they itched as that did, especially at 
 the change of temperature in undressing in a cool 
 room. 
 
 I will not profess more than a belief that there 
 may be an intimate relation, in some cases, between 
 an eczema and a regular pulse ; and that such a 
 relation existed in myself. I will not be so credulous 
 as to think I can explain it, or can conceive what 
 change from the ordinary condition of blood or 
 nerve-force it can be which, without any other appa- 
 rent alteration in any function in the body, can pro- 
 duce and maintain in combination a patch of eczema 
 and a disturbance of the tune-rate of the discharges 
 of force in the muscular fibres of the heart. I am 
 content to think of it as one of the facts which 
 justify the holding that few things are more incon- 
 ceivable than are many things which are certainly 
 true. 
 
 Sir Dyce Duckworth, in his admirable ' Treatise 
 on Gout,' page 319, has related a case very similar 
 to my own. 
 
 After 1886, when the foregoing paper was written, 
 my pulse remained regular, and I almost always had
 
 AN IRREGULAR PULSE 145 
 
 some little patch of eczema for about two years; 
 but the pulse became slower and was usually below 
 sixty. Then it became sometimes slightly irregular, 
 and so it has been at times ever since. Sometimes 
 I have had a trivial eczema ; sometimes muscular 
 aching or cramps ; sometimes a kind of flashing 
 neuralgia; but all these and other signs of incom- 
 plete gout, such as I have had for many years past, 
 have been of too short duration for me to find any 
 constant relation between them and the pulse. Only 
 I think I can be nearly sure that my pulse has 
 generally been regular at and near the times in 
 which I have had one or other of these signs of my 
 inheritance.
 
 146 SINGLE RARE CASES 
 
 CHAPTER XVI 
 
 SINGLE RAKE CASES 
 ABSCESS IN THE PATELLA 
 
 IN June 1860 I was consulted by a lady, forty years 
 old, who looked healthy, though, she said, she had 
 never been very strong and had, habitually, cold feet. 
 Near the end of October 1859 she began, without 
 evident cause, to have pains in the front of her left 
 knee. It was ascribed to rheumatism and so treated ; 
 but it increased and, after a very short time, though 
 she was free from pain during the day, she suffered 
 what she described as 'agonising' and 'excruciating' 
 pain every night. It began half an hour or more 
 after she went to bed, continued till she fell asleep, 
 and was attended with extreme sensibility to the 
 touch. There was, at that time, little if any swelling 
 at the knee ; the pain was at and near the patella. 
 In the second week of January there ensued ' pain, 
 swelling, and inconvenience ' in and about the knee- 
 joint, and a blister was applied, and after this she 
 never had the same nocturnal pain as before, but the
 
 SINGLE RARE CASES 147 
 
 swelling continued. In April, an additional swelling 
 appeared over the front of the middle of the patella ; 
 and here suppuration took place, as if with inflam- 
 mation of the patellar bursa, and pus was spontane- 
 ously discharged through an opening which remained 
 in June when first I saw the case. 
 
 There was now no appearance of general illness. 
 The w r hole knee-joint was slightly enlarged, rounded, 
 puffy, elastic as if with some increase of synovial 
 fluid, but, chiefly, with swelling of the tissues. But 
 the joint was not painful either in movement or on 
 pressure ; it could be moved quickly and there was 
 only slight lameness. Over the middle of the lower 
 part of the patella there was a small ulcerated open- 
 ing, like that of an abscess, through the thick tough 
 skin. It led to a subcutaneous cavity about half an 
 inch in diameter, the wall of which felt firm and in- 
 sensible ; but beyond this a probe could be passed to 
 a bare rough spot on the front of the patella near 
 ts lower border ; near this spot was a very sensitive 
 one, but the touching of the bone was painless. All 
 that could thus be found implied that the case was 
 one of necrosis of a piece of the patella such as 
 might have been produced by hard pulling of the 
 periosteum ; but neither this nor any other cause 
 could be assigned. 
 
 I cut right over the diseased part of the patella 
 
 I 2
 
 148 SINGLE RARE CASES 
 
 and found an opening of about one-sixth of an inch 
 in diameter, leading through the front wall of the 
 bone into a cavity of scarcely larger diameter extend- 
 ing right through its substance. The opening and 
 the walls of the cavity felt as if formed of sound 
 bone, not dead or very soft, and at its base the probe 
 felt only some soft structure ; as if the cavity, ex- 
 tending through the lowest part of the patella, 
 reached the fibrous and fatty tissues behind it, but 
 missed the articular cartilage and did not open into 
 the joint. I widened the external opening in the 
 bone, filled the cavity with scraped lint, covered it 
 with water-dressing and kept the limb completely at 
 rest. No trouble followed ; the wound and the 
 abscess slowly healed, [of course in more recent 
 times the healing would have been much more 
 speedy] ; and the recovery was complete. The 
 patient could walk as much as she wished, and, if 
 she did not walk fast, did not appear lame ; only the 
 knee remained slightly enlarged and the tibia was 
 a very little displaced backwards. She lived without 
 discomfort at the knee and had good general health 
 for more than twenty years after the operation.
 
 SINGLE 11AKK CASES 149 
 
 DEFECT OF ONE HALF OF THE DIAPHRAGM 
 
 Iii 1851, a man was admitted by my house-sur- 
 geon, Mr. Archer, into St. Bartholomew's, and he 
 said that, just before he came, his master was going 
 to strike him and, in his fright, he jumped back and 
 ' felt something give way ' in his chest. He was 
 faint and depressed and complained of some pain in 
 his left side ; but there was nothing indicating the 
 need of active treatment and he was left at rest in 
 bed. In the evening, a few hours after his admis- 
 sion, he had cough and dyspnoea, or, rather, a cough 
 which he had had for two weeks became worse, and 
 he was now found to have double pneumonia. With 
 this I found him next day and with this in two days 
 he died. [A more exact record of his case would 
 have been kept if there had been any suspicion of 
 what would be found after death.] 
 
 In the examination we found the greater part of 
 the lower lobe of the right lung and the lower half 
 of the upper lobe of the left lung completely solid, 
 in well-marked ' red hepatisation,' soft, brittle, with 
 thick turbid livid fluid. There were obsolete tuber- 
 cles in the upper part of the right lung ; but with 
 these exceptions the organs of the chest and abdo- 
 men appeared healthy. What was most remarkable
 
 150 SINGLE RARE CASKS 
 
 was that the left half of the diaphragm arched up to 
 the space between the third and fourth ribs, and the 
 stomach, which was very large, was pushed up so 
 high as to be nearly concealed by the left ribs, the 
 liver lying below and in front of it. The right half 
 of the diaphragm appeared normal. The reason of 
 this malposition appeared to be in the condition of 
 the left half, which was almost wholly devoid of mus- 
 cular fibres. In the left crus, which was altogether 
 about half as large as natural, there were strips of 
 pale muscular tissue ; but in the left half of the arch 
 there were only just so many fibres that, on holding 
 the diaphragm to the light, one could see a few 
 slender pale pinkish lines radiating from its central 
 tendon to its outer border. They were just visible ; 
 just enough for saying that muscular fibres were not 
 wholly wanting. No more than these existed either 
 by the central tendon or near the ribs. On the right 
 side all appeared natural. No defect of symmetry 
 was found either among the intercostal muscles or in 
 any other part ; but the phrenic nerves and arteries 
 were not examined. 
 
 [I venture to add the comment on the case 
 written at the time.] 
 
 Many things here deserve notice : 
 
 1. A very rare condition ; briefly, an almost com- 
 plete defect of the proper muscular substance of a
 
 SINGLE HARE CASES 151 
 
 diaphragm in its left half: the right half being 
 healthy. 
 
 2. Probably, this was a congenital defect; for 
 there was no apparent change of structure ; the 
 pleura and peritoneum were in contact, both healthy 
 in their structure and with no fat or other degene- 
 rate tissue between them. 
 
 3. There appeared, notwithstanding this defect, 
 to be sufficient respiratory power. The patient 
 breathed very forcibly in his dyspnoea and, in aus- 
 culting him, the sounds and movements of the chest 
 were just as in an ordinary double pneumonia. The 
 stomach was found to be very inflated and high-up ; 
 but there was nothing suggesting a suspicion of the 
 defect of the diaphragm, and I am quite sure that 
 the left side of the chest moved freely and that the 
 patient, in his dyspnoea, often lay on his right side. 
 
 4. Were then the intercostal muscles sufficient 
 for free respiration ? If they were, the case may 
 be adduced in evidence of their great inspiratory 
 power. 
 
 5. The history of the recent illness was too ob- 
 scure to make one think more than that the 'give- 
 way ' which the man felt and some of the subsequent 
 pain were due to the unequal ' tug ' of the diaphragm 
 when, in his fright, he may have made a sudden 
 deep inspiration.
 
 152 SINGLE BARE CASES 
 
 LARGE RANULA 
 
 April 1854. Gr. K., thirty-four years old, a 
 bookbinder, was a healthy-looking man, but had a 
 large swelling on the right side of his face and neck, 
 which felt like a cyst, flaccid and as if half-filled 
 with fluid. It was irregular, lobed, appeared subcu- 
 taneous and extended downwards to the cricoid 
 cartilage, upwards to the zygoma and malar bone, 
 backwards to the anterior border of the masseter 
 and the posterior border of the lower jaw, forwards 
 to near the middle line below the jaw and to near the 
 angle of the mouth above it. In all this extent the 
 swelling felt alike soft, flaccid, fluctuating, flapping. 
 All the skin over it was healthy : so was the mucous 
 membrane of the cheek which the swelling pushed 
 slightly inwards. Sometimes, when pressing the 
 swelling a little glairy fluid oozed through a small 
 aperture in the middle line in front of the frasnum 
 linguae ; but this did not always happen, and no con- 
 tinuation of the swelling could be felt under the 
 tongue ; there was here only a general rising of the 
 mucous membrane of the mouth, with some increased 
 firmness as if from former hardening of the part, 
 The swelling was not transparent. All other parts 
 appeared healthy.
 
 SINGLE BARE CASES 103 
 
 The patient said that this disease had existed four 
 years, and that it began as a swelling under his 
 tongue, which after about a year burst, discharged 
 a glairy fluid into his mouth and then disappeared. 
 He had never since had a swelling under his tongue ; 
 and the present swelling appeared soon after the 
 discharge of the former one, but only under the jaw 
 and not reaching to the cheek. About April 1852, 
 this second swelling emptied itself into the mouth 
 through an opening under the tongue, and the parts 
 collapsed and regained their healthy aspect. A third 
 time, however, the swelling formed and again, about 
 April 1853, similarly discharged itself. Then the 
 present swelling began to form : it steadily increased, 
 without pain, and now first extended over the jaw 
 and up the cheek. No treatment had been em- 
 ployed. 
 
 I made a puncture about half an inch long in the 
 lower part of the swelling and let-out nearly twelve 
 ounces of a thick glairy fluid, tinged pink as if with 
 colouring matter of blood. The cyst, so far as it 
 could be seen, had walls from J to J of a line in 
 thickness with a pure-white polished internal sur- 
 face. 
 
 In a week the swelling became as large as before. 
 It was then punctured with a trocar and cannula ; 
 then it inflamed and suppurated and was more freely
 
 154 SINGLE RARE CASES 
 
 opened, and then it slowly contracted with thickening 
 and hardening of all the structures round it and with 
 suppuration at different parts of its walls. It ap- 
 peared cured at the end of two months and I believe 
 no further trouble occurred.
 
 CHAPTER XYT1 
 
 THE USE OP TUB WILL FOR HEALTH. 
 
 IT may often be observed that not only the signs 
 of some diseases but their progress and issue may, 
 in some measure, be determined by the patient's 
 will ; I mean not only by the will to live prudently 
 or unwisely, but by the direct influence of the will 
 on sensation and motion. 
 
 The subject may be studied in, at least, three 
 sets of cases ; some show how the will, by acts of 
 attention, can affect the clearness and intensity of 
 pain and other morbid sensations ; others how it 
 can control the movements of muscles generally 
 involuntary ; others how it can, at least in some 
 degree, determine the methods of some of the pro- 
 cesses of organic life. And in every set of cases 
 illustrations may be found of the power of the pur- 
 posely-educated will to prevent or remedy the defects 
 due to its natural or permitted weakness.
 
 150 THE USE OF THE WILL FOR HEALTH 
 
 INFLUENCE OF THE WILL IN PAIN AND OTHER 
 SENSATIONS OF DISEASES. 
 
 We have no means of estimating the degrees of 
 pain from similar sources in different persons, or from 
 different sources in the same person. But we may 
 fairly speak of different diseases as more or less 
 painful, and of different persons as feeling some less 
 and some more acutely the pain of this or that 
 disease. On the whole, too, we may be sure that the 
 more cultivated races are far more sensitive to pain 
 than are the less cultivated ; and that, among our- 
 selves, a similar rule holds ; that mental cultivation 
 increases the sensibility to pain as well as to pleasures ; 
 and that it does this, in great part, by increasing the 
 force and facility with which the will, though it 
 may be almost unconsciously, can direct attention 
 to external things. Moreover, what is, in this respect, 
 true for pain is true for other morbid sensations, 
 itching, burning, tingling, and the like ; but pain, as 
 generally understood, will give the best illustrations 
 of my subject. 
 
 The influence of the attention, that is of the will 
 directed to sensations, is illustrated by facts at op- 
 posite extremes ; by those which, at one extreme, 
 show that pain is not felt when the attention is 
 completely distracted, and, at the other, that pain 
 becomes more keen and more constant when the
 
 THE USE OF THE WILL FUR HEALTH 157 
 
 attention is constantly, though it may be almost 
 unconsciously, directed to it. Among the former are 
 the numerous instances in which soldiers engaged in 
 battle have been for a time unconscious of having 
 received severe wounds. The latter are shown in 
 cases, to which my notes often refer, of persons who 
 have unwittingly cultivated a natural sensibility to 
 pain. These show that it is with pain as it is with 
 sight or touch or the muscular sense, or, for example, 
 with hearing. As some persons have, naturally, an 
 * ear for music,' so have some, and often the same 
 persons, a very fine sensibility to pain ; and, as one 
 who has habitually and very earnestly directed his 
 ear, i.e. his auditory nerve-centre, to the discernment 
 of sounds becomes, in time, keenly, and without 
 conscious effort, sensitive to even the least sound or 
 the least variation of a tone, so is it with some in 
 regard to pain. With almost constant direction of 
 the mind they increase every pain, and even find or 
 insert pain in places and conditions in which one less 
 exercised would not feel any. And this goes on till 
 they become able, without conscious effort, to observe 
 the least deviations from natural sensation and almost 
 wholly unable to distract the mind from them. 
 
 Hence it comes that, in a given kind and amount 
 of injury or disease, that which one person hardly 
 observes or regards as a mere discomfort, is to
 
 158 THE USE OF THE WILL FOR HEALTH 
 
 another an ' agony ' ; and this, it may be, not in 
 imagination, not in invention, but as really felt as are 
 those refined sensations of the artist, the musician, 
 or the gourmet, to which common people cannot 
 attain. I think that nearly every one in practice 
 must have seen cases illustrating these statements : 
 but I may tell of some for examples. 
 
 Thus, as showing insensibility when pain was not 
 expected or attended to : A boy from whom a part 
 of a finger was to be amputated refused to let it be 
 done without chloroform ; but, as it was not con- 
 venient to give this, the surgeon signalled to a dresser 
 to pretend to give it with a wet sponge. The boy 
 smelt the sponge till he believed himself insensible, 
 and the operation swiftly done was not felt. 
 
 And, for the indifference to pain of the un- 
 cultivated mind : A lady in New Zealand gave a 
 pair of leather boots to a naked-footed native boy. 
 They were too narrow for his toes, and he at once, 
 with a tomahawk, chopped a piece off the inner 
 border of the end of each of his great toes, covered 
 the wounded parts with some dry stuff that lay on 
 the ground, put his feet back into the boots and 
 wore them till the wounds were healed. 1 
 
 1 It is often said that 'savages' have exceedingly acute senses 
 because they hear or see some things which others cannot. But this 
 acuteness is only in relation to one or a few things ; just as dogs have 
 an exceedingly acute sense of smell for game or blood or some such
 
 THE USE OF THE WILL FOR HEALTH 
 
 i 
 
 And for an instance of the inducing of pain by 
 attention. A lady showed me a cancer of the breast 
 which I could be sure had existed for several months, 
 but which she had not been aware of till, some 
 days before she consulted me, she saw it in her 
 looking-glass. I asked if it had been painful, and 
 she answered, ' Of course it has been painful ever 
 since I saw it.' It had not been so till her attention 
 was directed to it. 
 
 From facts such as these, numerous as they are, we 
 may deduce some rules to be observed in practice : 
 
 (1) It is neither wise nor just to say that all 
 these ' painful ' people, as they may be called, only 
 imagine the pain which they describe. They really 
 feel it all, unless they wilfully tell lies, and they are 
 unable to distinguish the pain which may naturally 
 be due to the injury or disease from the augmentation 
 of it which is due to their too watchful attention. 
 
 But (2) in these, and, in various degrees, in many 
 other persons the pain suffered supplies no sure 
 evidence of the kind, quantity, or intensity of a 
 disease. The value of the evidence of pain cannot 
 
 thing, but none, so far as we know, for flowers or wines, or the many 
 more which are discerned by cultivated men. In this wide and 
 various range of keen sensibility in all the sense-organs the evolution 
 of our race is shown as evidently as in the range and variety of sen- 
 timents and intellectual power. In our estimate of the degrees of sen- 
 sibility of any sense-organ in ourselves and other animals we may 
 fairly reckon the range and variety of power as well as the intensity.
 
 1GO THE USE OF THE WILL FOR HEALTH 
 
 be estimated without some knowledge of each 
 patient's mental character, and, when he or she is 
 known to be naturally very sensitive or very 
 watchful, it will often be safe to hold that, in 
 obscure cases which have long endured, without 
 any grave injury to the general health or any 
 manifest change of structure or loss of weight, the 
 more the pain the less is the organic disease, if, 
 indeed, there be any at all, at the seat of pain. 
 
 (3) On the other hand, they that are careless 
 and not observant of themselves, however keen they 
 may be in their study of external things, may be found 
 with diseases long overlooked or neglected, or only 
 sometimes felt, even though they be diseases com- 
 monly very painful. Here, too, the diagnosis must 
 be determined by the surgeon's sensations rather than 
 by the patient's. He may have in his mind, ' It is 
 by what I feel, not by what you feel, that this question 
 is to be settled.' 
 
 (4) A lesson for all whose sense is quick for pain 
 is that they should strive for such control of will as 
 to be able to divert the attention, as much and as 
 often as possible, from the watching of pain. For 
 pain expected, watched for, long thought of, or 
 talked of, will come ; it will come in or from the 
 nerve-centre and may be as bitter as any from the 
 nerves' ends. Any real pain that is often described
 
 THE USE OF THE WILL FOR HEALTH 101 
 
 by one who feels it is thereby nurtured, and the 
 power of discerning it is being made stronger ; and, 
 conversely, the longer and the more often the atten- 
 tion can be diverted from any pain, the less does 
 the power of discerning that pain become, just as 
 the muscular or any other sense, when out of 
 practice, loses some of its cunning. And patients 
 should not trust to others for this distraction ; they 
 should educate their own wills so as to be able to 
 direct their attention to whatever may for the time 
 be best, 
 
 INFLUENCE OF THE WILL ON OTHER THAN THE 
 VOLUNTARY MUSCLES 
 
 The influence of the will on disorderly or incon- 
 venient muscular actions ma}' best and most usefully 
 be studied in the half-involuntary organs, whose 
 action is usually preceded by distinct sensations and 
 associated with an effort of the will. 
 
 The rectum and the bladder are the best of these. 
 Usually, in healthy persons, they have certain habits 
 in their acting ; the once a day for the one, the three 
 or four times a day for the other, and these at certain 
 regular periods of the day or night. The habit is 
 treuerally a good one : but I think it is advisable 
 that men should not hi this more than in anything 
 else become the slaves of habit ; for if they do, then, 
 
 M
 
 102 THE USE UF THE WILL FOR HEALTH 
 
 when the habit is perforce disturbed, it may bring 
 distress, and to some persons utter misery and 
 alarm. Cases of retention of urine are only too 
 common in those who, being in the regular habit 
 of passing it every three or four hours, are by some 
 accident obliged to hold it for six or eight. Or, 
 if they escape this trouble once or twice, then they 
 are frightened lest the difficulty should occur again, 
 and they are always watching their bladders, and are 
 on the alert for the sensation of fulness and of the 
 muscular disquietude of the walls ; the sensation 
 which, like all others, will come the quicker and the 
 sharper the more earnestly it is expected. 
 
 Healthy people should not allow this. These half- 
 involuntary organs are good servants but very bad 
 masters ; and the more they are indulged the more 
 peremptory do they become. They should be edu- 
 cated to subserviency ; and the earlier in adult life 
 that their education is begun the better it will be. 
 If they are fairly healthy, any one with a resolute 
 will may easily teach them. It is sufficient if the 
 sensation that usually indicates the need of action 
 be sometimes neglected ; if the attention be diverted 
 from it, or permission to act be resolutely refused, or 
 else be promised in half an hour or an hour. It is 
 well, at least for some, if this education be insisted 
 on, at first, only at times and in places in which it is
 
 TIII-: rsi: or TIIK WILL FOI; IIKAI.TII lf.3 
 
 sure that the promise to permit the action can be 
 fulfilled. A bladder imperfectly educated should 
 not have to claim such a fulfilment in a railway- 
 carriage or a church. But with a little prudence of 
 this kind I believe that any healthy and not too old 
 person may educate his bladder to be quiet for eight 
 or ten hours, and within these limits to act at any 
 time that is most convenient to him. Similarly, any 
 one may teach a healthy rectum, and may thus gain 
 a very desirable liberty for business or for pleasure 
 at the times that are most convenient to himself or 
 others. It involves nothing more than a resolute 
 extension of the usual range of the will. 
 
 It is needless to multiply the instances in which 
 one has seen the influence of the will in tendencies 
 to disorderly muscular action. A strong-willed man 
 can often repress the words and movements signifi- 
 cant of delirium ; or he can conceal such a degree 
 of drunkenness as a weak man would show in every 
 word and movement ; and, unless in real disease, he 
 can enjoy a wider range of liberty in respect of food 
 and drink and sleep, of work and of rest, than is 
 possible for one who is timid, self-watchful or 
 irresolute, although, in all that is commonly under- 
 stood as bodily health, they may be alike. 
 
 I feel strongly that this influence of the will upon
 
 101 THE USE OF THE WILL FOR HEALTH 
 
 the health should be a subject of resolute and careful 
 self-education. Men should resolve that they will not 
 allow every unusual sensation to distract their atten- 
 tion from work or any other important object. If 
 they would steadfastly go-on working in spite of 
 noises in the street or of talking in their rooms, they 
 would more easily be indifferent to sensations sug- 
 gestive of disease. The opposite of this is too often 
 allowed and even boasted of. It is common to hear 
 healthy people say, and sometimes as if it were praise- 
 worthy, that they cannot sleep on this side or that, 
 or without a pillow or some such help. In some of 
 these there may be just reason for their defect, but 
 in the greater number it is a mere habit grown out 
 of a want of the will to resist some discomfort. If 
 such people would resolutely pass some hours, or a 
 night or two, without sleep, sheer fatigue would 
 insure them sleep in any posture whatever. And 
 others, many of whom are healthy, tell that, unless 
 they have their meals at regular and fixed times, 
 they cannot digest them. There are few of these 
 who may not safely resolve that they will not fix 
 the times, but will breakfast and dine whenever they 
 please or when circumstances make it most con- 
 venient. Their digestive organs will submit to their 
 wills, if their wills do not submit to them. 
 
 These small imperfections should be, if possible,
 
 THE USE OF THE WILL FuR HEALTH \(\~, 
 
 amended by the will, because they all restrict that 
 reasonable and useful liberty of life which we may 
 enjoy, and they diminish our power for the work 
 which we ought to do ; they are hindrances to both 
 pleasure and duty. Besides, harmless as they may 
 seem in health, they may be serious complications in 
 disease. A man, for instance, who cannot sleep on 
 his right side is at a great disadvantage if he have 
 a pleurisy on the left ; he who cannot sleep on his 
 back is doubly distressed by a fractured thigh, till, 
 after some sleepless nights, the necessity of lying on 
 his back enables him to sleep on it as well as he used 
 to do on his side ; he who binds himself to certain 
 times for his meals is unfit for the casual and 
 irregular work by which others can prosper. 
 
 I may as well say that I am the more sure of 
 these things because I have myself done what I 
 have here recommended, and have thus worked hard 
 for more than fifty years, happily and without harm. 
 And I have learned to believe that many persons, 
 or all who are not definitely unhealthy, may go even 
 beyond these rules. If they will resolve that their 
 stomachs shall tolerate this or that food, or shall not 
 have this or that stimulant, whether wine or mustard 
 or any other, their stomachs will, in time, yield. 
 They need not be more resolute than most of those 
 must be who wish to be smokers; these find that,
 
 THE USE OF THE WILL FOR HEALTH 
 
 after a few days' distress, pleasure comes from the 
 very thing that was a cause of misery. They have 
 only to place themselves willingly in difficulties such 
 as others have to endure whether they will or no ; 
 as when, for pleasure or for duty, they go to sea or 
 to places where the food seems at first unfit to eat. 
 In time they learn to enjoy it and it serves for active 
 
 work. 
 
 ^*** 
 Elasticity and pliancy in all the functions of the 
 
 body are among the essential characteristics of health, 
 and all should strive to attain them. That is not 
 
 ritt 
 
 completely good health which cannot endure any 
 disturbance from the usual habits of life. I wish 
 there were as much ambition for really good health 
 as there is for athletic strength or bravery. There 
 is too much of the very opposite, and one hears 
 people boast that they cannot do this or that, and 
 they write or talk as if all others ought to be like 
 them. It is as if a cripple should insist that others 
 ought to limp as he does.
 
 INDEX 
 
 ABS 
 
 ABSCESS, detection of, 56; under 
 muscles, 59 ; in pelvis, 59 ; in 
 breast, 60 ; abdominal, 65 
 
 Acromion, necrosis of, 2 
 
 Acute necrosis, 3 
 
 Age, in relation to injuries, 8 
 
 Ague, sequels of, 99, 101 
 
 Anus, abscess near, 58 
 
 Attention, influence of, 156 
 
 BIRDS, chronometry in, 70, 80 
 Bladder, degeneration, 96 
 Bursas, diseases of metatarsal, 10 
 
 CARDIAC CENTRES, rhythm in, 75 
 Caries, after strains, 4 
 Chronic abscess, 63 
 Chronometry of life, 67 ; varieties 
 
 in same species, 77 
 Clavicle, swellings above, 136 
 Corpora cavernosa, diseases of, 15 ; 
 
 induration of, 18, 24; gouty, 18; 
 
 syphilis, 20 ; clots in, 20 
 Cramp, inducing periostitis, 6 
 
 DIABETIC GANGRENE, 116 
 Diaphragm, defect in, 149 
 
 ECZEMA, with irregular pulse, 143 
 Eggs, chronometry in development, 
 71 
 
 FASCIA, palmar, induration of, 18 
 Fatty tumours, diagnosis of, 126 
 Fistula, under prepnce, 60 
 Fly-fisher's elbow, 7 
 
 OSf 
 
 Foot, Dr. Morton on neuralgia in, 
 
 12 ; diseased bursse in, 10 
 Fractures, in children, 130 
 
 GANGRENE, diabetic, 116 ; repair 
 after, 120 ; shedding of nails, 
 122; necrosis; in scalp, 123 
 
 Glans penis, fistula in f 21 
 
 Gout, in penis, 1 5 
 
 Growth, delayed, 90 
 
 Gumma, suppurating, 65 
 
 HEART, rhythm, 75 
 Herpes of prepuce, 110 
 Hip-joint, 49 
 
 LAWN-TENNIS elbow, 7 
 
 Limbs unequal, 31 
 
 Loins, hollow, 34 
 
 Looks, as indications of age, 87 ; in 
 
 young, 87 ; in old, 92 
 Lupus, 53 
 
 Lymphadenoma, softening, 65 
 Lymph-glands, suppuration in, 57 
 
 MYXCEDEMA, localised, 138 
 
 NECROSIS, after strains, 2 ; of 
 acromion, 2 ; of humerus, 3 ; in 
 diabetes, 122 
 
 Nerve-force, disease due to disturb- 
 ance of, 105 ; rapid wasting, 105 ; 
 after herpes, 107; necrosis, 108 
 
 Nose, 51 
 
 (EDEMA, soft, 61 
 Osteitis deforman, 134
 
 168 
 
 INDEX 
 
 PAI 
 
 PAIN, insensibility to, 158 
 Paraplegia, sloughing in, 113 
 Parotitis, after sight of acid, 109 
 Patella, abscess in, 146 
 Penis, diseases of, 15 
 Penis, fistula in glans, 21 
 Perineum, abscess in, 58 
 Periostitis, after strains, 1 
 Postures, bad, 25, 29 
 Premature development, 94 ; de- 
 generation, 95 
 Psoas abscess, 5 
 Pulling, a cause of periostitis, 1 
 Pulse, irregular, 139 
 
 QUIET diseases, 48 
 
 RANULA, 152 
 Raynaud's disease, 110 
 Eepair after gangrene, 114 
 Kesidual diseases, 98 
 Rhythmic movements, 75 
 Rigor after operation, 101 
 
 SAVAGES, senses in, 158 
 Scapula, prominence of, 33 
 Selection of species, influence of 
 
 time-rates on, 82 
 Septum of nose, 51 
 Sequels of disease, 98 
 Shoulders, round, 34 
 Softening in abscesses, 56 
 
 WIL 
 
 Spines, various forms of, 26 ; sus 
 pected, 25 ; aching, 27 ; caries 
 of, 4, 39 ; in elderly people, 39 ; 
 obscure, 39 
 Sprains, 1 
 
 Subcutaneous ulceration, 125 
 Symmetry, deviations from, 30 
 Syphilis, sequels of, 99, 103 
 
 TEETH, chronometry in life of, 
 
 69, 94 
 Tibia, tubercle of, 6 ; ununited 
 
 fractures of, 130 
 Tumours, softening of, 64 
 Turtles, observance of time in their 
 
 habits, 72 
 
 ULCERATION, subcutaneous, 125 
 Unpunctuality, in life, 66 
 Ununited fractures in. children, 130 
 Urethra, gouty inflammation of, 15; 
 minute fistulae, 21 
 
 VACCINE, time-rate in, 72 
 Vertebrae, prominence of spines, l>6 
 
 WILL, use for health, 155, 164 ; in- 
 fluence on pain, 156 ; on half- 
 involuntary organs, 161 ; on 
 bladder and rectum, 161 
 
 PRINTED BY 
 
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