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Title: Some Medical Aspects of Old Age

Author: Sir Humphry Davy Rolleston

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*** START OF THE PROJECT GUTENBERG EBOOK SOME
MEDICAL ASPECTS OF OLD AGE ***

SOME MEDICAL ASPECTS
OF OLD AGE

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SOME MEDICAL ASPECTS
OF OLD AGE
BEING THE LINACRE LECTURE, 1922,
ST. JOHN’S COLLEGE, CAMBRIDGE

BY
Sir HUMPHRY ROLLESTON, K.C.B.
M.D., D.C.L., LL.D.
PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON
EMERITUS PHYSICIAN, ST. GEORGE’S HOSPITAL
SOMETIME FELLOW OF ST. JOHN’S COLLEGE, CAMBRIDGE

MACMILLAN AND CO., LIMITED
ST. MARTIN’S STREET, LONDON
1922

COPYRIGHT

PRINTED IN GREAT BRITAIN.

PREFACE
The material in this small volume was collected in connexion with the
Linacre Lecture at St. John’s College, Cambridge, and has been somewhat
expanded since its delivery on 6th May 1922. The introduction is chiefly of
local interest in connexion with the history of the Linacre Lecture. Without
attempting a complete account of old age and its diseases I have passed in
review some ancient and modern medical aspects of this subject, but, except
for incidental references, medical treatment has not been considered.
For ready help, especially as regards the illustrations, my cordial thanks
are due to C. J. S. Thompson, Esq., M.B.E., of the Wellcome Historical
Museum, and for the index I am much indebted to H. M. Barlow, Esq.,
Assistant Librarian of the Royal College of Physicians of London.
H. R.

CONTENTS
PAGE
I. Introduction 1
II. Duration of Life 9
III. Onset of Old Age 26
IV. Factors influencing Longevity 32
V. Causes of Senescence, with a note on
Senescence and Carcinoma 62
VI. Normal Structural Changes in Old Age 90
VII. The Physiology of Old Age 115
VIII. The Description of Old Age in the Twelfth
Chapter of Ecclesiastes 129
IX. Distinction between Healthy and Morbid
Old Age 135
X. Diseases in and of Old Age 139
Index 157

ILLUSTRATIONS
FIG. FACE PAGE
1. William Heberden, M.D., F.R.S. 2
2. Sir Thomas Watson, Bt., M.D., F.R.S. 4
3. Professor John Haviland, M.D., F.R.C.P. 6
4. Henry Jenkins, reputed to have lived 169 years 20
5. Thomas Parr, reputed to have lived 152 years 22
6. Katherine, Countess of Desmond, reputed to have
lived 140 years 24
7. Petratsch Zortan, in his reputed 185th year 26
8. Hungarian husband and wife, reputed to be 172
and 164 years old respectively 36
9. Sir Henry Pitman, M.D., F.R.C.P., a medical
centenarian 52

I

INTRODUCTION

The Linacre Foundation dating from 1524 is the oldest medical
Lectureship in the University, for it was sixteen years later that the Regius
Professorship of Physic was established by Henry VIII. Formerly this
College Lectureship was held more or less indefinitely by Fellows of the
College, with two eminent exceptions, namely, Sir George Paget and Dr.
J. B. Bradbury; but in 1908 the Lectureship was made an annual and open
appointment, and until this year no member of the College has held this
office: I am therefore most deeply conscious of the high honour that has
been conferred upon me.
Though the statute that the Lecturer should explain Galen’s treatises De
Sanitate Tuenda and De Methodo Medendi as translated by Linacre, or De
Elementis et Simplicibus, has long lapsed, his first words should be directed
to the pious memory of the founder; but as in 1908 the late Sir William
1
Osler devoted the first of the new series of Linacre Lectures to a
sympathetic consideration of his brother scholar-physician, it would be
worse than unwise to attempt more than the briefest reference.

Fig. 1.—William Heberden, M.D., F.R.S., in his 86th year. Linacre
Lecturer, 1734–38.
From an engraving by James Ward of a portrait painted by Sir William
Beechey, R.A.

Thomas Linacre (1460–1524) was born at Canterbury of parents who
have eluded research, and his connexion with the old family that took its
name (Linacre = flax farmer) from a hamlet near Chesterfield in Derbyshire

was regarded by J. F. Payne as merely an assumption. Believing that those
devoted to learning should be free from the obligations of the married state
2
Linacre remained single, so that he had no direct descendants; his will
contains references to his brother, who had the same Christian name—
Thomas—as himself, two sisters Alice and Joan, two nieces Agnes and
Margaret, and two cousins Robert Wright of Chester and Richard Wright;
3
but according to Payne the family history cannot be traced any further. I
recently had a faint hope that I had got on the track of collateral
descendants, but on enquiry it was courteously made clear that though the
family in question was descended from a Mrs. Linnecar, her connexion with
T. Linacre rested on tradition only and that no documentary evidence or
genealogical tree existed to justify any claim. It may be remembered that
Linacre was one of the earliest English students (circa 1488), more than a
century before William Harvey, to study medicine and take the doctorate at
the ancient University of Padua, which celebrated its seven-hundredth
anniversary in May 1922. It is, next, natural to look back to the first holder
of this Lectureship, and to wonder what manner of man he was and what he
taught. To the Master of St. John’s College I am indebted for the few details
that are known of Christopher Jackson (B.A. 1524–25, M.A. 1527), who
was buried in the old Chapel on July 2, 1528, his death according to a brass
4
erected to his memory in the new antechapel being “e sudore britanico.”
Some of the Lecturers were without a medical qualification, and of these
Matthew Prior (1664–1721), the poet and diplomatist, who was a “Medical
Fellow” for life and Linacre Lecturer from July 5, 1706, to July 7, 1710,
was the most famous. That he ever lectured is more than doubtful, but he
appears to have thought out reasons for not doing so: at any rate his Alma or
the Progress of the Mind (written about 1715) contains in its third canto the
lines:
how could I explain
The various labyrinths of the brain!
Surprise my readers whilst I tell them
Of cerebrum and cerebellum!
How could I play the commentator
On dura and on pia mater!

Three of the Linacre Lecturers under the old dispensation stand out for
special remembrance on account of their influence on Medicine:
William Heberden the Elder (1710–1801), the author of the
Commentarii de Morborum Historia et Curatione, published posthumously
(1802), held office from 1734–38, and was described by Sir William Osler
5
as the “English Celsus.”

Fig. 2.—Sir Thomas Watson, Bt., M.D., F.R.S. President of the
Royal College of Physicians of London, 1862–67. Linacre
Lecturer, 1822–26.

From an engraving by George Cousins, R.A., of a portrait
painted in 1867 by George Richmond. R.A., now in the
Royal College of Physicians of London.

Sir Thomas Watson (1792–1882), whose Lectures on Physic held its
place longer than any medical text-book of modern times and set an
example of style that still commands our admiration and imitation, was
Lecturer 1822–26, and in the first year of office was also a Proctor.
Subsequently (1862–67), he was President of the Royal College of
Physicians of London, the most magnificent of Linacre’s Foundations; this
appropriate association was shared by William Baronsdale (P.R.C.P. 1589–
1600), by Thomas Gisborne, who was President on three separate occasions
(1791, 1794, 1796–1804) alternately with his senior Sir George Baker, and
by Sir Norman Moore of St. Catherine’s College (P.R.C.P. 1918–22), who
gave the Linacre Lecture under the new regulations in 1913 on The
6
Physician in English History.
John Haviland (1785–1851), the only one of these three who remained
in Cambridge, and the only one who did not become a nonagenarian, was
Linacre Lecturer for two periods (1817–22, 1826–47), Sir Thomas Watson
intervening. As Professor of Anatomy (not human anatomy) from 1814–17
he delivered the first regular course of lectures on human anatomy; and
when he succeeded Sir Isaac Pennington (also Linacre Lecturer, 1767–
1816) as Regius Professor of Physic (1817–51) he was the first to give
courses in pathology and the practice of medicine, thus rousing the post
from the sleep of a sinecure, and to make the medical examinations a real
and rigid test instead of little more than a farcical form consisting of a few
viva voce questions. Further, had it not been for his influence and insistence
7
the medical faculty might have been abolished, and it was said after his
death that the subsequent success of the medical school was due to his
exertions. He wrote little and perhaps for that reason his name is seldom
mentioned now, but if the work that has since been done by this medical
school be his monument he could hardly have a greater.

Fig. 3.—John Haviland, M.D., F.R.C.P. Professor of Anatomy
1814–17, Regius Professor of Physic in the University of
Cambridge, 1817–51; Linacre Lecturer, 1817–22 and
1826–47.

From a drawing done in 1851 by Wageman. For this I am indebted to
H. A. Haviland, M.B.

The somewhat neglected subject of Old Age has a very pertinent
connexion with the most essential aim of medicine as a whole, namely, the
prevention of disease. For when the ideal of the prophylaxis of infection
and of other causes of morbid action is attained, a healthy old age and
physiological death without attendant disabilities and horrors should be the
common lot of man instead of being somewhat exceptional in the case of
the first and extremely rare as regards the final act. The conditions
favouring longevity and mens sana in corpore sano are those necessary to
make the future of the human race a happy and beneficent prospect instead
of a problem inspiring doubt if not pessimism; or in Descartes’ words, “we
might be free of an infinity of maladies both of body and mind, and even of
the infirmities of old age, if we had sufficient knowledges of their causes
and remedies.” But in addition to this broad ground of interest there are
reasons why a discussion of this subject has a special claim for
consideration in Cambridge. The objects of a University include the
preparation of its alumni for life in its fullest and best sense, and from this
point of view the permanent ornaments of the community ever set an
unobtrusive example of the way to deserve and enjoy a healthy, happy, and
useful old age, namely, activity of mind and body and moderation in all
things; such a life of 75 years (that of Professor G. D. Liveing) in the
University must be in your recollection as described by the Public Orator as
tam honesta, tam utilis. Further, as in private duty bound, I cannot forget
that Sir George Humphry, to whom this great medical school owes so much,
greatly interested himself in the subject of old age and published the results
of an elaborate collective investigation. Lastly, it is desirable that the
problems of old age should be attacked by young and active minds in the
laboratories of the University and not left as a semi-personal field of
enquiry and observation to those whose “way of life is fall’n into the sere,
the yellow leaf,” and who hear old age’s stealthy footsteps catching them up
in the race; for in the past most of the writers on geriatrics have written with
at least some personal qualification and interest, such as Cornaro, Sir John
Sinclair, Sir Anthony Carlisle, Charcot, Sir George Humphry, Sir Hermann
Weber, R. Saundby, Metchnikoff, Stanley Hall. As an exception, however,
8
we may point to Dr. John Smith, who, in his thirty-fifth year, was the
author of King Solomon’s Portraicture of Old Age, which paraphrases in
266 pages the “six former” verses of the 12th Chapter of Ecclesiastes
containing 205 words.

II

DURATION OF LIFE

In the protozoa and some other lowly forms of animal life
multiplication by binary fission occurs indefinitely, so that one organism is
succeeded by two, and as there is no vestige of a corpse, as Weissmann
9
expressed it, the organism is immortal. Maupas’s investigations indicated
that without occasional conjugation of two individual protozoa and the
resulting rejuvenation the organisms undergo senile degeneration and die;
10
but Woodruff has shown by observations extending over 13½ years that
Paramoecium, and so presumably infusoria in general, can multiply
indefinitely in favourable conditions without conjugation, though
11
periodically an internal reorganization (endomixis ) of the individual takes
place. It seems not improbable that endomixis provides the rejuvenation
12
otherwise resulting from conjugation. C. M. Child brings forward reasons
for modification of the explanation that death is escaped simply by division;
he shows that in certain circumstances senescence occurs in the protozoa as
it does in the higher animals, but that death is avoided by the
rejuvenescence in each process of reproduction, reconstitution occurring
and new organs being formed in the place of the old. In other words, all
organisms from the protozoa to man undergo senescence and die unless
rejuvenescence intervenes; this compensation holds good in the lower forms
and death may never occur; but in the higher forms rejuvenescence is so
much restricted by the evolutionary increase in the physiological stability of
the protoplasmic substratum and the resulting higher degree of
individuation that senescence is much more continuous and death is
inevitable. It is the penalty for high individuation, and is the result of
conditions and processes that have produced the complicated mechanism of

the higher animals and man. While holding out the faint hope that the
advance of knowledge and of experimental technique may make it possible
at some future time to bring about a greater rejuvenescence and retardation
of senescence in man and the higher animals, Child points out that the
present condition of their protoplasmic substratum is the result of millions
of years of evolutionary equilibration, and that this task must therefore be
one of extreme difficulty.
Modern biologists such as Driesch, E. Schultz, Child, Steinach, and
Julian S. Huxley, to the last of whom I am personally much in debt, have
indeed shown that experimentally the life cycle and growth, which are so
closely correlated, may be modified dramatically by various methods. By
starvation planarian flat worms become smaller and their life cycle is
reversed by the process variously called dedifferentiation, reduction, or
involution, whereby their structure becomes simpler; similar retrogressive
changes have been produced in the social ascidians, Clavellina and
13
Perophora (J. S. Huxley ), this process of dedifferentiation or reversible
differentiation being the primitive reaction of organisms to unfavourable
circumstances. By alternate feeding and starvation Child has kept planarian
flat worms at the same size while controls passed through nineteen
generations, thus showing that the life of cells is not a matter of time but of
metabolism. In the higher animals the conditions are of course more
complex on account of the self-regulating mechanisms, especially the
ductless glands. But by disturbing the endocrine balance experimental
biology has produced some remarkable results: by feeding white mice with
tethelin (a phospholipin obtained from the anterior lobe of the pituitary)
14
Robertson and Ray found that epithelial proliferation was accelerated,
though increase in weight of the animals was retarded, and that the duration
15
of life was prolonged. Drummond and Cannan, however, failed to confirm
these results, and feeding with the anterior lobe of the pituitary has given
rise to very contradictory reports; acceleration (Clark, Robertson, Goetsch),
retardation (Pearl, Wulzen), and no effect (Gudernatsch, Lewis and Miller,
16
Hoskins, Sisson and Broyles ) have been described. Steinach’s
rejuvenation of senile rats by ligature of the vas deferens, which is followed
by increase in the interstitial cells of the testis and definite prolongation of
life, will be referred to later (vide p. 76). The retardation of growth due to a

17
diet deficient in vitamins, first proved by Gowland Hopkins in 1912, may
be maintained for long periods, but when the diet is appropriately altered
growth is resumed and proceeds to the full standard (Osborne and
18
Mendel ); it remains to be proved that the total duration of life can thus be
prolonged. Though every living species of animal may in normal
circumstances have its allotted span of life, this is so subject to accidents
and modifications by external influences that the average duration of
existence, especially in the long-lived species, does not represent the natural
term of years. Thus the expectation of life at birth in England and Wales is
51·5 years for males and 55·35 years for females, as contrasted with the
ideal physiological duration of life for 100 years. Violent death in one form
or another—traumatic or infective—is so much the rule that the occurrence
of natural death in the animal kingdom has been questioned, just as de
Candolle denied the natural death of trees and ascribed it to injury or
19
disease. Metchnikoff, who paid special attention to this question,
described natural death in the Ephemerids, day-flies, the imagines of which
are incapable of feeding and after an hour or two of “aerial life devoted to
love” die, their ova falling into the water; Sir Ray Lankester accepts the
view that they are “wound up” for a few hours only of life, but according to
Child death is probably due to starvation. In man natural death from old age
—a physiological ending—is very rare, much less frequent indeed than
death certificates and ordinary parlance would suggest; for in such cases
there is very commonly some latent disease, such as pneumonia, which just
turns the scale in the trembling balance. Montaigne warns us “what an idle
conceit it is to expect to die of a decay of strength, which is the last of the
effects of the extremest age, and to propose to ourselves no shorter lease of
life than that, considering that it is a kind of death of all others the most rare
and hardly ever seen.” While it must be admitted that this still holds good, it
is a stimulus to our efforts to render it no longer true.
The length of days ascribed to Methuselah (969), Adam (930 or, if the
20
“conceit urged by learned men,” as Sir Thomas Browne says, that he was
50 or 60 years old when called into being be accepted, 980 years), Seth
(912), has aroused attempts at explanation on the basis of a difference in
chronology. The suggestion that the “years” were lunar and not solar, in
other words containing 30 instead of 365 days, was controverted at length

21
by Eugenius Philalethes (not Thomas, twin of Henry Vaughan “the
Silurist”) as too radical, for on this interpretation some of the patriarchs
would have become fathers of children before they were ten years old. Long
ago, Hensler, following Justin, put forward the view that the year consisted
of but three months up to the time of Abraham, when it was extended to
eight months until the era of Joseph, after which it contained our full
complement of twelve months. This explanation was supported by
22
Hufeland on the ground that some eastern nations still reckoned three
months to the year. Adopting this explanation Methuselah’s age would be
cut down to 243 years.
The Psalmist’s threescore years and ten and its sorrowful extension to
fourscore are so often exceeded by human beings who appear normal that
the possibility of a far longer existence has often been raised. John Sterne or
Stearne (1624–69) who, though founder of the Irish College of Physicians,
23
was, according to Mahaffy, more of a theologian than a physician,
believed that there was no reason why men should not live as long as the
patriarchs before the Flood; but he also argued that these patriarchal ages
must have been exceptional, for had all the human beings between the
Creation and the Flood, a period of more than 1400 years, lived to an
average breeding age of 400 years and begun, as did the patriarchs, to beget
children at the rate of one male every three years, the population of the
earth could not have found standing room on its surface; his colleague in
Trinity College, Dublin, Miles Symner, Professor of Mathematics, provided
him with a calculation showing that there would have been less than one
cubic foot available for each individual. This seems to be echoed in a
slightly different connexion by Weissmann’s conception of natural death as
due to natural selection and as an adaptation for the good of the species, the
degenerated organisms being no longer fertile or useful, an hypothesis
hardly necessary, as Metchnikoff points out, when degeneration which is
24
the prelude to dissolution has appeared. Roger Bacon stating that man,
originally immortal and after the Fall able to live for a thousand years, had
his life gradually abbreviated by corruption of his own making, believed
that it should be possible by taking care as to regimen to prolong life for a
hundred or more years than the common duration. Since the time of
Aristotle the vital cycle has been thought to be a multiple of the period of

growth. Francis Lord Bacon considered that animals in general should live
25
eight times as long as they take to come to maturity, and Hufeland,
adopting this principle, and regarding 25 years as the termination of
adolescence, concluded that man’s natural span should be 200 years. Buffon
took 14 years as the age of puberty, and multiplying it by 7 decided that
human life should naturally be 100 years. Assuming that union of the
epiphyses of the long bones marked the time when growth was finally
26
completed, Flourens calculated that throughout the animal kingdom life
was five times as long, and that as in man the epiphyses united at 20 or 21
years of age the span of human life should be 100 years.
More modern estimates of the duration of human life under ideal
conditions of protection against infection have been to the same effect, thus
27
conforming to the estimate of Cornaro, who died at that age, that a
hundred years was “the time allowed to man by God and nature.”
28
Metchnikoff, while admitting that there must be variations, considered
that man should live more than 100 years, and Luciani fixed the
physiological duration of life at 100 years. Ebstein’s (1891) estimate of 70
years as the usual duration of life, which is the age at which the maximum
number of deaths occur when the first few years of life are excluded, is
different from the ideal duration under the best physiological conditions and
corresponds more or less with B. W. Richardson’s rough rule that the
individual’s probable age at death can be arrived at by taking the average of
the ages of his parents and grandparents; in this procedure the important
factor of heredity is taken into account, and the disturbing part played by
accidents and infections in modifying the ideal expectation of life is to
some extent neutralized by taking the average of the six lives.
Although 100 years may be regarded as the physiological life of man it
is rarely reached, and one of several reasons is that the physiological
requirements for this apparently exaggerated term of years are very seldom
29
provided. Sir Ray Lankester suggested that just as giants in stature are
exceptional variations so centenarians should be regarded in the same light,
as giants in years instead of in inches. He meets the obvious objection that
whereas the parents of giants are of normal height, longevity and
centenarianism appear to run in families, by doubting if the actual quality of
potential long life is transmitted and by ascribing family longevity to the

inheritance of traditions and habits favourable to long life. In this connexion
it should be remembered that many giants are pathological and due to
acromegaly, whereas unusual height, over six feet, certainly runs in
families; analogy therefore makes it reasonable to believe that length of
days, like length in inches, may run in families, although these two
approaches to giantism very seldom occur in the same individual.

Fig. 4.—Henry Jenkins, reputed to have lived 169 years (1501–1670).
Present at Battle of Flodden Field on September 9, 1513.

The authenticity of persons alleged to be of great age rightly excites
critical examination, and some of the most famous examples, such as Henry
Jenkins (169), Thomas Parr (152¾), Katherine, Countess of Desmond
(145), as Sir George Cornewall Lewis and Mr. W. Thom showed, as well as
30
many of the 1712 centenarians in James Easton’s list covering the years
31
A.D. 66 to 1799, cannot be regarded as established. In the same category
we must place Petrasch Zorten (1537–1724), whose portrait at the reputed
32
age of 185 was reproduced by Sir John Sinclair. Old people take a natural
33
pride in their age and tend to exaggerate it; according to Mr. G. King the
excess in the census returns of persons over 91 and the deficit in those
between 85 and 90 years of age could only be explained by the conclusion
that the temptation to overstate the age so as to appear among the
nonagenarians had not been resisted. The vast majority of centenarians are
naturally among the bulk of the population, namely, the poor, among whom
natural selection is provided with a correspondingly greater opportunity of
finding those “vigorous frames which promise a long life,” and in these
circumstances the means of checking the exact age may be less easy than in
the case of the well-to-do.
Sex.—Females are more long-lived than males; the 1911 census for
England and Wales shows that after 10 years of age there are more females
than males living in all the quinquennial periods, the proportion of females
progressively increasing until at the age of 85 and upwards there are 645
females to 355 males in 1000 living at that age group. Among centenarians
also the ratio of the sexes is much in favour of that popularly said to be the
weaker. Out of the 691 reputed centenarian deaths registered in England
and Wales during the 10 years 1910–19 inclusive, 504, or 73 per cent, were
females, and 187, or 27 per cent, males. But during the same period in
Ireland the disproportion was much less: among the 945 reputed
centenarian deaths 545, or 58 per cent, were females, and 400, or 42 per
cent, males. It has been said, though without sufficient statistical evidence,
that although the female sex is favourable to longevity extreme length of
days is attained only by males. The superior longevity of the female sex, in
spite of the risks attaching to child-birth, depends on several factors, such as
an existence less exposed to accident and infection, a more temperate life,
and in addition, so Sir George Humphry argued, on a stronger inherent

vitality, for during the first year of life when there is no difference as
regards the first two circumstances more boys than girls succumb. The
higher male death rate in the first year of life, however, may be partly due to
a mechanical cause, namely, the large size of the male infant’s head, as a
result of which the numerical superiority of male infants born is reduced by
the effects of trauma. Another factor is, perhaps, that old women do not feel
so old as old men do, and that therefore auto-suggestion plays a less
powerful part with them.

Fig. 5.—Thomas Parr. Reputed to have lived 152 years (1483–1635).
From a Print by Payne.

The question must arise as to what is the object of the prolongation of
life after the reproductive function has waned as it does in women—the
more long-lived of the sexes—about half-way through the physiological
term of years. In some lower animals life terminates very shortly after
propagation of the species has been effected; but this is not the rule, and the

biological meaning of the continuation of the life of individuals that but
cumber the ground and may lead a parasitic existence requires explanation,
though educational advantages and moral lessons may undeniably be
provided by healthy old age with its store of what a Cambridge man, now
justly famous, described in his rather rebellious youth as “that greatly over-
rated property experience.” It has been suggested by Sir Ray Lankester that
the inherent property resulting in longevity may be bound up as a
“correlated variation” with some other characteristic useful in the struggle
for existence and the perpetuation of the species. An obvious possibility is
that the long-lived have a higher fertility rate than average mortals.
34
Hufeland argued that as very old people are nearly always married more
than once and generally at a very late period of life “a certain abundance in
the power of generation is favourable to longevity.” There are few
satisfactory data to determine the converse proposition with which we are
now concerned, namely, is longevity accompanied by unusual fertility? As
already mentioned, the great majority of centenarians are found among the
bulk of the population, namely the poor, who are far more prolific than the
well-to-do; but this does not prove much, for the inverse correlation of
fertility and good social status is largely artificial and due to voluntary birth
control. Among the 824 persons between 80 and 100 years of age analysed
35
by Sir George Humphry in 1889 there were 335 married men and 292
married women, and in each group the average number of children was six,
which is somewhat in excess of what is popularly supposed to be the
average size of a family; but the question of average fertility is one on
which Dr. Major Greenwood warns me that it is difficult to give an
unambiguous answer, for it all depends on whether completed or
incompleted fertilities are meant; thus in the 1911 census the completed
fertilities average 5·8 and the uncompleted 4·2. No value could, he
considers, be attached to the general figure obtained by dividing the total
number of children by the total number of couples enumerated. Hence Sir
George Humphry’s and other statistics are not really comparable. While
finding that longevity was equally shared by the single and married women
and by those who had children and by those who were barren, Sir George
Humphry stated that among those who had children fertility was associated
with longevity.

Fig. 6.—Katherine, Countess of Desmond. Died 1604 at reputed age
of 140.

III

ONSET OF OLD AGE

The onset of old age varies in different countries, and, like the
development of puberty, is accelerated by the high temperature of tropical
countries. There is also considerable variation in families and individuals of
the same race and country; thus while one man may be senile at 60 years of
age another is vigorous both in mind and body at 80. The inconstancy of
onset depends on the various factors that may play a causal part; old age
may be a physiological involution, but too often is a pathological product.
When the period of reproductive power (maturity) wanes that of old age
begins; in women this is marked by the menopause, the age of 45 years
being taken as the limit of fertility, but before this even in the late thirties
the spectre of fading attractiveness may upset the matron and lead to the
irregularities of the “dangerous age.” For man there is no such index, and
the change is so insidious that most of us would expostulate at Stanley
36
Hall’s statement that old age in men begins in the early forties and sooner
in women, or less than half-way through the physiological lifetime of a
hundred years. According to Dante 45 marks the termination of youth, and
it seems generally agreed that as a rule—and every one is entitled to
consider himself as the exception—
The gay bloom of fifty passes quickly away
And people get fat and infirm and all that.

Fig. 7.—Petratsch Zortan, a Hungarian. Reputed to
have lived from 1537 to 1724.

It has from analogy of the female sex been rather fancifully suggested
that in man there occurs about the age of fifty a critical period
37
(climacterium virile) due to changes in the sex glands (Mendel ) or
38
prostate (Rankin ); but of this there is no proof. It recalls as a kind of echo
the ancient conceptions of the grand climacterics at 49 (a multiple of the
number 7), 63 (7 × the magical number 9 of the Arabians), and 81, and the

39
description in 1807 by Professor B. Waterhouse of Cambridge, Mass.,
who in 1800 introduced Jennerian vaccination into America, of a kind of
male moulting between 43 and 50 and a worse one at 63, an idea expanded
40
into the climacteric disease imagined in 1813 by Sir Henry Holland.
There is indeed no doubt that after an illness, and the so-called climacteric
disease admittedly seldom occurred without some previous factor such as
an attack of gout, a common cold, a bout of intemperance, recent marriage,
or particularly grief or bereavement, old age may come on apace. In some
instances the so-called climacteric disease was perhaps really chronic renal
disease, in others merely the prolonged or imperfect convalescence due to
some lingering infection after an acute illness, such as influenza; and, as in
the latter case recovery may occur, Holland’s contention that recovery was
an argument in favour of the existence of this climacteric disease holds
good only in distinguishing it from permanent senility, which indeed was
the objection that he was concerned to meet. The conception of the
climacteric disease is interesting historically only; and it may be agreed that
apart from accidents of environment the progress of senescence in healthy
men is gradual and uneventful.
So stealthy is the onset of senescence that commonly it is not
recognized by its victim and, though he may seldom mention it, every man
is firmly convinced that he not only looks but is at least ten years less than
the register would tell him. Though unconscious of the change in himself he
notes it with perhaps some self-congratulation in his contemporaries. It is
only if he tests himself, for example by timing himself for a mile’s walk,
that a healthy man of say 70 years has it borne in on him that he is not what
he was. The information that he is old may be suddenly conveyed by
overhearing the chance remarks of others, by catching a reflection of his
bent back in a mirror, by tardy recovery from illness, or the advent of some
disability, such as hypertrophy of the prostate or dyspnoea on holiday
exertion. Perhaps the commonest warning is a feeling of fatigue. Sir
Andrew Clark regarded the onset of old age as the period when a man
ceased to adjust himself to his environment; but some persons never are
able to do this, and misfits are not necessarily old. Laurentius divided old
age beginning at 50 into the three stages of “the green because it is
accompanied with prudence, full of experience, and fit to gouerne common
weales,” the second at 70 years is “very cold and drie,” and the last, without

a specified age incidence, is that of decrepitude corresponding to the
famous description in the 12th chapter of Ecclesiastes. A more modern and
41
comforting division is that of Lacassagne of pre-senility, old age
beginning at 60 or sometimes 70 in men, and in women 10 to 15 years
42
earlier, advanced old age, and lastly decrepitude. Nascher speaks of a
senile climacteric about the latter part of the 7th or 8th decade—the
transitional period between old age and decrepitude—corresponding to the
changes at puberty and at the menopause.
Precocious old age due to the effects of disease, especially syphilis and
acute infections, and to metabolic defects, which permanently damage the
cells of the body, has a special interest as it supports Metchnikoff’s
pathological view that old age as ordinarily seen is a result of toxic injury
43
(vide p. 82). Hastings Gilford has specially investigated premature
senility, and under the title progeria has described a remarkable condition of
premature senility combined with, or secondary to, infantilism. This
44
condition was independently described in 1910 by Variot and Pironneau
as the senile type of nanism. In such cases it would appear reasonable to
ascribe these two opposite conditions to the same toxic or other factor, the
infantilism depending more on damage to the ductless glands before
development was complete, and the senile changes to direct injury of the
cells in the body in general.

IV

FACTORS INFLUENCING LONGEVITY

The determining factors of long life may be broadly divided into those
included under heredity, environment, due functional activity, and personal
habits. It is impossible to separate these factors into watertight
compartments, for a certain amount of overlapping between them is
unavoidable.

Heredity

The influence of heredity has often been insisted upon and is perhaps
the most important factor in longevity. Out of 824 persons between 80 and
100 years of age analysed by Humphry, 406, or 49·4 per cent, came of long-
lived families. Numerous striking examples of such families are on record,
45
but a few only need be given. Roy quotes the case of Dr. Iverex, who died
in 1700 at the age of 104, his father at 112, his mother 107, and his
grandfather 130 years, and gives four other examples of three centenarians
in the same family. Another remarkable family group was that of Joseph
Retas who died at Tarbes at the age of 118 in 1888, and was the son of a
man aged 111 years and had a brother aged 114 years. Two centenarian twin
46
sisters were recorded in a village near Athlone ; centenarian sisters and
47
brothers are not so very exceptional. Sir Hermann Weber recorded two
families, in one of which the average age of ten children was over 90 years
and in the other of eight children nearly 90 years.

A good stock may ensure long life in the face of adverse environment,
48
such as town life and alcoholism; thus Dr. John Brownlee showed
statistically that while persons dying at the age of 51 in the average
environment would have, had they lived in the country, a mean life of seven
years longer, this difference was less at higher ages, and remarks that a
person who has the potentiality of living to the age of 80 years has a force
of life which is more or less independent of environment. Sir George
49
Savage often noted that of two aged members of the same family one was
sober the other intemperate; and a good many centenarians have taken
alcohol in quantities that would be too much for ordinary people.
Heredity is not an all-powerful factor, for an individual whose family
history is not remarkable for longevity may greatly prolong his life by
carefully correcting unfavourable hereditary tendencies. Thus the late Sir
Hermann Weber, who lived to the age of 95 as the result of practising the
maxims of his Prolongation of Life, mentions that his mother died of
cardiac failure before she was 60 and his father at 60 from cerebral
haemorrhage, and he gives other instances of the same happy result of wise
management. Not unfrequently husband and wife both live to an advanced
age, no doubt often as the result of favourable environment. A photograph
of a married couple both 101 years old appears as the frontispiece of Sir
George Humphry’s book on Old Age, and must of course be accepted; but
the same cannot be said of the frontispiece to volume ii. of Sir John
Sinclair’s Code of Health and Longevity (1807), representing the Hungarian
husband and wife, aged respectively 172 and 164 years, who had been
married 147 years.
It has been suggested that “cell-memory” by providing experience as to
the proper way to behave at the different periods of life has a bearing on the
50
coming of old age; Samuel Butler argued that cells without hereditary
memory of past existence at, say, 75 years, would become puzzled and so
51
disordered as to die. Parkes Weber has modified this view by assuming a
failure of the wish to live on the part of the nerve cells of the brain, a want
which might also be hereditary. The possession by the cells of “the will to
live” would be an important factor in longevity and should be obtained by
individual effort or in other words be an acquired character, though the

52
reverse conditions such as physical mutilations, often spoken of as
acquired characters, are known not to be inherited.
In different countries and in different individuals the cells of the body
53
may differ in the rate at which they live; they have, as Sir James Paget
said, a different “time-rate”; in some the time-rate is rapid, for example in
the natives of hot climates where maturity comes early and old age at a time
that seems very premature by our standard; in others the body, sometimes
the mind, works slowly, is set at a more leisurely rate and therefore takes
longer to run its course. In some persons this appears to be shown by a slow
pulse, a characteristic that may also be hereditary.

Fig. 8.—John Rovin and Sarah his wife,
Hungarians, at their reputed ages of 172
and 164 years respectively; their married
life lasted 147 years.

Of the hereditary factors most concerned in longevity the inherent
vitality of the central nervous system is the most essential; physiological
death in man and the higher animals is probably due to failure of the cells of

the brain, which do not multiply after birth and are less capable of
rejuvenescence than those of the other organs. The integrity of the cardio-
54
vascular system is also most important; in Sir William Osler’s words
much depends “on the quality of arterial tissue (vital rubber) which the
55
individual has inherited.” According to Sir Clifford Allbutt there are two
modes of hereditary transmission of arteriosclerosis, the direct and the
indirect; the direct which he calls decrescent or primary, consisting in an
original frailty or toxic susceptibility which like other peculiarities may run
in families; and the indirect or hyperpietic, a secondary event due not to
inherent taint in the arterial walls but to metabolic changes causing high
arterial pressure; it is in such families with hereditary high blood pressure
that cerebral haemorrhage occurs in one generation after another about the
same age (65–70). In examining people the discovery of a blood pressure
low for their age often justifies, in the absence of any pathological
condition, the suggestion that the family is long-lived. The frequency of
cardiac hypertrophy (43 per cent of Councilman’s cases), even though it be
a pathological condition, shows that its reserve power is good. Death among
the aged very commonly depends on some morbid change in the cardio-
vascular system; thus at the Royal Hospital, Chelsea, Majors R. J. C.
56
Thompson and R. E. Todd found that among 169 deaths of pensioners
with an average age of 77·2 years the largest number 64, or 38 per cent,
were due to this cause; lesions of the respiratory system, pneumonia, and
bronchopneumonia, coming next with 41 deaths, or 24 per cent, malignant
disease being responsible for 22, or 13 per cent. The nervous and
circulatory systems are intimately correlated with each other, disorder or
disease of one, particularly of the cardio-vascular system, exerting an evil
influence on the other. In a negative manner weakness of the digestive
system may favour longevity by preventing the excesses which vigorous
individuals may for a time at any rate indulge in with impunity; but as a rule
the digestion of the long-lived is good.
57
The first-born is significantly handicapped, as Karl Pearson has
shown, and more subject to tuberculosis, insanity, and criminality. But out
of 71 centenarians analysed by Sir George Humphry 17, or 24 per cent,
were firstlings, and 24 per cent of 824 persons between 80 and 100 were
first-born. It must be remembered that first-born are more numerous than

any others, and some of the above were only children. The most frequent
position in the family among these 895 old people analysed by Sir George
Humphry was the third.

Environment

The influences included under the head of environment are numerous,
and this factor cannot be entirely separated from that of heredity, for
environment may favour and shape hereditary characteristics. The subject
of the harmony and the want of harmony existing between man and his
surroundings is so vast that it is possible to touch on a few only of these
aspects.
The average length of life varies in different countries; a temperate or
moderately cold climate is conducive to a slower development of maturity
and so to a longer life than tropical regions. The Balkans, Greece,
Scandinavia, the Pyrenees, California, and small islands are considered
favourable to longevity. A high elevation has been regarded as an important
factor, and the great age of the monks of Mount Athos has been thus
explained, though other influences, such as simplicity of life, may well play
a part. Switzerland, however, does not conform to the view that a high
elevation confers long life on its inhabitants. From observations around
58
Dijon Noirot drew up a scale showing that the elevation above the sea and
length of life rose together. National habits have a bearing, and this may
help to explain the longevity of the Jews, who follow the Mosaic laws of
health, and why the French appear to be more long-lived than the Germans.
The long-continued persecution and hard life that the Jews have undergone
has led to the survival of the fittest and a hereditary factor. The former
simplicity of the Russian peasants would also provide a reason for their
reputed longevity (one centenarian in every thousand). In Ireland, though
much depleted by migration of young adults, the absolute number of
centenarians is very high; in 1888 there were 208 such deaths, or 43 per
million living; in the ten years 1911–20 inclusive there were 1030
centenarian deaths, or about 23 per million living; and the Registrar-
General, Sir William J. Thompson, kindly informs me that in 1921 there
were 314 centenarians living in a population of 4,496,000, or about 70 per

million of the population. It seems probable that this is the outcome of a
simple life. In England and Wales the number of centenarians is both
relatively and absolutely less; in 1887 there were said to be about 2 and the
1911 census returns showed 3·6 living centenarians per million of the
population; the return of the 1921 census is not yet available. In the ten
completed years 1910–19 there were 691 centenarian deaths, or an average
of 69 annually among a population averaging about 35 millions—about two
59
per million living. In California there are, according to Laurent, 300
centenarians in a population of three millions, or 100 per million, the
extremely favourable climatic conditions accounting for this high ratio. In
the same country there is a difference, much to the advantage of the rural
inhabitants, between the prospect of longevity in the towns and in the
sparsely populated districts. From their open-air life agricultural labourers
provide the largest percentage of long lives.
Improved Conditions of Life.—There is good evidence that the average
expectation of life has improved in this country during the period that
increasing attention has been paid to sanitation. This is shown by the tables
of the Registrar-General. For most of the following information I am
indebted to Dr. T. H. C. Stevenson of the General Register Office, Somerset
House. In 1838–54 the expectation of males at birth in England and Wales
was 39·91 years, in 1901–10 the male and female expectations at birth were
48·53 and 52·38 years respectively, and the latest available expectations at
birth (English Life, Table No. 8, Supplement to the Seventy-fifth Annual
Report of the Registrar-General, Cd. 7512) are 51·6 for males and 55·35
years for females. But the expectation is probably considerably more now,
as the death rates have fallen appreciably since 1910–12. The Prussian male
expectation of life at birth has increased from 35·38 years in 1867–77 to
60 61
46·43 in 1906–10; and the Swedish expectation of life at birth from
39·5 years in males and 43·6 years in females in 1816–40 to 54·5 and 57
62
years respectively in 1901–10. In North America there has been a fall in
the death rate in every age group in 1920 as compared with 1910.
The increased expectation of life has been especially prominent in early
and adult life. Examination of the Registrar-General’s census returns from
1851 to 1911 show that although there were more persons per million living
between the ages of 55 and 75 there were less above the age of 75 at the end

than at the beginning of this 60-years’ period. It has been suggested that the
increased survival in the earlier period of old age is due to the saving of life
in infancy and that, as these lives are not prolonged above the age of 75 or
so, the diminished proportion of persons living to become octogenarians is
explained (H. Weber).
The influence of past diseases is perhaps most conveniently considered
in connexion with environment. As infection must necessarily impair the
vitality of the cells of the body, either temporarily or permanently, it would
be natural to expect that those who live to a great age would show a
remarkably clean bill of health. This is often true. But it is at first sight
rather disconcerting to find that nearly half of the 824 persons between 80
and 100 years of age analysed by Sir George Humphry had had severe
illnesses at one time or another; many of these, however, were acute
infections. It is noticeable that 85 per cent were free from rheumatism in the
hands (selected as a convenient test in his collective investigation), which in
the light of present opinion that arthritis is the result of a focal infection
would appear to show that these old people are remarkably free from
chronic disease. Long-continued infection or intoxication would be a far
more potent factor than a transient illness in producing permanent change in
the cells. A short acute infection would cause changes in the cells which
63
might, like those of fatigue, be temporary and recoverable. Saundby’s
dictum may be accepted as fairly accurate, exception being made for
peripheral mutilations, namely, that those only can expect to live to extreme
old age who at the age of 60 possess bodies free from disease. But critical
examination would no doubt show that focal infections become increasingly
frequent as the years go on; this is particularly true as regards oral sepsis;
after two years’ experience of 500 pensioners at the Royal Hospital,
Chelsea, Thompson and Todd have never seen a tooth in a healthy condition
there. It is noteworthy that dental disease seems to have become common
with the advent of civilization, as judged by examination of ancient skulls,
though the loss of teeth is an accompaniment of the bony changes in old
age, and very old people seldom have more than a few teeth left. On the
other hand, an acute illness is often the apparent starting-point of old age;
there may be a long and imperfect convalescence due to persistence of
infection, or deterioration may be due to auto- or hetero-suggestion (vide p.
48).

The influence of syphilis, whether congenital or acquired, is one of the
most important in the prevention of healthy longevity; it not only directly
disables and kills, especially in infancy and in the fifth decade, but it
damages the vitality of the cells thus producing degeneration and premature
senility, and favours secondary infections.
It is clear that for the preservation of health detection of disease in the
earliest stage is all-important, and that this can be attained by periodic
examination by a medical man; but obvious though this may be, the average
man waits to call in a doctor until he knows that he is ill. Timely advice as
to methods of life, food and drink, occupation, or environment would often
prevent disease and premature death. In 1913 the Life Extension Institute
was founded in New York for such periodic examination and report, and the
Life Assurance Companies, finding that persons so examined showed, at
any rate for some years, a death rate lower than that anticipated, gave it
financial support.

Functional Activity

As is well known, disuse leads to atrophy, and biologically conditions
rendering an animal’s supply of food extremely easy and safe are followed
by atrophy of the parts no longer necessary in a state which may thus come
to border on parasitism; in an extreme degree this result is shown in
barnacles (degenerated crustaceans) and ascidians (degenerated
vertebrates). In man the cessation of an active life on retirement to the
country, described by Samuel Johnson as “a kind of mental imprisonment,”
or the sudden acquisition of wealth, often exerts a most evil influence; for if
the whole body is no longer kept in a condition of functional activity, those
parts allowed to remain relatively idle begin to degenerate and atrophy; loss
of function means a diminished blood supply and nutrition, and so
degenerative atrophy. According to Laurentius “nothing hastens old age
64
more than idleness.” James Easton, who collected 1712 records of
centenarians, many of them open to criticism, endorses Hufeland’s dictum
that no idler has ever attained to a remarkably great age; and Sir Thomas

65
Browne’s quaint injunction “Dull not away thy days in sloathful supinity
and the tediousness of doing nothing” is old but true wisdom.
The axiom that disuse leads to atrophy applies perhaps even more to
mental activity, for resting and rusting of the brain slow the pace of the
whole body, whereas an alert mind can exist in an infirm body. There is no
doubt that occupation with a strong desire to live for the accomplishment of
a definite purpose exerts a most beneficial influence, and there have not
been wanting some, such as Karl Marx, who have preached that old age is
in great part a matter of will. Speaking of the circle in which Madame du
66
Deffand moved Lytton Strachey says “They refused to grow old; they
almost refused to die. Time himself seems to have joined their circle, to
have been infected with their politeness, and to have absolved them, to the
furthest possible point from the operation of his laws. Voltaire, d’Argental,
Moncrif, Hénault, Madame d’Egmont, Madame du Deffand herself all lived
to be well over eighty, with the full zest of their activities unimpaired.”
Want of this joy in life necessarily engenders carelessness and neglect of
personal hygiene, and loss of the power to react to the environment. As the
years advance and the younger generation come up, the suggestion that “his
day is done,” that he has had his innings, and that it is time for him to step
aside, is made to the senior not only by his family and his juniors—hetero-
suggestion—but by himself, and he may then, after the modern fashion, get
into the habit of repeating mentally “I am getting older and older every
day.” A slight illness or incapacity may be magnified into a conviction that
the end is near, and as a result of the loss of self-reliance a state of
increasing invalidism is established and becomes progressive without any
other cause. Just as a fall, an exacerbation of rheumatic pain, a slight
operation or indisposition, necessitating rest in bed for a short time, may be
followed by a functional loss of power in the lower extremities, so a more
general suggestion of failing powers may lead to mental deterioration. Thus
too often a man’s last occupation is to shorten his existence and make it
67
miserable. Finot, who rather optimistically believes that man should be
able to live 150 years, regards this poisonous auto-suggestion as one of the
factors that prevent such an achievement. Observation of contemporaries
suffering from premature senile changes, due to pathological factors, may
no doubt stimulate this destructive form of auto-suggestion. There is

68
therefore a basis for the idea attributed to the late Lord Rhondda that old
age was a transferable disease, and for his avoidance, as far as possible, of
the society of the aged on account of the risk of contagion. Association with
the young keeps one more or less of the same age, very probably by
suggestion to the unconscious, or in Oliver Wendell Holmes’s words “While
we’ve youth in our hearts we can never grow old.” From experience at the
Royal Hospital, Chelsea, where there are 500 pensioners, Thompson and
69
Todd are convinced of the powerful factor of lowered mentality due to
loss of self-reliance, self-respect, and the instinct of self-preservation in
inducing premature senility, and have been most successful in counteracting
this by antidotal suggestion conveyed by cheerful chaff and by the
avoidance of sympathetic condolence.
In addition to the joie de vivre a happy disposition that thinketh no evil,
has no jealous suspicions, and is free from the tendency to worry has an
important influence in keeping the mind and body young. The power of
detachment from work and anxieties, as if the mind were fitted with
thought-tight compartments, is a valuable asset in maintaining vitality
unimpaired; this was a trait in Gladstone and Kitchener.
Professional men who retain their offices as in the Church, the Civil
Government, the Bar, tend to live longer than business men who retire to
70
leisured ease after a strenuous struggle. B. Yeo’s analysis of 42 Bishops
and Deans, 49 Judges, and 188 Peers, showed that in all three classes the
average duration of life was practically the same, namely, 72 years. Among
churchmen mention may be made of Cardinal de Salis (110), Gregory IX.
(100), Abbé Maignon (100), Martin Routh (100), for 63 years President of
Magdalen College, Oxford, thus surpassing the more modern instance of
Edward Atkinson, aged 96 years, for 59 of which he was Master of Clare,
but not that of Laurence Chaderton (1536–1640) who, after being Master of
Christ’s College, Cambridge, with great success for 38 years, survived for
18 years and became a centenarian. There are some remarkable examples of
artists retaining an active life to a very advanced age, such as Titian,
Giovanni Bellini, Michael Angelo, Sidney Cooper. Politics often keep men
busy and active to an advanced age, and the names of Palmerston,
Brougham, Lyndhurst, the octogenarian premiers Gladstone and
Clemenceau, Strathcona, Sir Charles Tupper naturally come to one’s mind.

In the legal profession Chief Justices and Judges can retain their seats and
so keep up their vigour long past what is regarded in some walks of life as
the retiring age. Sir Edward Coke (82), Lord Mansfield (89), Lord
Brampton (90), Lord St. Leonards (93), and Lord Halsbury (97), are
examples in point. Within recent years there have been two octogenarian
Lord Mayors of London, Sir Thomas Crosby (in 1911), and Sir John James
Baddeley (1921); the first created a record by being the first medical man to
hold this office, and Sir John Baddeley celebrated his year of Mayoralty by
bringing out a beautiful historical account of Cripplegate.

Fig. 9.—Sir Henry Alfred Pitman (1808–1908), M.D., Camb.,
F.R.C.P., Registrar of the Royal College of Physicians of
London, 1858–1889.

From portrait in the Royal College of Physicians of London, painted in
1886 by W. W. Ouless, R.A.

From the inevitable exposure to infection and worry the medical
fraternity is generally considered to rank low in the professions as regards
longevity, but it is easy to point to exceptions especially among those whose
mental vigour made them prominent in their own and in one instance for all
time. Hippocrates is variously stated to have died at the ages of 85, 90, 104,
or 106 years with the words “I leave behind me two great physicians,
71
temperance and frugality.” I have references to 43 medical centenarians
for 18 of which, including the record of W. G. Meade, physician at
Tunbridge Wells and buried at Ware, Herts, in November 1652, aged 148¾
years, I am indebted to my friend Mr. R. R. James. The only one that I knew
personally was Sir Henry Pitman, for 31 years (1858–89) and until his 82nd
year Registrar of the Royal College of Physicians of London. Among the
others Dr. de Bossy of Paris may be mentioned as the son of a centenarian.
72
From analysis of 2113 eminent medical men Drinkwater found that the
average age was 67 years, or considerably above the average age of the
male population over 21 years, which was estimated at 59 years, and that
627 or nearly a third of them all were between 71 and 80 years of age.
But the examples given of mental activity late in life, and they could
73
easily be multiplied, are exceptions to the rule that the majority of men
begin to fail in their work between 60 and 70. This no doubt is because
most septuagenarians suffer in greater or less degree from pathological old
age. In the case of the healthy vigorous man enforced retirement at the age
of 65 or 70 is not to the advantage of either the retiring victim or the
community, for it restricts his opportunities for production and useful
activities guided by ripe experience. To quote examples of epoch-making
work done by men long past the age when the majority have lost originality,
initiative, and elasticity of mind: Galileo, Newton, Charles Darwin,
Sophocles, Voltaire, Molière, Goethe, Michael Angelo, and Titian, made
original and lasting contributions to science, literature, and art long after
fifty. Morgagni’s famous De Sedibus et Causis Morborum, brought out
when he was 80, and the Commentaries of W. Heberden (aged 91),
published posthumously, represent the accumulation of many years and so
cannot be fairly quoted as examples of ability persisting into late life. Rules
and regulations must, however, be based on what is best for the majority
and hence, though the exceptions are prominent and regrettable, the age

limit of 65 to 70 must at present be accepted as generally advisable for
otherwise permanent appointments.
Although functional activity maintains the tissues in a state of health, it
is not an infallible panacea for the prolongation of life; in the first place the
danger of overwork and excessive fatigue must be borne in mind. While the
attractive suggestion that excessive functional activity leading to extreme
hypertrophy may exhaust the vitality of the tissues and lead to atrophy, may
not be borne out by the examples quoted in its favour, such as the
occupational neuroses and atrophy of the upper arm muscles in hammermen
and file-cutters, there is some reason to retain a belief that this sequence of
events may occur, for example in dilatation of the extremely hypertrophied
hearts seen in long-continued high blood pressure, renal disease, and
74
valvular lesions; but even here the possibility of other degenerative
changes, due to toxaemia, must be borne in mind. Further, functional
activity while keeping the cells of the body in a healthy state depends on
their structural integrity, and this in its turn is the outcome of the
modifications due to environment, and possibly of the inborn lease of
vitality. So that although an active life may within limits prolong life, there
are many instances in which, from extrinsic pathological influences or
inherent inadequacy, it fails to do so, and a man becomes unequal to the
demands of his position.

Personal Habits

All experience, medical and lay, such as is embodied in Cornaro’s oft-
quoted memoirs, Leonardus Lessius’s Hygiasticon or the right course of
preserving life and health until extreme old age (1613), George Cheyne’s
Essay of Health and Long Life (1724), Metchnikoff’s orthobiosis, and the
75
Arabian proverb of the ninth century, quoted by Lacassagne, that “the
greatest dangers for an old man are a good cook and a young wife,” is in
agreement as to the immense importance of strict moderation in indulging
the appetites for the prolongation of life. The life histories of centenarians
show that they have usually been small eaters, especially of meat. This is
generally explained in terms of minimizing toxaemia, and it has been said

that “man does not die, he kills himself” (Montaigne) and more graphically,
if coarsely, that “he digs his grave with his teeth.” In some lower forms of
life, such as the planarians (Child), partial starvation and the resulting
reduction lead to rejuvenescence and so to the inhibition of the onset of
senescence; hibernation has somewhat the same effect, though perhaps this
might be partly explained as merely starvation during prolonged sleep. The
question has often been raised whether partial starvation in man has any
such positive influence, and unprofessional “cures” on these economical
lines have not been unfashionable. It might indeed be argued that the Allen
treatment of diabetes, in which starvation is followed by increased
carbohydrate tolerance, depends on a certain degree of rejuvenescence.
Cures consisting in purgation may act by partial starvation as well as by
obviating toxaemia. After a period of starvation a normal person may
become heavier than before, and his general health be improved. But in the
present state of our knowledge and in the light of the dangers of starvation
the further investigation in man of this problem is one that demands serious
hesitation.
As to the bad influence of alcohol on longevity there can be no
reasonable doubt. Alcohol is a protoplasmic poison causing degenerative
changes in the cells and reducing the resistance to infection. A collective
76
investigation undertaken by Sir Isambard Owen showed that there were
very few hard drinkers among the long-lived, and Sir George Humphry
concluded that the characteristics of the aged included temperance; among
46 centenarians one, and among 73 men over 90 one confessed to taking
too much occasionally, and out of 298 men between 80 and 90 years of age
45, or 15 per cent, were classified as taking much alcohol. That such
exceptions occur is explicable by great inherent vitality. It has been said that
“wine is the milk of old people,” but from his experience of the hygiene of
the elderly Sir Hermann Weber was not in sympathy with this view, and he
pointed out the weakness of the popular idea that the moderate enjoyment
of alcohol was harmless; for so-called moderate drinking is in reality often
immoderate indulgence for the individual, and most of us must have
recognized from observation that long-continued though moderate use of
alcohol is followed by premature deterioration. The proverb vinum lac
veneris and the tendency that alcohol has to lead to incontinence and so to
venereal infection may be borne in mind in considering its influence on

longevity. As a medicine alcohol has its occasional use, and though it may
be a food it is an expensive one.
Smoking among centenarians was specially investigated by Sir George
Humphry, who found that among 19 male centenarians 8 smoked much, one
a little, and 10 not at all; while out of 30 female centenarians 4 smoked
much, 2 moderately or little, and 24 not at all. There is no doubt that with
advancing years there is commonly a relative loss of tolerance for tobacco,
so that unpleasant symptoms ranging from cardiac extra-systoles, through
abdominal pain, to tobacco angina, may dictate discontinuance of the habit.
But a large number of old people have smoked in earlier life though
subsequently non-smokers. Personal tolerance to tobacco shows great
variations, and there is no doubt that well-marked symptoms may be caused
by tobacco. But that moderate smoking diminishes the chance of longevity
has certainly not been proved. Much discussion has taken place as to the
relation between smoking and arteriosclerosis; it is true that in animals
nicotine in considerably larger doses than can be absorbed by smokers,
damages the arteries, and Huchard and Lazarus were convinced that it
77
caused arteriosclerosis. Sir Clifford Allbutt, after quoting the various
opinions, points out that if tobacco be a cause of arterial disease, it acts very
slowly, for at 45 years of age, after a quarter of a century’s exposure, the
smoker’s arteries are not distinguishable from those of the abstainer’s; and
he mentions the arteriosclerosis of the ancient Egyptians and of women as
incidents detracting from any argument that tobacco is an important cause
of arterial disease.
A large proportion of the centenarians and persons over 80 years of age
collected by Sir George Humphry obeyed the adage early to rise and early
to bed, and I well remember that he used to lay stress on the factor of
getting up directly one woke and so denying the flesh the luxury of further
sleep. Whether going to bed early and getting up early is more than an
index of a life otherwise spent in accordance with the late Sir Andrew
Clark’s “laws of physiological righteousness” may be questioned.
Bodily Conformation.—Long-lived people are usually spare, obesity
being rare, and, allowing for some shortening due to age, of a good average
height (Humphry). It is interesting in this connexion to quote the
78
conclusions arrived at by Robertson and Ray from comparison of groups

of long-lived and short-lived white mice in similar conditions. The long-
lived were relatively stable, highly resistant to external disturbing factors,
displaying subnormal variability and a more or less well-marked, but not
invariable, tendency to early overgrowth and relative paucity of tissue
accretion in late life; while the short-lived animals showed exactly the
opposite features with a tendency to rapid increase of tissue in late life.
The importance of a healthy life with plenty of fresh air, sunshine,
exercise, proper diet, and absence of worry hardly needs insistence.
79
Leonard Williams has epigrammatically summed up the hygiene of old
age as “Fresh air, meagre fare, freedom from care.”

V

THE CAUSES OF SENESCENCE AND
GENERAL ATROPHY: LIMITED VITALITY
OF CELLS—INFLUENCE OF THE
ENDOCRINE GLANDS—METCHNIKOFF’S
PATHOLOGICAL EXPLANATION

SENESCENCE AND CARCINOMA
The causation of old age is so complex that it is not possible to argue
with any conviction that any one of the following explanations exclusively
solves the problem satisfactorily.

Limited Vitality of the Cells

To explain the atrophic processes normal to old age it has naturally
been assumed that the constituent cells are endowed with a certain store of
vitality for themselves and their descendants, and that as this becomes
exhausted the process of involution begins. This conception of an inherent
limit of life is probable from the analogy of the existing limit of height and
size, though in certain plants and trees growth in size and length of days do
not show a natural limitation. The process of ageing of the cells is thus
regarded as just as much part of their development or life cycle as are their
earlier and progressive stages. The exception is that the reproductive cell
when it meets with its complement—the ovum with the spermatozoon—and
as it were with new blood, starts a fresh lease of life, and so in Sir Edward

80
Sharpey-Schafer’s words “we can only be immortal through our
descendants.” That there is a more or less definite cycle during which the
cells multiply and after which they cease to do so receives support from the
anatomical and physiological changes in old age; thus the ovary undergoes
fibrotic atrophy and ceases to be actively functional after the menopause.
The atrophy or hypoplasia of the organs is due to diminution of the
proliferation of the constituent cells. This is well shown in the lymphatic
glands and spleen which are so active in youth and atrophied in advanced
81
life. Salimbeni and Gery point out that the hypoplasia in the woman aged
93 whom they minutely examined was most prominent in the lymphatic
tissues and the bone marrow which have to supply the cells most constantly
needed. Even in the lowest forms of life senescence and death would occur
in the absence of the rejuvenescence associated with reproduction. In the
complex congeries of cells making up the higher animals and man this
rejuvenescence does not accompany reproduction, and the vitality of the
constituent cells diminishes until eventually atrophy and death supervene.
82
Many of the vital phenomena of cells may, as Martin Fischer,
83
Lumière, and others point out, be interpreted in terms of the behaviour of
84
simple hydrophilic colloids. Bechhold has shown that, like a simple
colloidal jelly, the cells of the human body, which are colloidal masses, lose
their affinity for water progressively with age and become less elastic; the
water content of the fetus being 94 per cent, as compared with 70 per cent
at birth and 58 per cent in adult life, thus recalling the old idea of the
85
dryness of elderly bodies. According to Marinesco dehydration of the
colloids in the cells is an inherent progressive change in evolution and leads
to senescence and death. It has also been thought that as the result of
differentiation and metabolism the cell protoplasm may become overladen
with products inimical to its vitality, which it cannot, as can the protozoa,
utilize for rejuvenation, and which hinder metabolism. The micellae, or
aggregations of albumin constituting the colloids of the cells, alter in
structure and become more stable until the colloid state disappears and the
cell accordingly dies (Lumière, Danysz). Such changes must obviously be
86
greatly influenced, as H. Campbell and others have insisted, by their
environment; the individual cells are in some degree of material continuity
by “protoplasmic bridges” which probably serve not only for nutritional

purposes but also for the transmission of physiological impulses. It also
appears that the life cycle of the cell is determined not so much by time as
by the interaction of the tissues and the plasma. By cultivating connective
87
tissue in the plasma of chickens of different ages Carrel showed that its
growth was more abundant in the plasma of younger chickens than in that
88
of older ones. Working on these lines Loeb and Northrop concluded that
the duration of life was determined either by a substance leading to old age
or by the destruction of a substance which normally prevents old age and
89
natural death. More recently Carrel and Ebeling found that in these
cultures of connective tissue the rate of multiplication of fibroblasts and the
duration of life in vitro varied in inverse ratio to the age of the animal from
which the plasma was taken, and that this depended on the presence of an
inhibitory body in the plasma of older animals. These experiments recall the
practice centuries old of transfusion of young persons’ blood into the old
which, however, led to disastrous results on account of a technique now
known to be dangerous. Whether with modern methods success will be
obtained remains to be proved, but probably repeated transfusions would be
required. But to return to the subject: Carrel, Champy, and Grandcourt have
shown that, with frequent washings to remove waste products, tissue cells
can be cultivated indefinitely for years in vitro, and in themselves have an
unlimited capacity for multiplication; it therefore appears that the ageing of
cells in the living organism is determined by extrinsic factors in the plasma
rather than by any inherent limitation in the cells. In the ordinary conditions
of life senescence of the cells might be regarded as the result of increasing
differentiation and, possibly from accumulation of material which cannot be
utilized for rejuvenation, of diminished metabolic activity. In the
physiological life of gland cells, for example, the salivary glands and
pancreas, granules are manufactured and discharged, but the hypothetical
material which collects in elderly cells, of which pigment may possibly be
an example or the visible sign, remains in these cells and hampers their
functional activity. As atrophy of the functional cells and increase of
connective tissue are regarded as characteristic of senescence, and a high
90
proportion of cells as characteristic of embryonic life, Robertson and Ray
suggest that the potential longevity of any individual is determined by the
relative velocities of anabolism in the cells on the one hand, and in the
fibrous tissue on the other hand. A low rate of cellular anabolism increases

the growth of the cells and delays the increase of fibrous tissue; this they
were able to effect by feeding white mice with tethelin. The relations of the
functionally active cells and the connective tissues have also been
91
investigated by Nathan and his collaborators, who bring forward
experimental evidence in favour of the modified view that while dense
connective tissue inhibits cellular proliferation, young loose connective
tissue favours the multiplication of cells in proportion as it approaches the
92
structure of the embryonic mesenchyma. Drew’s observations on the
culture of tissues and tumours show that the stroma acts like embryonic
tissue in favouring growth.
To sum up: the cells of the complex organism depend for their duration
of life not so much on an inborn store of vitality as on metabolic changes in
the colloids which in their turn are modified or controlled by extrinsic
factors of various kinds.

Relation of the Endocrine Glands to Senescence

As the metabolic activities of the cells of the body generally are
markedly influenced by the secretions of the ductless glands, the relations
between these endocrine glands and senescence demand some discussion.
The process of reproduction leads to rejuvenescence in the protozoa,
and it might therefore be imagined that in the higher animals continued
activity of the sexual glands would similarly exert a rejuvenating influence
on the remaining cells of the body. But the process of specialization has
gone so far in the cells of the higher animals that the highly differentiated
cells, especially of the nervous system, cannot fairly be compared with the
constituent molecules of a unicellular organism. As sexual activity is the
biological reason for existence and as in vigorous men sexual power may
last long beyond the usual period, man being regarded as old as his sexual
glands, it has been widely imagined that the functional activity of the sex
glands is in some way a cause, rather than a manifestation, of the
preservation of bodily vigour, and conversely that failure and atrophy of the
sexual glands cause old age and senility. There is an attraction, though not
without the danger of fallacies, in interpreting the words of older writers as

prophetic anticipations of quite modern knowledge. But with this caution in
93
mind there is some ground for crediting Hufeland with some idea of the
internal secretion of the sexual glands: as long ago as the end of the
eighteenth century he wrote “the organs of generation have the power of
secreting the finest and most spiritual parts of our nourishment; but at the
same time they are so organised that these perfected and ennobled juices
can again return and be received into the blood. Like the brain, therefore,
they belong to those important organs which serve for bringing to
perfection and ennobling our organic matter and power, and even
ourselves.”
Since 1889 when Brown-Séquard, at the age of 72 (6 years before his
death) put forward the idea that rejuvenation could be brought about by the
hypodermic injection of testicular emulsion, the view that old age and
senile changes are due to failure of the glands of internal secretion has
become popular. The thyroid (V. Horsley, Léopold-Lévi), the testis and
ovary, or most or all of the glands (pluriglandular insufficiency) have been
94
incriminated; Lorand, indeed, regards old age as a disease caused by
95
degeneration of not one but several of the endocrine glands, Biedl
expresses much the same view in referring old age to a disturbance of the
96
endocrine balance, and Berman in a recent semi-popular book states that
old age is an exhaustion permanent and irreparable of all the glands of
internal secretion; like Lorand he ascribes considerable importance to
failure of the internal secretions of the sexual glands. It is highly desirable
to arrive at some conclusion as to the relation between changes in the
glands of internal secretion and senescence, for in medical practice this
conception of cause and effect has been acted upon; various glandular
extracts have been employed to counteract and delay the disabilities that
may accompany advancing years and, though not so freely, operations, viz.,
ligature of the vas deferens and implantation of testicular grafts, have been
carried out.
97
Lydston implanted testes from boys recently dead into men
with atrophied or destroyed testes and reported improvement.
98
Stanley and Kelker implanted 11 cases with testicular grafts
obtained from executed criminals, and 5 cases with the testes of

rams, obtaining improved general condition, though not claiming
99
that life was prolonged. Stanley injected by means of a large
syringe strips of testes of rams, goats, or bears under the skin of the
abdomen of more than 300 prisoners, and stated that conditions of
neurasthenia and senility were relieved.

The stimulating effect of thyroid secretion on growth and metabolism,
shown both experimentally and clinically in the therapeutic triumphs of
thyroid treatment in myxoedema and hypothyroidism, seems to justify the
view that failure of thyroid function plays an important part in reducing the
capacity for multiplication and regeneration of cells. Between the
manifestations of hypothyroidism and those of old age there are
undoubtedly striking resemblances, such as the dry skin, the loss of hair, the
diminished mental and bodily energy, and the increased amount of
interstitial fibrous tissue. In some respects myxoedema and cretinism
imitate the senile state; myxoedema has indeed been described as more than
a simulation and as the best example of secondary senilism (Hastings
100
Gilford ); but this is a very different condition from healthy old age which
does not present the picture of complete loss of thyroid function; old age
therefore cannot be regarded as due to athyroidism. Usually atrophy of the
thyroid accompanies and corresponds to that of the senescent body as a
whole. No doubt pathological changes may occur in the thyroid, especially
in women, during advancing years, and it is in such instances that thyroid
feeding produces so much improvement that it has revived in our day the
hope of an elixir of life and perpetual youth. It is not improbable that the
administration of thyroid gland extract may, by preventing high blood
pressure, delay or obviate the onset of arteriosclerosis, and so stave off
senility due to this cause, but this is pathological old age and not the
physiological involution.
In addition to the seminal tubules and ova, which provide their external
secretion, the testes and ovaries contain the interstitial cells described by
101
Bouin and Ancel or, in Steinach’s phrase, “the puberty gland”; the germ
cells and the interstitial cells differ from each other in structure, function,
and reaction to external influences; thus the germ cells though dominant are
more susceptible to damage, for example by ligature of the vas deferens, x-
rays, alcoholism, or pressure, as in the case of a cryptorchid. It is stated that

when the seminal tubules are active and prominent the interstitial cells are
scanty, and conversely that when the seminal tubules atrophy the interstitial
102
cells multiply; Lipschülz, Ottow, Wagner, and Bormann showed that
hypertrophy of the interstitial cells as observed in various experimental
conditions depends on local factors in the testes and has nothing to do with
their internal secretion in relation to the body as a whole. After ligature of
103
the vas deferens in animals there are, according to Steinach, Kuntz, and
others, two stages (1) the seminal tubules atrophy while the interstitial cells
multiply, and (2) after some time the seminal tubules regenerate while a
104
certain amount of increase in the interstitial cells persists. Nathan
ascribes the regeneration of the seminal tubes to the influence of the
interstitial cells, which he considers act like young connective tissue by
favouring growth. The interstitial cells of Leydig in the testis and the
interstitial or lutein cells of the ovary are generally regarded as responsible
by their lipoid internal secretion or hormone for the secondary sex
105 106
characteristics (Bouin and Ancel, K. Sand ), though Blair Bell and
107 108
Sternberg deny this. Sir Frederick Mott, who has extensively
investigated the interstitial cells, especially in connexion with dementia
praecox and other forms of mental degeneration, concludes that in fetal life
they act as sex determinants, and that later in life they are responsible for
the sexual appetite. It has been argued that atrophy of the interstitial cells is
the cause of senescence. Against this view is Sir Frederick Mott’s
observation that after birth the interstitial cells undergo progressive atrophy
and disappear, that they reappear and are in a state of functional activity at
109
puberty (a sequence of events described by Aron as two different
110
interstitial glands), and that they are present in extreme old age; Retterer
also described their presence in the testes of men over 70 years of age. So
far it might be concluded that changes in old age, such as diminution in
number and pigmentation, shown by the interstitial cells, are not the cause
but an accompaniment of senescence.
111
Kenneth Walker’s observation that the interstitial cells of the testis
show a gradual diminution in number from the age of about 30 years, might
be quoted in favour of the contention that atrophy of these cells plays a part
in the production of senescence. In addition there are the dramatic

112
experiments on rats carried out by Eugen Steinach, who was formerly
Professor of Physiology in the German University of Prague and since 1912
has been Director of the Physiological Section of the Experimental
Biological Institute at Vienna. He found that in apathetic senile rats with
degenerative changes in the thyroid, pituitary, and interstitial cells ligature
or section of one vas deferens causes atrophy of the seminal tubes and
active growth of the interstitial cells; the hormone thus provided stimulates
the thyroid, pituitary, and brain, and the rat is rejuvenated, the sexual
instincts and emotions become active, and the rat may have offspring; when
relapse into senility occurs, a repetition of the operation on the other side
brings about a further rejuvenation; and later the same result is effected by
grafting the testes of a young rat. In this way life is definitely prolonged.
This procedure has been advocated in man with some success by Steinach;
Lichtenstern of Vienna, who has done 36 such operations and 21
implantations on account of senile changes, has not encountered any bad
results, but admits that he has not been uniformly successful, and that the
number of cases is not sufficient to justify a final conclusion. From
113
observation in Vienna Benjamin estimated that the operation was
followed by no results at all in from 10 to 20 per cent of the cases.
Obviously a considerable time must elapse before any decision as to
prolongation of life can thus be assured.

In the autumn of 1921 a man aged 70 was advertised to speak at
the Albert Hall on “How I was made 20 years younger by the
Method of Dr. Steinach of Vienna,” but he died on the morning of
113
the day from pneumonia (Benjamin ), the necropsy not revealing,
so it is said, any trace of an operation; the hypertrophy of the
interstitial cells, however, may have been induced by the exposure
of the testes to x-rays.

Steinach’s observations naturally aroused great interest and have been
114
repeated with discordant results by a number of investigators: Simmonds
115
and Tiedje have failed to confirm the occurrence of the changes in the
116 117
testes after vasectomy; and Romeis and Marinesco have not obtained
the striking clinical results described by Steinach. Levy Lenz and

118
Schmidt, however, report rejuvenation in 23 out of 24 cases of
vasectomy, and Voronoff encouraging results from implantation of
chimpanzee’s testes into man. But Marinesco compares Steinach’s
published results with those of Brown-Séquard.
It may be added that the operation of ligature of the vas deferens which
was performed some 25 years ago, before prostatectomy became
established, in order to cause atrophy of enlarged prostate, was not noticed
to be followed by rejuvenescence. Mr. C. Mansell-Moullin, who
119
published a series of 14 such cases, has kindly informed me that his
patients did not show any evidence of such a change. Romeis has also
raised this objection to Steinach’s results which it has been thought might
be explained by suggestion (Freudenberg)—a view hardly tenable in the
light of the remarkable results described in animal experiments.
The internal secretion of the ovary has never been isolated, and the
evidence of its existence rests on the results of removal. Castration in men
and in women does not bring on the phenomena of old age, though this
operation is followed by well-marked changes as regards the secondary sex-
characters, and, according to Voronoff, eunuchs are short-lived. It may also
be pointed out that the obesity so common after castration is not a feature of
“the lean and slippered pantaloon.” Further, after the menopause the ovaries
undergo fibrotic atrophy, and it appears from Professor Turnbull’s
observations (vide p. 114) that the interstitial cells are very scanty or absent;
further observations are necessary as to the presence of interstitial cells in
senescent ovaries, but presuming that they are scanty it would follow, on
the hypothesis that the interstitial cells exert an influence in preventing the
onset of old age, that women should become old much sooner than men in
whom the interstitial cells are apparently much more in evidence. It cannot
of course be admitted that such a difference in the sex incidence of old age
exists. The improved health and rejuvenation after x-ray treatment for
metrorrhagia and uterine fibromyomas at the climacteric or post-climacteric
age have been regarded by Steinach and Bordier as due to hypertrophy of
the ovarian interstitial cells following induced atrophy of the ova, but to
accept this there must be definite evidence that the interstitial cells are
120
increased in number. Harrower’s dictum that the absence of a hormone
provided by the interstitial cells is responsible for premature senility does

not appear to be borne out by our present knowledge, but a great deal of
further work must be done before a final decision is justified.
Testicular and ovarian extracts, often in combination with those of the
thyroid and pituitary, which are known to have a definite physiological
action, have been extensively used as a panacea. But is there any
undeniable evidence that the extracts of testis and ovary so far employed
121
have any effect apart from that of suggestion? According to Frank the
available ovarian preparations are defatted and thus deficient in the potent
lipoid extracts; and very serious doubts as to the activity of testicular
extracts have been expressed by Professor Cushny.
The possibility must be borne in mind that the use of thyroid and other
gland extracts that have a definite effect on metabolism is not devoid of risk
to cells that are gradually undergoing involution; for, by stimulating
metabolism unduly, the existing vitality may be prematurely exhausted and,
though for a time there is a gratifying show of energy, it is but a flash in the
pan that precedes a more rapid loss of function. We are irresistibly reminded
that “no man putteth new wine into old bottles: else the new wine doth burst
the bottles.”
At the present time it would be unwise to express a dogmatic opinion
about the relation of the endocrine glands to normal old age. That old age is
due to endocrine insufficiency or loss of balance cannot be regarded as
proved, and it is probably safer to regard changes, such as atrophy, in the
various glands of internal secretion as concomitant with, rather than causal
of, those in the senescent body.

Metchnikoff’s Pathological Explanation

As an alternative to the belief that there is an inherent quantum of
vitality which may be harmfully or beneficially influenced by environment
and the wear and tear of life, it has been suggested that the process of
ageing depends solely on external factors and that either there is no intrinsic
limitation to the life of the organism or that the possibility is entirely cast
into the shade by predominance of extrinsic influences. This doctrine is free
from any tinge of fatalism and has the advantage that it is a direct stimulus

to efforts in the direction of hygiene in all its forms; for as things are now
old age owes its discomforts to superadded and in most instances avoidable
complications. Élie Metchnikoff, as is well known, attributed the senile
accompaniments of advanced years to pathological and preventible causes,
namely toxaemia induced by alcohol, syphilis, and especially by bacterial
activity in the colon which in common with Barclay-Smith and Arbuthnot
Lane, he regarded as a harmful phylogenetic relic, this point of view being
expressed by the epigram “the longer the colon the shorter is life.” He
considered that the putrefactive bacteria in the colon produce phenol, indol,
skatol, and aromatic bodies which cause degenerative changes in the cells
of the body; and that the more resistant macrophages, which do not attack
healthy tissues, absorb the damaged cells. He therefore employed means to
prevent excessive bacterial activity in the large intestine, and in addition to
care in diet so as to diminish the risk of introducing bacteria into the
alimentary canal, he advocated the destruction of putrefactive bacteria in
the colon by means of sour milk and cultures of Bacillus bulgaricus, which
form lactic acid and thus render the contents of the bowel acid and
unsuitable for the growth of the harmful micro-organisms. Metchnikoff
thoroughly practised his doctrine, but he did not begin his regime until he
was well over fifty, and, in spite of several severe illnesses which had
damaged his heart, he lived longer than any of his family and passed the
70th milestone. His views on the method of production of senility aroused
122 123
great interest and criticism not only from Marinesco, Léri, Sand,
Laignel-Lavestine, and Voisin, who disputed the reality of the macrophages
124
devouring the cells of the central nervous system, and Ribbert who
denied the existence of such a physiological intoxication and ascribed old
age and death to the inevitable physico-chemical changes incident to life,
125
but also from Salimbeni and Gery, working in the Pasteur Institute, who
while supporting most of his contentions did not consider that they provided
the whole explanation, e.g., the involution of the ovaries at a fixed age was
not thus accounted for. The means Metchnikoff advised for the
postponement of senility and death were on much broader lines than the
popular conception summed up by “sour milk” might suggest, for he
expounded the philosophy of orthobiosis or a correct method of living.

That intestinal toxaemia due to stasis has a very important influence in
126
producing disease cannot be doubted, and Sir Arbuthnot Lane has
brought this prominently to our notice; while clothing in modern language
127
the old ideas of the primae viae he recalls to our memory Abernethy’s
panacea for many ills of the flesh, namely a blue pill at night followed by a
mixture of gentian and senna in the morning.
128
Among his collaborators Mr. Ernest Clarke has insisted on the
premature ageing of persons with intestinal stasis. From the analogy of
syphilis, alcoholism, and other intoxications, which may produce
degenerative changes simulating those found in old age, the hypothesis of
intestinal toxaemia gains a certain amount of support, and it may not be so
easy to exclude the agency of intestinal toxaemia as in the case of syphilis
and some intoxications. But intestinal toxaemia may, as far as can be
judged, be absent in healthy old age, and conversely be present in early life
without causing the phenomena of old age. Further objections have been
raised:—why should intestinal toxins be harmless for 40 or 50 years and
then exert such a serious influence? why should women who are more
subject than men to constipation be more long-lived; and that in constipated
persons the faeces, as shown by Schmidt and Strasburger, contain fewer
129
living bacteria than in health.
As applied to normal old age and death this hypothesis is pathological
and therefore has rather failed to interest those who are working at the
biological aspect. Perhaps the most that can be safely concluded in
balancing the pathological and biological arguments is that while
Metchnikoff’s view may be partially true it does not account for all senile
changes, and that normal old age or senescence cannot be regarded as the
result of toxins absorbed from the alimentary canal.

Old Age of Cells and Carcinoma

The relation between ageing of the cells on the one hand and the
development of carcinoma on the other hand is a subject of great interest.
130
According to Karl Pearson’s statistical enquiry the incidence of

carcinoma reaches its maximum at the age of 46 years in women and 56
131
years in men; Lazarus-Barlow concluded that the range of years over
which cancer is likely to occur is practically the same in the two sexes,
namely 46 to 64, and that among 4659 cases of malignant disease there
132
were only 35, or 0·7 per cent, over 80 years of age. The cancer age,
therefore, coincides with the waning of maturity and the onset of old age;
that carcinoma is rare in very old persons is also shown by the occurrence
of one case only among 71 centenarians collected by Sir George Humphry.
133
Laurent considered that whereas longevity depends on a condition of
vital equilibrium, the development of cancer is due to a want of this
equilibrium, to a state of anarchy, and that the factors disposing to orderly
vitality are conducive to longevity and antagonistic to the development of
new growth. The reason why malignant growths are prone to appear with
the onset of old age has naturally been the subject of much debate.
According to Thiersch degeneration lessens the controlling influence
normally exerted by connective tissue on epithelium, the inherent
proliferative capacity of which then runs riot. Ribbert believed that from
loss of resistance or diminution of surface tension in the connective tissues
post-natal “rests” of epithelium were produced as the result of irritation and
that these displaced cells then grew because there was no controlling
opposition. Adami suggested a reversion of the highly specialized epithelial
cells to a simpler form with powers of proliferation, the cumulative habit of
growth taking the place of the habit of work, and practically anticipated the
134
more modern view. According to Hastings Gilford malignant disease is a
premature cell senility and the result of the partial reversion of immature or
adult cells to an embryonic or quasi-embryonic state. From a study of
135
senescence in dogs Goodpasture concludes that degenerative changes in
the cells lead not only to death of some cells but to dedifferentiation of
others, which, becoming simpler in structure and function, recover their
juvenile power of growth in varying degrees, and that hence metaplasia and
tumour growths occur as accidents of commencing old age. A little later
136
Oertel insisted on his view that cancer is not an embryonic reversion or a
specific change in the cell but a phenomenon of senescence—a
degenerative proliferation depending upon disturbances in the nucleus
plasma relations, specifically upon the loss of nuclear chromosomes; from

age or degeneration the tumour cell loses the higher functional
chromosomes and retains the genetically older and more resistant ones
controlling reproduction and vegetative activities; thus there arises a race of
cells without the differentiation of undegenerated cells.
These various expressions of opinion would justify the conclusion that
with the onset of old age the degenerative processes in the cells lead to the
production of less specialized cells which have the compensating property
of more vigorous growth, and that in certain circumstances, one of which is
very probably a diminished power of resistance on the part of the
surrounding tissues and another, and very important one, irritation in some
form or another, riotous proliferation of the cells invades the adjacent parts.
That the conditions necessary are usually local is strongly suggested by the
appearance of the new growth at one spot only and by the frequent absence
of recurrence after free removal. There may be a premature local
senescence of the tissues, just as there is premature old age of the body
generally, and this would explain the exceptional occurrence of malignant
disease in early life or long before the usual time.

VI

NORMAL STRUCTURAL CHANGES IN OLD
AGE

Physiological old age, namely a process of involution and atrophy
uncomplicated by superimposed pathological changes, is extremely rare;
pathological processes may initiate and hurry on a condition imitating old
age, and indeed the morbid changes found after death in old people
commonly show the lesions of past infections in addition to those of
physiological involution, and the longer life lasts the greater the probability
that changes due to disease will accumulate. It is therefore difficult to
determine accurately where physiological involution ends and pathological
lesions begin, and there has been much confusion between physiological
old age and pathological senility. It must, on the other hand, be admitted
that the ideal condition of physiological involution without some definite
evidence of superadded pathological change hardly ever comes before us.
In fact at the best old age is almost always but relatively physiological, in
other words, as Metchnikoff wrote in 1903, there is at present, from the
conditions of inharmonious environment, no chance of a really
physiological old age and death for mankind. But the view that old age is
invariably the accumulated product of multiple injuries due to infection and
poisons, or that it is due to arteriosclerosis (Boerhaave, Haller, Demange) is
an entirely different proposition and does not fit in with biological
knowledge. While fully recognizing the difficulties an attempt may be made
to tabulate the natural changes accompanying and responsible for old age,
and to contrast them with the pathological changes commonly complicating
the normal structural involution of the human body.

The general atrophy of old age, as grossly shown by loss of weight,
does not proceed equally in all parts of the body. The supporting fibrous
tissues of the body and organs certainly atrophy less than the nobler,
because actively functional, cells of the organs; it is difficult to estimate the
atrophy of the fibrous tissues, for from shrinkage of the parenchyma of
organs and of muscles the fibrous framework stands out in greater
prominence. Some proliferation or replacement fibrosis follows atrophy of
the nobler tissues, and pathologically infection may cause fibrosis. But that
the fibrous tissue does to some extent share in the general atrophy is
rendered probable on the analogy of the change in the allied tissue of bone
which undergoes rarefaction and thinning. The subcutaneous and
perivisceral stores of fat diminish out of proportion to the fibrous
supporting tissues around them. The place of the fat in the fat cells may be
taken by fluid—serous atrophy—or the cells may simply revert to the
condition of connective tissue cells. In passing it may be pointed out that it
is curious that with the diminished metabolism of old age the stores of fat
are not increased as they are in similar circumstances in adult life; Is it due
to a widespread atrophy of the connective tissue cells that store fat? If so, an
accumulation of fat in the liver might be expected, but this is not so.
Possibly it is the result of deficient assimilation. The heart, as
137
Councilman has shown, is on the whole better preserved than the other
organs; but it might well be argued that the existence of such a cardiac
condition is a determining factor in the attainment of advanced age.
The skin is dry, thin, smooth, glossy from atrophy, inelastic like
parchment, and is wrinkled from degeneration and disappearance of the
elastic tissue, subcutaneous fat and muscular fibre. These changes are most
advanced on the face, especially the forehead, and backs of the hands from
exposure. The degeneration of the elastic fibres, recently studied by
138
Kissmeyer and With, gives a characteristic mesh-like appearance,
depending on the rigid wrinkles, to the skin, which takes a yellow tint. The
ivory pallor and coldness are due to the diminution in the capillaries; the
skin may show areas of pigmentation and leucodermia—changes described
by Sir Lenthal Cheatle as due to the wear and tear of life (biotripsy); in a
woman aged 93 Salimbeni and Gery described almost complete
disappearance of the papillae and of the collagen fibres. The pigmentation
has been regarded as a means of protection, for there is a relation between it

and malignant disease, the latter being prone to occur when pigmentation
139
fails (Pringle ). These atrophic changes are far commoner on the backs
140
than on the palms of the hands, and it is noteworthy that among Cheatle’s
200 collected cases of malignant disease of the hand there was one only on
the palm. The subcutaneous fat is diminished in amount, which is regarded
by Sir Arbuthnot Lane, though not with any special reference to old age, as
one of the many results of colonic toxaemia. The yellow fat contains excess
of cholesterol. There is diminished secretion by the sweat and sebaceous
glands, and from this cause and the diminished vascularity there is less loss
of heat to correspond with the slower metabolism.
Hair.—Greying or whitening of the hair occurs commonly in old age,
but not universally for some centenarians have retained the natural colour of
the hair; coarse jet-black hair is specially prone to whiten early. The change
in colour has been ascribed by Metchnikoff to the action of phagocytes
(chromophages) which invade the roots of the hairs and carry off the
pigment granules. Like the arcus senilis it may occur quite early in life and
without any other indication of age, and is often hereditary; as the sage of
Norwich wrote, “Hairs make fallible Predictions, and many Temples early
141 142
Gray have outlived the Psalmist’s Period.” Lord Bacon indeed said,
“Hasty gray hairs, without baldness, is a token of long time; contrarily, if
they be accompanied by baldness.” But baldness is often due to seborrhoea
and so only secondarily connected with advanced age. In some rare
instances the hair already grey or white has been known to regain its normal
143
colour; the late Sir Charles Cameron recorded this event in his own life
after an accident confining him to bed for some months in his eightieth
year, and refers to the hair of a man aged 90 years returning to its original
144
brown colour; cases were also reported by Graves. Velasquez de
145
Tarente recorded an abbess who after an illness which promised to be
fatal in her hundredth year had a crop of brown hair, and, like Sir Charles
146
Cameron, put on weight. Four other cases are given by Sir John Sinclair
in persons aged 80, 104, 105, and 114 years. Baldness may be definitely
due to thyroid insufficiency and not to atrophy of the hair follicles and
sebaceous glands.

A pensioner aged 75, whom I saw with Major R. J. C.
Thompson, in the Royal Hospital, Chelsea, with baldness and a grey
beard, was given thyroid extract, as he was thought to have
hypothyroidism; his general condition then improved wonderfully,
and his scalp became covered with dark brown hair which had to be
cut at intervals. Parkinsonian tremor was rather more obvious
during the first six months that he was on thyroid treatment.

The hair of the body may become scanty and lose its tendency to curl.
Excessive growth of hair (hypertrichosis) in women after the menopause is
an indication of disordered endocrine balance (loss of ovarian internal
secretion?) and is only so far an accompaniment of age; it may be seen in
comparatively young women from various causes.
The nails are often longitudinally ridged, brittle, hard, and thickened;
but onychogryphosis is rather the result of neglect or of disease than solely
of old age.
147
The brain as a natural result of atrophy becomes lighter; Boyd’s
tables show that the male brain is 3 oz., and the female brain 4 oz., lighter
in persons over 80 years of age than in the decade 20 to 30. The
convolutions, therefore, become separated and the amount of cerebrospinal
fluid greater. The atrophy is not uniform, being less in the posterior third
than in the anterior two-thirds. The nerve cells become smaller, pigmented,
and degenerate. The brain is said by Cerlette to be affected by a process
special to old age—miliary necroses scattered over the cortex and
associated with changes in the small arteries which show remarkable knots;
a condition which suggests a pathological softening secondary to
arteriosclerosis, especially as the change does not come on constantly at a
definite age period. Cavities with thickened walls, possibly due to miliary
haemorrhages, or to softening around the vessels are also described.
Metchnikoff’s description of phagocytic destruction of the nerve cells by
macrophages has been seriously questioned and thought to be based on
erroneous observation, the glia cells being regarded as macrophages
(Marinesco).
The spinal cord shows an increased number of amyloid bodies, some
diffuse sclerosis, often obliteration, by epithelial proliferation, of the central

canal, and atrophy with pigmentation of the nerve cells, especially in the
anterior cornua. The membranes may contain small calcareous plaques.
The arcus senilis, due to infiltration with fats, especially cholesterol
and lipochrome, and to degeneration of elastic tissue at the periphery of the
148
cornea, is often associated with arteriosclerosis (Monauni ). It is not a
necessary accompaniment of age; among 321 persons over 80 years of age,
it was absent in 114, or 35·5 per cent (Humphry); and it is well known that
149
like grey hair, it may occur in those young in years. Nascher, the author
of Geriatrics, had an arcus senilis as a schoolboy. Rigidity and flattening of
the crystalline lens lead to presbyopia, which may be premature and due to
150
toxaemia, among the causes of which Ernest Clarke gives intestinal
toxaemia a high place. The power of accommodation is also impaired by
weakness of the ciliary muscle brought about in the same way.
Skeleton.—The atrophy characteristic of senescence is well shown in
the fixed tissues of the bony skeleton. Though the bones do not as a rule
alter materially in size or shape, they do so markedly in substance from
rarefaction and absorption, the latter taking place mainly from the inside of
the bones and especially the cancellous tissue, the medullary cavity and the
Haversian canals becoming larger (senile osteoporosis). Hence fractures
near the joints, particularly intracapsular fracture of the neck of the femur,
are favoured. The absorption of the alveolar border of the jaw is intimately
connected with the loss of the teeth, and brings the mental foramen to the
top of the edentulous mandible. The angle of the jaw at the junction of the
body and the ramus now opens out and comes to resemble that of an infant.
It is often stated that the angle of junction of the neck and shaft of the femur
becomes less, more of a right angle, but Humphry regarded this as
exceptional.
From muscular weakness the back becomes bent and as a result the
vertebrae become altered in shape. Ossification of the anterior common
spinous ligament—a change analogous to rheumatoid osteophytes around
the more movable joints—is an added and not uncommon change but, like
calcification of the costal and laryngeal cartilages, it is a morbid process,
and when advanced constitutes spondylitis deformans. The intervertebral
discs undergo some loss of elasticity and atrophy, thus contributing to the
loss of height. The cranial bones are usually thinned, and the parietal bones

may show symmetrical or nearly symmetrical oval areas of excessive
absorption of the outer and even of the inner table, so that the epicranium
and the dura mater may be in contact. These areas which are close to the
longitudinal fissure must not in the case of ancient skulls be mistaken for
examples of early trephining. The bony sutures tend to become obliterated.
Instead of thinning and loss of weight the skull, especially the vault, may
show thickening and be heavier than normal—a change involving chiefly
the inner surface and ascribed by Sir George Humphry to shrinkage of the
brain.
Calcification of the costal and laryngeal cartilages, which have a
yellow tint from fatty change, is, like a similar change in the arteries,
pathological and not part of the process of senescence. Thus among 10
recorded necropsies on centenarians the costal cartilages were calcified in 2
only. Calcification of the costal cartilages interferes with the respiratory
movements and was regarded by Sir George Humphry, who tested for it by
estimating the elasticity perceived when gentle pressure is exerted on the
lower part of the sternum, as a bad omen for the future.
The teeth are usually, but not invariably, few in the aged, for care or
lack of it, the accumulated effect of long-continued mechanical injuries,
altered calcium metabolism, and diminished resistance to infection will
necessarily influence the amount of decay. Statistics, especially Humphry’s,
show that in extreme old age very few teeth are present, and it is tempting
to correlate the diminished provision for mastication with the lessened need
for food. Sir Isaac Newton, however, at the age of 85 was said to have lost
one tooth only. The numerous reputed instances of a third dentition can be
explained only by the appearance of a previously buried tooth through the
atrophying gums, for a genuine third dentition would necessitate the
presence of dental germs which do not exist.
The gastro-intestinal tract shows atrophy of the muscular coat and its
secreting glands, so that dilatation of the thin-walled, pale stomach and
colon occur on less provocation than in adult life and digestion is impaired;
from lack of mucous secretion combined with loss of motor vigour
constipation is common. It may be added that hypertrophy of the prostate
by interfering with peristalsis of the colon has been thought to cause
151
gerontal constipation (Hollis ). The pancreas shows fibrotic atrophy and

becomes smaller and harder. From the loss of fat and muscular atrophy
visceroptosis is not uncommon.
The liver diminishes in size and weight by about one half; atrophy of
considerable areas may expose the vessels and ducts on the surface of the
organ. Boyd’s tables show a difference of 18 oz. between the weights in
persons in the decade 20–30 and in those over 80. Microscopically atrophy
of the lobules and of the cells in the centres of the lobules have been
152
described (Luciani ), but the latter change is not constant, for in a woman
153
of 93 Salimbeni and Gery definitely noted that the cells were not
atrophied. That such atrophy of the liver cells is pathological is perhaps
154
supported by D. Symmers’s observation that in the pancreas of such
cases the islands of Langerhans may show moderate enlargement, as if to
compensate for failure of the glycogenic function of the liver. Pigmentation
of the cells by a lipochrome is excessive, and the name brown atrophy has
been applied to the condition which is seen in the other viscera of the old.
The lungs become smaller, lighter, and the elastic tissue degenerates;
this is atrophous emphysema, and the chest capacity diminishes. Roussy
155
and Leroux found that these lungs commonly show endarteritis
obliterans and fibrosis, conditions which favour infarction, infection, and
the terminal bronchopneumonia to which the aged are so prone.
156
The voluntary muscles, according to Durante, contain many fibres
157
with large globules of fat; but Jewesbury and Topley, who describe
coarse fat globules mingled with brown pigment in the immediate
neighbourhood of the muscle nuclei in 50 per cent of cases of various kinds,
and almost constantly in old subjects, regard this condition as independent
of true fatty degeneration, and are doubtful if it has any pathological
significance. Excessive fatty and fibrotic change is found in cases of senile
paraplegia without any lesion in the spinal cord or brain.
Heart.—Some difference of opinion exists as to the condition of the
158
heart; Parkes Weber says that the only true senile change is diminution in
size and weight; this as it is worded is no doubt correct; but pure atrophy is
159
less rare in the heart than in most parts of the senile body. Charcot indeed
stated that it does not atrophy in old age, but preserves the dimensions of

middle life. The heart may even hypertrophy in old people; this is
160
pathological; Councilman found it in 248, or 43 per cent, of 580 persons
over 60 years of age, and could not refer it to aortic or renal arteriosclerosis
or to the diminished capillary area in the skin; but the average blood
pressure 158 systolic/88 diastolic of the cases with cardiac hypertrophy was
higher than that 130/78 of the others.
Fatty degeneration of the myocardium is very frequent; Charcot stated
that at the Salpêtrière it was almost constant in old women, but according to
Councilman there is no clear evidence that it produces permanent injury or
functional insufficiency; he noted some fibrosis in 15 per cent of his cases.
Atrophy of the epicardial fat—serous atrophy—is common, and increase of
the so-called lipochrome pigment in the muscular fibres which become
smaller and fewer—brown atrophy—is frequent as it is in the other organs
in old age.
Chronic valvulitis and subendocardial fibrosis are, like arteriosclerosis,
common morbid changes.
Arteriosclerosis, contrary to what has been stated by Huchard and
others, is not constant in a considerable degree in old people, and therefore
cannot, as Demange and others considered, be regarded as the cause of the
atrophic changes seen in old age. Arteriosclerosis is due to several factors,
namely, infection and intoxication of various kinds and to damage caused
by long-continued high arterial blood pressure. The primary changes are
degeneration and weakness, however brought about, in the middle coat.
161
Ophülz has recently discussed the question whether the degeneration is
entirely or largely a senile change; if it were so, the curve of the incidence
of arterial sclerosis would begin gradually about the age of 40 years, so as
to include premature cases, and rise slowly until the age of 55 years, when
there would be a sudden increase to 80 or 90 per cent, and at the age of 70 it
would be improbable that any one would be free from well-marked
arteriosclerosis. He found that the curve of incidence was very different
from this; beginning much earlier its rise is gradual all the way without any
sudden increase, and indeed seems, if anything, to be retarded by old age.
Old persons may have practically healthy arteries, so, although
arteriosclerosis may undoubtedly produce atrophy and senile changes in the
tissues and organs by diminishing the blood supply, for example in the case

of the red granular kidney, it cannot be regarded as the causal factor in
healthy old age.
The primary calcification of the middle coat, sometimes called
Mönckeberg’s sclerosis, which leads to the formation of regular rings in the
degenerated muscular media and the “pipe-stem” arteries associated with
senile gangrene, may be independent of, or combined with, endarterial
sclerosis. It follows fatty degeneration of the media, which is the
commonest form of medial degeneration in the aged, and specially picks
162
out the elastic fibres. The femoral, tibial, radial arteries and the aorta are
most often affected. It is difficult to estimate its incidence, but that it is not
very common, at any rate in a high degree, seems probable from the
comparative infrequency of its detection in x-ray examinations of the lower
limbs in old people. It would be natural to associate its occurrence with the
rarefaction of bone that goes on in advanced life, and so to consider it as in
some respects different from the secondary calcification in endarteritic
sclerosis; in answer to an enquiry Professor W. T. Councilman of Harvard
kindly wrote to me that he did not regard calcification as characteristic of
any particular type of arterial disease, lime salts being in certain cases more
easily deposited in any pre-existing lesions. Klotz describes fatty and
calcareous change in the middle third of the media of the aorta as quite
characteristic of senescence.
Cazalis’s famous aphorism “man is as old as his arteries” is true in so
far that the state of the arteries is a good index of the general condition, for
they are extremely prone to suffer as the result of infection, toxaemia, and
strain; strictly speaking, therefore, the state of the arteries is not so much an
index of the individual’s age as of his adventures.
Phlebosclerosis, analogous to arteriosclerosis, is common, and
dilatation, often due to stagnation and lack of the normal vis a tergo, of the
veins is a familiar change in the aged.
The capillary area is diminished in the skin and elsewhere, but not
uncommonly there are dilated venules or angiomas on the skin; the latter,
commoner on the trunk and upper limbs and in men, were formerly known
as “de Morgan’s spots” and were thought to accompany cancer, but the
association is only due to a rough correspondence of their age incidence.

The blood of healthy octogenarians may not show any departure from
that of the earlier periods of life as regards the number of the reds and the
163
amount of haemoglobin (Hansen ), though some have described a
164
secondary anaemia. Thus in a female centenarian Macnaughton found
slight secondary anaemia with a normal number of leucocytes, the
differential count showing a relative lymphocytosis. The red bone marrow
diminishes, its place being taken by fat cells.
The lymphoid tissues undergo atrophy all over the body including the
leucoblastic bone marrow, but though it does not appear that the blood
shows any definite change in the leucocyte count it is tempting to correlate
the diminution of resistance to acute infections, such as pneumonia and
erysipelas, with the atrophy of the lymphoid tissue. The alimentary canal
often shows lymphoid atrophy in a high degree, but two normal Peyer’s
165
patches were present in a man reputed to be 106 years old (G. Rolleston ).
The spleen, in common with the lymphoid tissues elsewhere, shows
atrophy, sometimes to an extreme degree, so that instead of the normal
weight of 7 oz. it weighs a few drams only. The capsule is thrown into
folds, and is somewhat opaque; from atrophy of the pulp and Malpighian
corpuscles the vessels and fibrous trabeculae become prominent. The
thymus, contrary to the general opinion that it undergoes involution long
166
before puberty, has been found by Hammar to increase in size up to
puberty when involution begins, but proceeds so gradually that even in old
age it is functional.
The thyroid, unless there is cystic change, is smaller than natural; thus
out of 40 thyroid glands from individuals between the ages of six months
167
and 77 years the smallest was in a woman aged 77 (Hale-White ). In
colour it is darkish brown and on section rather dry. Dr. Donaldson,
Lecturer on Pathology at St. George’s Hospital, has specially examined 19
thyroid glands from patients between the ages of 57 and 93; of these five
showed cystic change; they all showed increase in the amount of fibrous
tissue which was progressive with age, and in the absence of cystic change
the size of the vesicles and amount of colloid material were diminished.
The Parathyroids.—From examination of a number of specimens Dr.
Donaldson finds that in old people the parathyroids appear to be free from

retrogressive changes, but he cautiously requires further experience before
concluding that this is the rule.
The adrenals show involutionary atrophy in common with the body as
a whole, but sometimes the cortex is enlarged from excess of lipoids,
usually associated with considerable atheroma, and may also show
adenomas. As the increase in size of the adrenals is cortical its relation to
high blood pressure, if any, is that of a remote result, namely from
arteriosclerosis, and not causal as has been suggested. According to G. M.
168
Findlay the amount of lipochrome in the cells of the adrenals increases
with advancing years and is accompanied by the appearance of melanin in
their nuclei.
169
The kidneys show definite atrophy, and Councilman, who has
recently made a study of them in 580 persons over 60 years of age, calls the
condition chronic atrophic nephropathy. The fat in the renal pelvis is more
obvious than usual, the capsules are slightly thickened and occasionally but
by no means always adherent, the surface finely rough and sometimes
showing small cysts, but the large and irregular depressions characteristic of
a granular kidney are not common. There are, however, areas of fibrosis,
and the cortex and medulla are equally atrophied. Microscopically some
glomeruli are fibroid, others smaller than natural. In three-fourths of his
cases the renal vessels showed arteriosclerosis due to primary atrophy of the
media with compensatory hypertrophy of the intima; but Councilman gives
reasons for hesitation in accepting the obvious conclusion that the senile
kidney is the result of the vascular change.
The prostate shows some degrees of enlargement after the age of fifty
in the vast majority of men, but in only a percentage of these are there
170
symptoms referable to it. Kenneth Walker finds that the maximum size is
reached at the age of 60 and that from then onwards there is a slow
diminution in size; among 340 men between 80 and 90 there were 11, or
3·2 per cent, and among 92 men between 90 and 100 one only with
hypertrophy of the prostate (Humphry). The causation of prostatic
hypertrophy has been much discussed; that its association with
171
arteriosclerosis (Launois ) is anything more than a coincidence, the two
conditions being common in the later years of life, seems improbable;
Walker found the two associated in 10 per cent, and he regards the change

as part of a general enlargement and thickening of the peri-urethral, sub-
cervical, and sub-trigonal glands, and, as the interstitial cells in the testes
become fewer and degenerated, he considers that the prostatic enlargement
is possibly a degeneration connected with a disturbance of the endocrine
172
balance. Nemenow argued that prostatic enlargement was due to
proliferation of the interstitial cells following senile atrophy of the seminal
tubules of the testes, but K. Walker found that in prostatic enlargement the
interstitial cells are diminished rather than increased in number. An
interesting parallel has been drawn between the involutionary changes in
the mamma and the prostate, and it is probable that the same underlying
173
factor is at work in both (Walker, Paul). Hertoghe regarded some cases of
prostatic hypertrophy as due to senile dysthyroidism, and recently benefit
has been reported from thyroid medication and also from prostatic extract.
Dr. Leonard Williams has told me of cases, as yet unpublished, showing
well-marked relief of symptoms and diminution in the size of prostatic
enlargement after doses of thyroid extract (½ grain once) and colloidal
iodine (one dram three times) daily. The prostatic plexus of veins is often
enlarged and may contain phleboliths.
The testes become smaller, softer, and commonly show some atrophy
of the tubules with disappearance of the epithelial lining and thickening of
the basement membrane; but the testes of old men may be free from any
such change and the spermatozoa in the vesiculae seminales may be active.
According to K. Walker the interstitial cells gradually diminish in number
174
from the age of 30, but they may be present in men over 80, and Mott
remarks that their persistence may account for an increased and perverted
sexual appetite, due to stimulation of the desire without the power to
perform the sexual act.
The penis becomes smaller, often retracted, the glans harder, and the
scrotum smaller.
The ovaries become shrivelled and fibrotic; the ova disappear or small
cysts may form. It is difficult to find statements about the presence or
absence of interstitial cells in the senile ovary. Professor Turnbull has
kindly informed me that in old women an occasional cell which might be,
but is not certainly, an interstitial cell is visible, and that if they are
interstitial cells their number must be small and their development poor.

The uterus becomes small, its cavity round, and the cervical canal may
be obliterated. The external genitals atrophy.
The mamma in women shows involution changes and when excessive
175
(cystic disease) these may, as Paul has pointed out, be compared with
prostatic enlargement in the male.

VII

PHYSIOLOGY OF OLD AGE

The basis of the physiology of old age is progressive diminution in
functional activity, which corresponds to the characteristic structural
atrophy of the organs and tissues. Thus the lowered functional activity of its
176
glands is manifest in the dry skin; according to Haneborg there is usually
a fall in the percentage of hydrochloric acid in the gastric juice, though
177
Bell disputes this. The lessened amount of mucus from the intestine
probably plays some part in the tendency to constipation. Other evidences
of lowered metabolic rate are seen in the diminished efficiency of the acid-
178
base equilibrium (MacNider ) and the increased degree of urea-nitrogen
in the blood, as shown in 50 per cent of 41 persons between 70 and 88 years
179
of age examined by Rappleye.
Temperature.—Before the era of the clinical thermometer it was
supposed that the body temperature of the aged was below normal. This
belief was part of the ancient view that the cause of old age was exhaustion
by the natural heat of the radical moisture which, like lamp oil, supported
the innate heat and with the passage of years could not be supplied as
perfectly as before; as a result of this loss of radical moisture the body was
180
thought gradually to dry and cool. But it is now known that the internal
temperature is almost constant at all ages, and Charcot proved that the only
real difference is that the axillary is lower than the rectal reading; this is due
to the diminished vascularity of the skin and to the corresponding fall in the
loss of heat, which again may be correlated with the lower metabolic rate of
181
old age. Aub and Dubois’ observations on six men between 77 and 83
years of age, mainly with arteriosclerosis, granular kidney, and emphysema,

showed that the basal metabolism was 12 per cent below the average for
men between 20 and 50.
Blunting of sensibility to pain is a beneficent process, suggesting that
with the gradual process of involution and approach to a physiological
death the need for the warning normally conveyed by symptoms is no
longer needed. This is connected with the simultaneous atrophy of the
nervous tissues which look after the conduction, perception, and reference
of pain. The latency of disease, as shown by an absence of the characteristic
symptoms observed in earlier adult life, is often remarkable in the aged.
Thus death may occur suddenly from extensive but entirely unsuspected
pneumonia; the passage of biliary or urinary calculi may be unaccompanied
by the violent colic of these events in ordinary cases, and extensive
malignant disease may exist without any definite localizing discomfort.
This failure in the power to react is also shown in fevers and infections
(vide p. 142).
Cutaneous sensation is little affected, and indeed the aged are very
sensitive to cold. Taste and smell are impaired, and presbyopia is due to
changes in the crystalline lens. The pupils are contracted and the iris
sluggish. From weakness of the orbicularis palpebrarum muscle ectropion
and epiphora may noticeably change the facial appearance. With advancing
years hearing commonly becomes less acute from various causes, and after
60 there is a successive decrease in the number of persons with normal
182
hearing. According to Albert Gray there is probably a characteristic form
of deafness for the higher notes of Galton’s whistle in all old people, even
when for all practical purposes there is no obvious defect or tinnitus; this he
regards as due to progressive atrophy of the ligamentum spirale. Chronic
progressive labyrinthine deafness, due to atrophy of the auditory nerve and
fibrosis of the ductus cochleariae, is the most common condition in persons
over 60. Fixation of the stapes frequently causes deafness, and the sequels
of middle-ear disease accumulate with advancing years. Gouty eczema of
the external auditory meatus and collections of wax may seriously interfere
with hearing. Tinnitus in the elderly is commonly associated with high
blood pressure and arteriosclerosis.
Appetite for food is sometimes capricious; old people may eat
excessively, possibly because the pleasures of the table are the only ones to

which they feel equal.
Muscular movement is slow and somewhat uncertain, and the reflexes
are diminished except in the presence of sclerosis of the spinal cord.
According to Moebius the knee-jerk is often absent in normal old persons,
but Sternberg, by employing methods of reinforcement not available in
Moebius’ time, found that it was invariably present even in the tenth
decade.
The sleep of the aged is less continuous, and from interruptions often
appears to them to be much less than it really is. There is often a tendency
to irregularity, bad and good nights alternating. But too much attention to
disturbed sleep in the aged must be avoided, as hypnotics are inadvisable,
and it has been urged by Sir Hermann Weber and others that too much sleep
is more harmful than too little.
In old age the mental condition varies in different individuals according
to their previous character and their present physical state. Freedom from
sexual and other perturbations often renders the minds of old people calm,
tolerant, less susceptible to disappointed ambition, and philosophic when
the part of spectator has been accepted in place of that of actor in life’s
drama. In what may be regarded as normal old age psychical activity
diminishes; not only do initiative, elasticity, and originality fail, but new
ideas and fresh lines of thought are assimilated with difficulty; hence the
old are commonly conservative and laudatores temporis acti. Mental
fatigue occurs more readily and the power of concentration and attention is
impaired so that the old may appear deaf; the mind begins to show
disintegration and a return to the primitive condition in which each act
demands individual care; it has indeed been said that old age is nothing but
progressive fatigue. A less agile memory for names is commonly one of the
early symptoms of senescence, and long precedes the characteristic loss of
memory for recent events while that for the remote past remains, as if the
nerve cells were photographic plates which in course of time have all
become occupied with impressions. With commencing failure of memory
there is often a tendency to make the same remark or tell the same story
repeatedly, to mislay things, and unconsciously to become careless about
personal appearance and habits. As a kind of protest against the inevitable
there may, in the early stage of old age, be a tendency to ape the young and
to conceal the true age; thus a man may remove the date of his birth from

Who’s Who and books of reference, and a mother may delay the “coming-
out” of her daughter. On the other hand, at a later stage there may be the
opposite desire to appear a wonderful prodigy of senescence. The old are
notoriously less subject to feel the loss of relatives and friends by death;
they become more self-centred; this may be because retirement from active
work switches their minds on to their own feelings, and possibly in part
depends on loss of touch with the external world, resulting from failure of
the sense organs. This when exaggerated develops into selfish dependence
and demands on relatives. Senile vanity is not uncommon, and Eden
183
Phillpotts remarks that all old people love to be in the centre of the stage,
one of the pathetic things in life being that they are seldom allowed to be
there. The ego-centric frame of mind may lead to hypochondriasis with fads
and meticulous attention to details of personal health and to experiments in
diet and patent medicines. Loss of control, due to failure of the higher
centres, engenders restlessness, garrulity, emotional weakness, and
peevishness. There may be considerable variation in the moods, so that the
deep depression of one day may vanish the next, and irritability and apathy
may alternate.
Regression, which closely corresponds to the “devolution” of
Hughlings Jackson, who argued that in disease the organism tends to retrace
the steps of its development, accounts for the phenomena of “the second
childhood.” Thus the old are prone to nervous apprehension, and liable to
184
suggestion and to hysteria which Rivers defined as a protective
mechanism representing a recrudescence of the reaction to danger in an
early stage of animal development. Will power, like their gait, becomes
hesitant and uncertain. This devolutionary change progresses partially and
not universally; memory for personal names, as mentioned above, is often
the first to fail, because, like the mathematical faculty, it has from the
attendant difficulty a high place in the order of mental processes; hence
forgetfulness of personal names is a criterion of psychical fatigue and
185
neurasthenia (Dupuis ).
In old animals it is natural for the instinct of self-preservation to fade,
as is exemplified in the day-flies which in their larval stage are well
endowed with this property, and as their end draws near animals seem to
acquire an instinct for death comparable to that for sleep. But in human

beings, although they usually dislike old age, there is generally what
186
Matthew Arnold called “a passionate, absorbing, almost bloodthirsty
clinging to life.” Metchnikoff specially investigated this point and found
hardly any instances in which death was anticipated with the same feelings
of pleasure as is sleep by the weary. Considering the discomforts of many
old people it is rather remarkable how very seldom they endorse the words
of the burial service: “We give thee hearty thanks for that it hath pleased
thee to deliver this our brother out of the miseries of this sinful world.”
Various explanations have been offered for this want of harmony between
the mental and physical states of the old; it has been ascribed to the idea of
eternal punishment, and to the presence of pathological conditions which
bring on senility and death prematurely and thus alter what should be the
normal mental attitude of healthy old age. In speaking of the usual fear of
death in old people it should be mentioned that shortly before death this
187 188
commonly disappears and, as G. E. Day, R. W. Mackenna, and
Thompson and Todd point out, the aged when seriously ill commonly
regard death as a welcome release; the famous William Hunter’s last words
in his sixty-fifth year expressed his sense of resignation: “If I had strength
enough to hold a pen, I would write how easy and pleasant a thing it is to
die.”
The Cardio-Vascular System.—The pulse rate is usually rather
increased in frequency as compared with that in adult life; extra-systoles are
so common in persons who appear otherwise normal that they cannot be
regarded as having any important significance. Among Sir George
Humphry’s collection of 824 persons over 80 years of age one-fifth had an
irregular or intermittent pulse.
Although, like arteriosclerosis, a well-marked high blood pressure
without evidence of renal disease, to which Sir Clifford Allbutt has given
the name of senile plethora or hyperpiesia, is common in the decline of life,
it is a pathological and not a physiological change; and a distinction must be
drawn between the gradually rising blood pressure seen from birth onwards
and an increase above that normal to an arterio-vascular system that has
been active for over half a century. In the same way the venous pressure
189
increases with age (Hooker ). That a definitely high blood pressure in the
aged is pathological appears to be shown by observations quoted by

Councilman from the Peter Bent Brigham Hospital, Boston; among 94
patients (male and female) averaging 66 years of age, 44 per cent with
cardiac hypertrophy as shown by necropsy, had an average blood pressure
of 158 systolic / 88 diastolic, whereas the 56 per cent without cardiac
hypertrophy had an average blood pressure of 130/78. In both series the
differences between males and females were never more than 7 mm. Hg.
From observation of 102 Chelsea pensioners over 75 years of age
Thompson and Todd found that the average blood pressure was 145 systolic
/ 80 diastolic, estimations varying from 190/100 to 115/70, and that the
average pulse pressure, or difference between the systolic and diastolic
pressures, was 67 mm. They came to the conclusion that it was not possible
to arrive at a normal blood pressure for old people on account of the
190
varying conditions of the heart and arteries.
The urine, in consequence of the lowered metabolism and general
atrophy, is somewhat diminished in quantity with a fall in the solids, though
the specific gravity remains about normal. The chlorides are stated to be
normal and the phosphates and urea to be diminished. Slight glycosuria as a
191
result of a low sugar tolerance (vide Spence ) is not uncommon,
especially in obesity. Prolonged confinement to bed has been thought to be
responsible for casts in the urine. A trace of albumin is not rare; this may be
due to various factors, and in itself is not a cause for anxiety; but a well-
marked fall in the specific gravity is a sign of renal inadequacy which may
be preceded and anticipated by the discovery of nitrogen retention in the
blood.
Sexual activity in man wanes generally speaking after 50, but there are
great variations in this respect, and sometimes there are periods of
considerable excitement in old men, often thought to be associated with
prostatic enlargement.
It would naturally be expected that wounds and fractures of bones
would heal more slowly in the old than in the young, and, according to
192
Carrel and Ebeling, the cicatrization of human wounds varies inversely,
if accurately measured, with the age of the patient; Humphry, however,
found that, provided sloughing did not occur, wounds and ulcers in the aged
heal as quickly as in middle life, and that the failure of union in

intracapsular fracture of the neck of the femur is due to want of apposition
and not to the age of the patient.
In some respects the reaction to drugs in the senescent body is different
from that in ordinary adult life. In old people absorption from the
alimentary canal is slow and this is particularly so with gelatin-coated pills
and drugs, such as cinchona, containing tannin, which should therefore be
avoided. The physiological response to drugs is slower and more prolonged
than in early life, so that for this reason and from the frequency of
constipation an accumulated action is thought to be more likely to occur in
the aged. It is sometimes said that large doses are not borne well by the old
193
and that morphine is dangerous as it is in infants, but Nascher states that
if, in order to obviate the paralysing effect of morphine on a weakened
respiratory centre, atropine is given before the morphine so that their action
can be timed to coincide, instead of giving them at the same time when the
effect of the atropine comes later, morphine can be given in the same doses
as in maturity. Purgatives may be required in larger doses than in ordinary
194
practice. According to Leonard Williams bromides are likely to produce
mental confusion in old people and if persisted in, even in ordinary doses,
may be followed by vascular thrombosis and permanent impairment of the
intellectual powers. Sedatives and hypnotics when necessary should be
given in small doses and discontinued as soon as possible; but they may be
necessary for restlessness which would otherwise seriously exhaust the
failing strength.

VIII

THE DESCRIPTION OF OLD AGE IN THE
TWELFTH CHAPTER OF ECCLESIASTES

When first approaching the subject of old age every one must recall the
famous description in the first six verses of the twelfth chapter of
Ecclesiastes beginning “Remember now thy Creator in the days of thy
youth while the evil days come not, nor the years draw nigh when thou shalt
say I have no pleasure in them.” Formerly ascribed to King Solomon (977
B.C.) the book of Ecclesiastes (in Hebrew Koheleth = the preacher) has been
shown by the higher criticism to date only from the end of the third century
B.C., and from internal evidence, namely references to the brain, spinal cord,
and other anatomical structures, though expressed with poetic imagery, it
may fairly be assumed that a medical man was concerned with its
195
construction. In his attractive work, A Gentle Cynic, the late Professor
Morris Jastrow, jun., of Philadelphia explained that the book of Ecclesiastes
as it appears in the authorized version, consists of (i.) the original, cynical,
but good-natured obiter dicta of the unknown dilettante who preferred to
veil his identity under the name of Koheleth, and (ii.) additions and
modifications made by various hands to render it more orthodox and
compatible with the tradition that it was written by Solomon; thus the
admonition “of making books there is no end and much study is a weariness
of the flesh” may very probably have been intended as a hint that
Koheleth’s views should not be taken too seriously. Following this
conception Jastrow reconstructed the text of the book of Ecclesiastes to
what he argued was its original form, and compared it with the more
modern writings of Omar Kháyyám and Heinrich Heine. As we all must
have speculated over the correct interpretation of the various metaphors in

this description of the last stage of life, the explanations offered by others,
196 197
such as Andreas Laurentius (1599), Master Peter Lowe (1612),
founder of the Faculty of Physicians and Surgeons of Glasgow, Bishop J.
198 199 200
Hall (1633), John Smith (1665), Richard Mead (1775), and Jastrow
may be very briefly mentioned. The second verse, “While the sun, or the
light, or the moon, or the stars, be not darkened, nor the clouds return after
the rain,” is regarded by Laurentius, Lowe, and Hall as referring to the
ocular disabilities of old age, whereas Smith and Mead consider that mental
failure and depression are meant. As regards the third verse, “In the day
when the keepers of the house (the hands) shall tremble, and the strong men
(the legs) shall bow themselves (become bent), and the grinders (teeth)
cease because they are few, and those that look out of the windows (the
eyes) be darkened,” there is general agreement, Lowe specially designating
cataract as meant in the last sentence. “And the doors shall be shut in the
streets,” is regarded as referring to the mouth by Laurentius and Mead, and
to the various orifices including the results—constipation and dysuria—by
Smith; “when the sound of the grinding is low,” is considered by Jastrow to
mean impaired hearing, and by Smith as a lowered rate of metabolic
processes, such as assimilation, blood formation, and various secretions.
“And he shall rise up at the voice of the bird,” implies, according to Smith
and Mead, the early waking of the elderly; “and all the daughters of music
shall be brought low” signifies to Laurentius the failure of voice, to Mead
deafness, and to Smith all the organs concerned with sounds, namely the
lips, tongue, larynx, and the auditory apparatus. “Also when they shall be
afraid of that which is high, and fears shall be in the way” is regarded by
Smith as describing the general mental attitude of anxiety for things both
small and great and a bad head for height, but a more modern commentator
suggests that “afraid of that which is high” refers to dyspnoea on climbing a
hill. “And the almond tree shall flourish” is by Laurentius, Hall, and Smith
thought to refer to the white hair or “churchyard flowers” of the old, but
Mead argued that loss of smell is meant. “And the grasshopper shall be a
burden” has been very variously interpreted: Hall is content to accept the
literal meaning that the least weight is a nuisance; Laurentius and Lowe
understand oedema of the legs; John Smith that the aged body undergoes
the reverse change of shrivelling, hardening, and angularity; Mead suggests
scrotal hernia, and Jastrow, as according to the Talmud the grasshopper is a

symbol for the male sexual organ, considers that the sentence refers to the
loss of sexual activity. In the sixth verse the words “Or ever the silver cord
be loosed,” refers, according to Laurentius, Lowe, Mead, and Jastrow, to
kyphosis, but Smith translates them into paralysis of the spinal cord and
nerves. “Or the golden bowl be broken,” signifies cardiac failure to
Laurentius and Lowe, but cerebral haemorrhage to Smith, who thus
explains the next line, “or the pitcher (the veins) be broken at the fountain
(the right ventricle), or the wheel (the arterial circulation) broken at the
cistern” (the left ventricle), and therefore concludes that King Solomon was
perfectly acquainted with the circulation of the blood discovered by
William Harvey in 1616. “The pitcher” is regarded as the vena cava by
Laurentius, and as the urinary bladder by Mead and Jastrow; “the wheel
broken at the cistern” suggests the kidneys and bladder to Laurentius and
Lowe, cardiac failure to Mead, and intestinal and hepatic insufficiency to
Jastrow.

IX

DISTINCTION BETWEEN HEALTHY AND
MORBID OLD AGE

In any individual instance the exact line which separates healthy old
age (senescence) from old age complicated by a morbid process, i.e. by
some factor other than the gradual atrophy and restriction of functional
activity, or senility, may be difficult or impossible to draw. The dictum of
Terence, Cicero, and Sanatorius that old age is a disease probably still finds
acceptance with many. It is indeed clear that exposures to infections and
poisons would produce changes more easily in cells that are beginning to
fail in vitality. Healthy old age should be a normal process of involution
with progressive atrophy and loss of vitality, and free from any morbid
change due to other factors whether extrinsic, such as infection, or intrinsic
and due to abnormal metabolism. As the bodies of the aged usually show a
number of changes additional to those of normal involution, some of which,
such as arteriosclerosis, are so frequent that they have sometimes been
erroneously regarded as part or even the cause of old age, it is essential to
recognize and to try to draw a distinction between physiological old age and
senility from the effects of disease (Senium ex morbo). But about the
anatomy and physiology of normal old age much remains to be learnt; more
indeed is known about the pathology of the aged, a subject which includes
the damage done in the past, perhaps in youth, and morbid processes
starting during advanced life.
In attempting to decide when old age should be regarded as a disease or
merely as a process of involution or retrogression which naturally follows
the earlier and progressive stage (youth) of development, it may be well to
refer to the meaning of “disease” and “health.” Disease, or want of ease, has

been variously defined as evidence of imperfect function, as discord, and as
201
maladjustment between the individual and his environment (Moon ), and
Health as the indication of perfect functional activity, as harmony between
the individual and his environment. In the different stages of life’s cycle
there should be a correspondence between the individual’s desires and his
powers so that there is harmonious co-ordination; this should hold good in
normal old age as it does in youth.
The frequent complaints of old people show that there is maladjustment
and disease, for if the decline of vitality were uniform throughout the body
the equilibrium would, though altered as a whole, still be maintained, and
there would no longer be a discordant desire for activity, for which other
parts of the body are, from a more advanced state of atrophy or morbid
change, unable. Thus it would appear that the conscious disabilities of old
age are not the necessary results of a true physiological involution, and that
the late Sir Andrew Clark’s definition of Old Age as “the period at which a
man ceases to adjust himself to his environment” should be regarded as true
of senility or morbid old age but not of senescence or healthy old age.
The organs of the body do not all start to grow old at the same time or
progress at the same time. That such variations in involution may be so
exaggerated as to become morbid without any very obvious cause is highly
probable, but the latter event is clearly a departure from the progress of
normal old age. The precocious atrophy of some tissues or organs may be
ascribed to several factors, such as inherent weakness, the effects of
overstrain, though without producing gross changes, or to the influence of a
definite infection or intoxication in the past. Thus deafness may be
hereditary, senile paraplegia has been known to occur in energetic walkers,
and thyroid deficiency may be the outcome of a past attack of enteric fever.
202
These errors in the chronometry of life, as Sir James Paget termed the
different ageing of organs, cannot be regarded as a physiological process.

X

DISEASES IN AND OF OLD AGE

Strictly speaking, it cannot be said that there are any diseases special to
length of days, for premature senility shows the changes and diseases
usually correlated with ordinary old age. Inherent want of vitality and the
resulting degenerative atrophy, or Gowers’s abiotrophy, may imitate the
results of prolonged wear and tear of the tissues, and thus it appears that
203
Charcot’s group of diseases special to old age, namely senile marasmus,
senile osteomalacia, senile atrophy of the brain, senile heart weakness, and
arteriosclerosis, are not confined to senescence. Old age, however, is prone
to the incidence of diseases which are chiefly but not exclusively seen in the
evening of life, such as those due to the degenerative changes resulting
from the accumulated effect of past infections and from metabolic
disturbance. Thus arteriosclerosis, granular kidney, cardiac failure, cerebral
haemorrhage, emphysema, hepatic cirrhosis, prostatic enlargement, and
carcinoma commonly appear in the sixth decade. In a series of five
publications dealing with the diseases of the age of fifty, which he calls the
204
critical age, Leclercq describes, in addition to some of the above, gout
and paragouty affections, obesity, diabetes, cardio-aortic diseases, and
albuminuria. Old age, moreover, modifies the manifestations and course of
infections, notably of pneumonia and erysipelas. It would be unnecessary
and from reasons of space impossible to refer to all the diseases that may
attack the aged, but a few remarks will be made about some disorders that
appear to call for special notice.
Senescence has some nosological compensations; thus some acute
infections, such as measles, scarlet fever, enteric fever, and diphtheria, are
very rare, probably because immunity has gradually been developed in the
course of time; pneumonia and erysipelas, however, are notable exceptions

in being specially prone to occur in the aged. Migraine usually becomes less
troublesome or disappears with the march of years. As mentioned on p. 86,
malignant disease is comparatively rare in very advanced age;
lymphadenoma and leukaemia are rarer than in early life; and as
pathological, like normal, processes are slower, carcinoma, especially of the
breast, may become stationary.
Diseases of the Skin.—From atrophy of the skin and its secretory
glands the skin is less resistant to infection and accordingly has been
thought to be more susceptible to parasitic attack, such as pityriasis
versicolor. The aged who are often less scrupulous in cleanliness than their
juniors are more prone to skin affections, such as eczema, erythema, and
erysipelas. The so-called senile prurigo is largely due to the presence of
lice. From the atrophic condition of the skin the cutaneous nerves are more
exposed, and this has been regarded as playing a causal part in senile
pruritus, which is an exception to the general rule that sensory impressions
are less prominent in the aged than earlier in life. It may, like prurigo, be
due to an external cause, such as pediculi, or it may be metabolic in origin.
In almshouses and institutions for the aged epidemics of scratching may
develop from imitation of a genuine case of pruritus. Senile pruritus is
usually general and from its obstinate resistance to treatment may be a
terrible affliction. Sir Gilbert Blane (1749–1834) suffered from it for the
last 13 years of his life, and was obliged to take opium in increasing
quantities until his daily dose reached the equivalent of a dram of the solid
drug.
Erysipelas, like pneumonia, with which or with bronchopneumonia it
may be combined, is less obvious in its symptoms than in ordinary adult life
on account of the diminished power of reaction, as shown by the slight
degree of leucocytosis in the aged in erysipelas (Lamy) and by its longer
course. From want of resistance and arteriosclerosis, especially
Mönckeberg’s form with calcification of the media, senile gangrene may
follow slight accident or injury, such as occurs in cutting the toe nails.
Absorption from the gangrenous area may cause toxic glycosuria, and such
cases, when they come under observation at this stage, are sometimes
regarded as diabetic gangrene. It is remarkable how well amputations for
diabetic gangrene do; in July 1922 I saw with Professor F. H. Edgeworth a

man with double amputation of the legs perfectly healed, and in good health
though the glycosuria persisted.
Herpes zoster, though far from confined to advanced life, has in the old
the unfortunate tendency to leave persistent pain in its site. Rodent ulcer,
although sometimes seen comparatively early in life, is specially common
in advanced years. It often supervenes on the dry yellow or brown spots
(senile keratosis) seen on the face in persons over 60 years of age.
Vertigo is extremely common in later life and may be due to various
causes; the most frequent form is that of aural origin, such as labyrinthine
or nerve lesions and chronic changes in the middle ear. Increased blood
pressure and cerebral arteriosclerosis are frequently responsible. Attacks of
giddiness may occur in Stokes-Adams disease or follow exertion in the
aged, as if from cerebral anaemia; and gastric disturbance may apparently
also be a determining factor. In rare instances epilepsy or migraine may be
represented or initiated by vertigo.
Senile tremor, rare under the age of 70, begins in the hands, especially
in that most used, and spreads to the neck and head, rarely occurring in the
lower limbs. It is a slow intention tremor, from 4 to 5 per second, and is
distinguished by its relation to movement from that of paralysis agitans
which is continuous but diminished on muscular contraction. The tremor of
the jaw resembles that of munching food; that of the lips is fine. It is
compatible with good health.
Paralysis agitans, described by James Parkinson, surgeon and
palaeontologist, in 1817 as “the Shaking Palsy,” has now about a century
later been shown, largely as a result of S. A. K. Wilson’s work, to be one of
the forms of the extra-pyramidal symptom complex and due to degenerative
changes in the efferent motor system of the globus pallidus system.
Although juvenile forms occur and encephalitis lethargica may show the
Parkinsonian syndrome, paralysis agitans is a disease of the early part of the
later period of life, the great majority of the cases beginning between 50
205
and 70 (Gowers ), after which there is a small incidence only. It is twice
as common in males as in females. Though unfortunately, from the
degenerative nature of the lesion, incurable, it is a chronic disease; thus
206
Maclachlan refers to a Chelsea pensioner aged 107 years in whom it was
known to have existed for 47 years.

Vascular lesions, haemorrhage or thrombosis, are the most important
factors in the production of grave nervous disease between the ages of 50
and 70; among 500 cases of cerebral haemorrhage 321, or 64 per cent, and
of 110 cases of cerebral thrombosis 67, or 61 per cent, occurred in the sixth
207
and seventh decades (Michell Clarke ). Cerebral haemorrhage increases
with frequency from the fourth decade and the largest number of cases
occur between 50 and 60. From analysis of 154 cases at St. Bartholomew’s
208
Hospital F. W. Andrewes found that the apparent maximum is in the
middle of the sixth decade, but that correction for the age distribution of the
population shows that the liability of the individual to this form of death
increases steadily up to old age. Thrombosis of atheromatous vessels is an
accident of later incidence than cerebral haemorrhage, and thus contrasts
with hemiplegia due to syphilitic endarteritis which occurs about the prime
of life.
The physiological involution of the mind and accompanying organic
changes in the brain gradually shade off into senile dementia. A regression
209
to the mental state of childhood, which Dupré called puerilism, may
occur in widely different conditions, such as structural change of the brain,
hysteria, and toxaemia. It may be acute and be transient or come on slowly
and be permanent. Just as an old man may relapse into the speech and
accent of his youth, so if he had a hard pecuniary struggle in his early days
may he become miserly in the evening of his life.
Senile dementia is an exaggeration of the mental changes occurring in
old age and due to further changes in the brain from vascular disease or
toxic influences. It varies much in its features; some patients are maniacal,
others depressed and melancholic, some feeble, some delusional, and a few
immoral. The senile mania may be mainly nocturnal and was compared by
210
Clouston to the night delirium of a febrile neurotic child; it may pass into
dementia. Of the melancholic group in which suicide may occur Clouston
found that 30 per cent recovered.
Senile paraplegia may be divided into four etiological groups: (1) The
211
functional dysbasias or pseudo-paraplegias described by Marie and Léri,
which in general terms resemble those met with during adult life, but the
212
varieties are less distinct in the old. Quesnel recognizes three groups of

functional disturbance of walking in old people: (a) the slight and usually
curable, (b) severe functional disturbance depending essentially on the
mental state of the patient, and (c) the organo-functional in which a bony,
articular, or nervous lesion is present; thus confinement to bed for a fracture
may cause a functional paraplegia. (2) Spastic paraplegia due to sclerosis in
the lateral and posterior columns of the spinal cord; the influence of
arteriosclerosis, as advocated by Oppenheim, has been the subject of some
debate, and Lejonne and Lhermitte point out that the nervous lesions are not
necessarily perivascular and that there is a want of proportion between the
vascular and the nervous changes. (3) Paraplegia of cerebral origin with
descending degeneration in the cord and mental deterioration. (4)
Paraplegia from muscular fibrosis and contracture, the central nervous
system being intact.
From the presence of emphysema bronchitis is prone to occur in the
old. Lobar pneumonia and bronchopneumonia. Lobar pneumonia has
always been considered the great enemy of the aged; it is often latent, and
may be found after sudden death and in persons supposed to have died of
old age, because they were walking about or complained not at all or only
213
of trivial symptoms. In spite of Charcot’s considered opinion to the
contrary, it is probable that pneumonia has been often used to describe what
214
was really bronchopneumonia. For Roussy and Leroux found that among
300 necropsies at the Hospice Paul Brousse there were 164 cases, or 55 per
cent, of bronchopneumonia and only 4 cases, or 1·4 per cent, of lobar
pneumonia. The bronchopneumonic areas are triangular with the base
towards the pleural surface, and indeed are infarcts, due to pre-existing
endarteritis obliterans which disposes to secondary infection. In 110 out of
the 164 cases of bronchopneumonia there was arterial thrombosis, which
was of older date than the infected areas of infarction and
bronchopneumonia.
Senile tuberculosis, contrary to what has sometimes been stated, is
fairly common though it is often latent; a patient with pulmonary
tuberculosis may have little or no cough, expectoration, fever, or night
sweats, and the physical signs, if present, may be regarded as those of
bronchitis and emphysema or bronchiectasis, unless the sputum is available
and examined for bacilli. Such unrecognized cases are an obvious danger in
institutions, and it may be added that hereditary disposition plays a much

less important part in the aged than in early life. Senile tuberculosis,
however, is usually either a persistence of that infection or a recrudescence
of quiescent infection, and is seldom primary. The disease may be chronic
or acute, and either local or generalized.
The senile heart has attracted much attention, and myocardial
degeneration and fibrosis due to past infections or to coronary
arteriosclerosis are extremely common. The myocardial change is of great
importance in reducing the reserve power of the heart, so that cardiac
failure is prone to supervene in acute infections, such as influenzal
pneumonia. Chronic valvulitis akin to and associated with arteriosclerosis is
common; the mitral valve is often affected and incompetent, with a loud
systolic murmur at the apex which is displaced outwards; but the most
characteristic lesion of advanced years is pure aortic stenosis; this is
commonly regarded as part of the arteriosclerotic process in the aorta, but,
as I have often noticed, the aorta may be remarkably healthy and even
thinner than usual in old people with extensive calcification of the valves
reducing the aortic orifice to a chink; it has indeed been thought that such
stenosis of the aortic valves may protect the aorta from strain and so from
arteriosclerosis. Although involvement of the bundle of His giving rise to
the symptom complex of Stokes-Adams disease, and angina pectoris may
complicate aortic stenosis, the presence of this valvular defect is compatible
with remarkable prolongation of life. This may be due to the more placid
215
life of these old patients, as is suggested by Sir Clifford Allbutt, who
regards aortic stenosis as more unfavourable in persons under 55 years of
age than in their elders.
Aneurysm of the large arteries is rare in the aged, although
arteriosclerosis is common. Diffuse dilatation especially of the arch of the
aorta and of the common iliacs is not infrequent, and occasionally latent
saccular aneurysms are present. In rare instances large abdominal
aneurysms causing pain or remaining latent until rupture occurs are
216
reported. Among 112 abdominal aneurysms collected by Nunneley 15
were over 50 years of age; these figures included 32 from St. George’s
Hospital, three of them being over 65 years of age. Miliary aneurysms are
of course extremely common in the subjects of cerebral haemorrhage.

Spasm, especially of arteriosclerotic vessels, may be responsible for
attacks of giddiness or faintness, particularly on exertion, and there may be
some doubt whether such symptoms are the outcome of cerebral anaemia or
of cardiac insufficiency. Frequent transient attacks of aphasia or paralysis,
due to spasm of arteriosclerotic middle cerebral arteries, may occur in
217 218
patients with high blood pressure (Peabody, Osler ).
Varicosity either localized, like aneurysms, or throughout the length of
veins, are common, especially in the lower limbs of women who have borne
children and done much standing; this condition disposes to varicose ulcers
in the lower third of the leg, and to acute phlebitis. As pointed out by
Trousseau, who was an illustration of his own dictum, venous thrombosis
may occur in the course of intra-abdominal malignant disease.
Though dyspepsia of adult life often diminishes or passes away in the
219
more tranquil conditions of old age, it is common; Fenwick estimated
that it occurred in 21 per cent of the population over the age of 65. Oral
sepsis may be responsible for chronic gastritis and much debility in the old.
Constipation often comes on after 60 and is mainly due to atonic dilatation
and failure of peristalsis in the colon, though diminished secretion of mucus
may play a part. Prostatic enlargement has been thought to interfere with
220
peristalsis (Hollis ), and in women large fibromyomas of the uterus may
have this effect. Gerontal constipation is usually more troublesome in
women than in men. Faecal accumulation in the rectum is a frequent cause,
especially in bed-ridden subjects, of what they describe as diarrhoea, the
real significance of which may be easily overlooked unless digital
examination of the rectum is undertaken. The pecten band of fibrous tissue
arising in the submucosa of the pecten, inside the external sphincter,
narrows the anal orifice and so prevents complete evacuation of the rectum
and diminishes the size of the faeces which are generally voided in short
pieces. It is usually, but not always, associated with internal piles and due to
221
the attendant congestion. W. E. Miles, who described the pecten band,
tells me that it may be regarded as a pathological development of advancing
years, and that he has found that it may so reduce the anal orifice in the
elderly that it is with difficulty the little finger can be introduced. Pruritus
ani, due to piles and local congestion, is not uncommon in the aged.

Piles are common in the aged and are related to the frequency of
constipation. Like other diseases, they do not give rise to discomfort so
soon or so forcibly as in younger persons. From muscular atrophy hernia,
umbilical in both sexes, in men inguinal and in women femoral, is prone to
occur.
Gallstones are more frequent in advanced life, especially in women,
than at other times of life, gallstones being found after death in about a third
of persons over 70 years of age, though, as mentioned elsewhere, biliary
colic is comparatively rare in old age.
The urinary bladder in cases of prostatic enlargement shows
hypertrophy succeeded by dilatation, fasciculation, and sacculation in
response to the obstruction to micturition and degeneration of the muscular
fibres. The ureters in similar circumstances become dilated, and the
incidence of cystitis and pyelonephritis is thus favoured.
Arthritic Affections.—Although gout is due to a defect in protein
metabolism analogous to diabetes mellitus as regards carbohydrate
metabolism and to obesity as a manifestation of disordered metabolism of
fat, reference to this disease may be made here. Heredity has a potent
influence on the incidence of the disease particularly in early life, but
acquired gout is essentially a disease of the latter part of life or the early
stage of old age when degeneration is beginning. The first attack may not
occur until old age, and is then usually mild in character, and, in Sir William
222
Roberts’s words, appears almost as if it were an incidence of senescence.
How far the various conditions spoken of as irregular gout, goutiness, or
paragouty diseases, which are so numerous as to recall Murchison’s
lithaemia, should be regarded as gouty is uncertain, but that they depend on
disordered protein metabolism is highly probable. The connexion of gout
223
with infection, as urged by Llewellyn, has a bearing on the fibrositis and
Dupuytren’s contraction often regarded as gouty phenomena. Dupuytren’s
contraction of the palmar fascia, which has been thought in some instances
224
to be secondary to arteriosclerosis of the medulla oblongata (Jardini ),
often accompanies the fibrous pads on the interphalangeal joints of the
225 226
fingers described by Garrod and Hale-White. The tendency of focal
infections, especially oral sepsis, to become more frequent with advancing
years also has a distinct bearing on the occurrence of chronic infective

arthritis of various forms. The most characteristic is morbus coxae senilis
which is not uncommonly associated with Heberden’s nodi digitorum, and
sometimes with Morrant Baker’s cysts due to distension of synovial bursae
with fluid; it may be confused with sciatica. Heberden’s nodes are
unimportant and commonly free from attendant symptoms.
Spondylitis deformans with ankylosis of the articulations and
ossification of the ligaments of the spine, in some cases further complicated
by an extension of the process to the proximal joints of the limbs
(rhizomelic spondylitis), may occur in the aged though also earlier in life.
Osteitis deformans or Paget’s disease of bone begins as a rule in the
227
later half of life, the average age being 50 years. Lannelonge and
228
Fournier argued that it is a lesion due to congenital syphilis; but although
luetic periostitis and osteitis may imitate it, there is no convincing evidence
in favour of their contention.

FOOTNOTES
1
Thomas Linacre, Linacre Lecture, 1908, St. John’s College,
Cambridge, by William Osler, M.D., F.R.S., Cambridge
University Press, 1908.
2
Life of Thomas Linacre, by John Noble Johnson, M.D., p.
344, 1835.
3
De Temperamentis, Galeni Pergamensis, etc. (translated by
Thomas Linacre), by J. F. Payne, p. 5, Cambridge, 1881.
4
The fourth of the five epidemics of the remarkable disease
the English Sweating Sickness between 1486 and 1551
occurred in 1528–1529, and is regarded by Dr. F. G.
Crookshank as influenza [Proc. Roy. Soc. Med., 1922, xv.
(Sect. Hist. Med.) 27].
5
The portrait of Heberden in his 86th year was painted by Sir
William Beechey, R.A., who when he got to Windsor found
he had forgotten his canvas and sent for a shirt on which he
painted the picture, now in the dining-room of the Master’s
Lodge, St. John’s College, Cambridge; there are two copies
in the possession of the Heberden family, and one in the
Censors’ room of the Royal College of Physicians. For some
of this information I am indebted to Mr. W. B. Heberden and
to Mr. W. Fleming, Bedell of the Royal College of
Physicians of London.
6
The Cambridge University Press, 1913.

7
Vide Gentleman’s Magazine, 1851, N.S., xxxv. part i. 205.
8
Γηροκομία βασιλική or The Pourtract of Old Age wherein is
contained a Sacred Anatomy, both of Soul and Body, and a
Perfect Account of the Infirmities of Age Incident to them
Both, by John Smith, M.D., London, 1665.
9
Maupas, Arch. de zool. expér., 1899.
10
Woodruff, L. L., Proc. Nat. Acad. Sc., Washington, D.C.,
1921, vii. 43.
11
Woodruff and Erdmann, Proc. Soc. Exper. Zool., N.Y., 1913–
14, xi. 73.
12
Child, C. M., Senescence and Rejuvenescence, p. 310,
Chicago, 1915.
13
Huxley, J. S., Journ. Microscop. Sc., 1921, lxv. 643.
14
Robertson, T. B., and Ray, L. A., Journ. Chem. Biol., 1919,
xxxvii. 455.
15
Drummond and Cannan, Biochem. Journ., Cambridge, 1922,
xvi. 53.
16
Sisson and Broyles, Johns Hopkins Hosp. Bull., Baltimore,
1921, xxxii. 22.
17
Hopkins, G., Journ. Physiol., Cambridge, 1912, xliv. 425.
18
Osborne, T. B., and Mendel, L. B., Journ. Biol. Chem., 1915,
xxiii. 439.
19
Metchnikoff, The Nature of Man, English translation, 1903,
p. 272.
20
Browne, T., Pseudodoxia Epidemica, p. 396, 6th edition,
1672.

21
Eugenius Philalethes, junior, F.R.S., Long Livers: A curious
History of such Persons of both sexes who have liv’d several
Ages, and Grown Young again, 1722, p. 27.
22
Hufeland, C. W., The Art of Prolonging Life, vol. i. p. 121,
English translation, 1797.
23
Mahaffy, J. P., John Stearne, An Address at the Bicentenary
of the Medical School of Trinity College, Dublin, July 1912.
24
Bacon, R., The Cure of Old Age and Preservation of Youth, p.
63, 1683. Translated by R. Browne.
25
Hufeland, C. W., Art of Prolonging Life, 1797, vol. i. p. 176.
26
Flourens, De la longévité humaine ou de la quantité de vie
sur la globe, 1856.
27
Cornaro, L., Discourses on a Sober and Temperate Life, p.
101, English translation, 1779, London.
28
Metchnikoff, The Nature of Man, p. 278.
29
Lankester, E. Ray, The Advancement of Science, p. 237,
1890, London.
30
Easton, J., Human Longevity, 1799, Salisbury.
31
The Observer of March 26, 1922, contained a note on the
discovery of a tombstone in the graveyard of Lamas Street
Welsh Congregational Chapel, Carmarthen, recording the
death on Nov. 14, 1831, of Ann David, aged 181 years.
32
Sinclair, J., The Code of Health and Longevity, Frontispiece
to vol. i., account in vol. ii. p. 274, 1807.
33
King, G., Census of England and Wales, 1911, vol. vii. p.
xlvi.

34
Hufeland, C. W., The Art of Prolonging Life, 1797, vol. i. p.
168.
35
Humphry, G. M., Old Age, p. 126, 1889, Cambridge.
36
Hall, G. Stanley, Senescence: The Last Half of Life, 1922,
London and New York.
37
Mendel, K., Neurol. Centralbl., 1910, xxix. 1124.
38
Rankin, G., Brit. Med. Journ., 1919, i. 63.
39
Waterhouse, B., Letter to Sir John Sinclair in the latter’s
Code of Health and Longevity, 1807, i. 33.
40
Holland, H., Med. Trans. Coll. Phys., London, 1813, iv. 316.
41
Lacassagne, A., L’Homme vers la fin de sa vie, p. 7, 1919,
Lyon.
42
Nascher, I. L., Geriatrics: The Diseases of Old Age and their
Treatment, p. 18, London, 1919.
43
Gilford, Hastings, Med.-Chir. Trans., London, 1897, lxxx. 17.
Disorders of Post-natal Growth and Development, 1911.
44
Variot et Pironneau, Bull. Soc. pédiat. de Paris, 1910, xii.
307.
45
Roy, D., Thèse de Paris, No. 110, 1910.
46
Lancet, 1889, ii. 349.
47
Weber, Hermann, On Longevity and Means for the
Prolongation of Life, 1919, 5th edition, by F. P. Weber,
London.
48
Brownlee, J., The Use of Death Rates as a Measure of
Hygienic Conditions, p. 51. Special Report Series No. 60.
Medical Research Council, 1922.

49
Savage, G., Memorial to Sir William Osler, vol. i. p. 247,
1919, New York.
50
Butler, S., Evolution, Old and New, p. 380, 1911.
51
Weber, F. P., Med. Press, London, 1920, N.S., cix. 271.
52
Compare Fischer, Martin H., The Unpopular Review, 1919,
ix. 323.
53
Paget, J., “Errors in the Chronometry of Life,” in Studies of
Old Case Books, p. 92, 1891, London.
54
Osler and McCrae, The Principles and Practice of Medicine,
p. 834, 1920, New York and London.
55
Clifford Allbutt, Diseases of the Arteries including Angina
Pectoris, vol. i. pp. 164–7, 1915, London.
56
Lancet, 1922, i. 874.
57
On the Handicapping of the First-Born, Eugenics Lecture
Series, x., 1914.
58
Noirot, L., L’Art de vivre longtemps, p. 195, 1868, Dijon.
59
Laurent, O., Bull. Acad. de méd., Paris, 1919, lxxxi. 835.
60
Annuaire internationale de statistique, Part II., Europe,
Movement of the Population, Table 12, pp. 180–81.
61
Statistiska Meddelanden, Ser. A., Band I. 1 Dödlighets- och
Lifslangdstabeller for Åren 1816–1910 af Kungl. Statistiska
Centralbyrån, Stockholm, 1912, p. 28. (For this reference I
am indebted to Dr. Major Greenwood.)
62
Public Health Reports, Treasury Department, Washington,
1922, xxxvii. 487.

63
Saundby, R., Old Age, Its Care and Treatment, p. 21, 1913,
London.
64
Easton, J., Human Longevity, p. xxvi, Salisbury, 1799.
65
Browne, T., Christian Morals, Part I. Section XXXIII.
66
Strachey, L., Books and Characters, p. 83, London, 1922.
67
Finot, J., Rev. mondiale, Paris, 1922, xxxiii. 387.
68
The Mirrors of Downing Street, by a Gentleman with a
Duster, p. 165, 1920.
69
Thompson, R. J. C., and Todd, R. E., Lancet, 1922, i. 874.
70
Yeo, B., XIX. Century, 1883, xxiii. 390.
71
Vide F. Adams, Genuine Works of Hippocrates, Sydenham
Society, vol. i. p. 10, 1849.
72
Drinkwater, H., Practitioner, London, 1914, xciii. 844.
73
For a consideration of this subject see Sir Hermann Weber’s
Means for the Prolongation of Life, and Dr. Lapthorn Smith’s
book How to be Useful and Happy from 60 to 90, London,
1922.
74
Compare Allbutt, C., St. George’s Hosp. Rep., 1870, v. 43,
and C. Hilton Fagge, Principles and Practice of Medicine,
1886, vol. ii. p. 22, London.
75
Lacassagne, A., L’Homme vers la fin de sa vie, p. 44, Lyon,
1919.
76
Owen, I., Brit. Med. Journ., 1888, i. 1312.
77
Allbutt, C., Diseases of Arteries, including Angina Pectoris,
vol. i. p. 250, 1915, London.

78
Robertson, T. B., and Ray, L. A., Journ. Biol. Chem., 1920,
xlii. 71.
79
Williams, L., Minor Ailments, p. 319, 1920, London.
80
Sharpey-Schafer, E. A., Presidential Address, Brit. Assoc.,
1912, Brit. Med. Journ., 1912, ii. 589.
81
Salimbeni et Gery, Ann. Inst. Pasteur, Paris, 1912, xxvi. 577.
82
Fischer, M. H., Oedema and Nephritis, 1921, New York.
83
Lumière, A., Rôle des colloïdes chez les êtres vivants, 1921,
Paris.
84
Bechhold, H., Die Kolloide in Biologie und Medizin,
Dresden, 1912.
85
Marinesco, G., Études histologiques sur le mécanisme de la
sénilité, 1904; also Presse méd., Paris, 1922, xxx. 309.
86
Campbell, H., Treatment, London, p. 153, 1909.
87
Carrel, A., Journ. Exper. Med., Baltimore, 1913, xviii. 287.
88
Loeb and Northrop, Journ. Biol. Chem., 1917, xxxii. 103.
89
Carrel, A., and Ebeling, A. H., Journ. Exper. Med.,
Baltimore, 1921, xxxiv. 599.
90
Robertson, T. B., and Ray, L. A., Journ. Biol. Chem., 1920,
xlii. 71.
91
Nathan, Ann. de méd., Paris, 1922, xi. 59.
92
Drew, Brit. Journ. Exper. Path., London, 1922, iii. 20.
93
Hufeland, C. W., The Art of Prolonging Life, 1797, vol. i. p.
227.

94
Lorand, A., Old Age Deferred, pp. 51, 114, Philadelphia,
1921.
95
Biedl, A., Endocrinology, Los Angeles, 1921, v. 523.
96
Berman, L., The Glands Regulating Personality, p. 260, The
Macmillan Co., 1921, New York.
97
Lydston, G. F., Journ. Amer. Med. Assoc., Chicago, 1919,
lxxii. 396.
98
Stanley and Kelker, Journ. Amer. Med. Assoc., Chicago,
1920, lxxiv. 1501.
99
Stanley, Endocrinology, Los Angeles, 1921, v. 708.
100
Gilford, H., The Disorders of Post-natal Growth and
Development, p. 643, 1911, London.
101
Bouin et Ancel, Compt. rend. Acad. Sc., Paris, 1903, cxxxvii.
1289, 1904, cxxxviii. 110.
102
Lipschülz, Ottow, Wagner, and Bormann, Proc. Roy. Soc.
Lond., 1922, ser. B, xciii. 132.
103
Kuntz, A., Endocrinology, Los Angeles, 1921, v. 190.
104
Nathan, Presse méd., Paris, 1922, xxx. 237.
105
Sand, K., Journ. de physiol. et de path. gén., Paris, 1921, xix.
525.
106
Blair Bell, The Sex Complex, p. 28, 1920.
107
Sternberg, Berl. klin. Wehnschr., 1921, lviii. 556.
108
Mott, F. W., Brit. Med. Journ., 1919, ii. 658; Proc. Roy. Soc.
Med., 1922, xv. (Sect. Psychiat.), 1–30.
109
Aron, Compt. rend. Soc. biol., Paris, 1921, lxxxv. 107.

110
Retterer, E., Compt. rend. Soc. biol., Paris, 1919, lxxxii. 423.
111
Walker, K., Brit. Med. Journ., 1922, i. 297.
112
Steinach, E., Verjüngung durch experimentelle Neubelebung
der alternden Puberstätsdrüsen, J. Springer, Berlin, 1920.
113
Benjamin, H., New York Med. Journ., 1921, cxiv. 687.
114
Simmonds (quoted by Marinesco), Deutsche path. Ges., Jena,
1921.
115
Tiedje, H., Deutsche med. Wehnschr., 1921, xlvii. 35.
116
Romeis, B., München. med. Wehnschr., 1920, lxvii. 600,
1821.
117
Marinesco, Presse méd., Paris, 1922, xxx. 309.
118
Lenz, L., und Schmidt, P., Deutsche med. Wehnschr., 1921,
xlvii. 327.
119
Moullin, C. W. M., Enlargement of the Prostate, p. 194, 3rd
edition, 1904.
120
Harrower, Practical Hormone Therapy, p. 344, 1914.
121
Frank, Journ. Amer. Med. Assoc., Chicago, 1922, lxxviii. 181.
122
Marinesco, Études histologiques sur le mécanisme de la
sénilité, 1904.
123
Léri, Le cerveau sénile, 1906.
124
Ribbert, H., Der Tod aus Alterswäche, Bonn, 1908.
125
Salimbeni et Gery, Ann. Inst. Pasteur, Paris, 1912, xxvi. 577.
126
Lane, W. A., The Operative Treatment of Intestinal Stasis,
1918, London.

127
Abernethy, J., The Constitutional Origin and Treatment of
Local Diseases, 1811.
128
Clarke, E., in The Operative Treatment of Intestinal Stasis, p.
246, London.
129
Vide Saundby, Old Age, its Care and Treatment, pp. 5, 28,
London, 1913.
130
Pearson, K., Arch. Middlesex Hosp., 1902, ii. 127.
131
Lazarus-Barlow, W. S., Ibid., 1905, v. 43.
132
On analysis of the Registrar-General’s returns for England
and Wales (1901–1909) C. Singer (Quart. Journ. Med.,
Oxford, 1911–12, v. 33), found that the incidence curves of
carcinoma of the lip, face, and breast were exceptional in
rising up to the highest age recorded (90).
133
Laurent, O., Bull. Acad. de méd., Paris, 1919, lxxxi. 835.
134
Gilford, H., The Disorders of Post-natal Growth and
Development, 1911, London; and Brit. Med. Journ., 1913, ii.
1617.
135
Goodpasture, E. W., Journ. Med. Research, Boston, 1918,
xxxviii. 127.
136
Oertel, H., Ibid., 485.
137
Councilman, W. T., Contributions to Medical and Biological
Research, dedicated to Sir William Osler, 1919, vol. ii. p.
918, New York.
138
Kissmeyer and With, Brit. Journ. Dermat. and Syph.,
London, 1922, xxxiv. 175.
139
Pringle, J. J., System of Medicine (Allbutt and Rolleston),
1911, ix. 549, London.

140
Cheatle, G. L., West London Med.-Chir. Journ., 1921, xxvi.
154.
141
Letter to a Friend, in Greenhill’s edition of Religio Medici, p.
135, Macmillan, 1898.
142
Bacon, F., The History of Life and Death.
143
Autobiography of Sir Charles Cameron, p. 137, 1920.
144
Graves, R. J., Dublin Quart. Journ. Med. Sc., 1847, N.S., iii.
339.
145
Quoted by D. Roy, Thèse de Paris, No. 110, 1910.
146
Sinclair, J., Code of Health and Longevity, 1807, i. 68.
147
Boyd, R., Phil. Trans. Roy. Soc., 1861, cli. 241.
148
Monauni, Arch. d’opth., 1921, xxxviii. 180.
149
Nascher, I. L., Geriatrics, p. 36, 2nd edition, 1919, London.
150
Clarke, Ernest, in Operative Treatment of Intestinal Stasis, by
W. A. Lane, p. 245, 1918, London.
151
Hollis, W. A., Brit. Med. Journ., 1916, i. 677.
152
Luciani, Text-book of Physiology, English translation, vol. v.
p. 302, London.
153
Salimbeni et Gery, Ann. Inst. Pasteur, Paris, 1912, xxvi. 577.
154
Symmers, D., Arch. Int. Med., Chicago, 1909, iii. 270.
155
Roussy, G., et Leroux, R., Ann. de méd., Paris, 1921, ix. 161.
156
Durante, Manuel d’histologie pathologique (Cornil et
Ranvier), 1902, ii.

157
Jewesbury and Topley, Journ. Path. and Bacteriol., 1913,
xviii. 432.
158
Weber, F. P., System of Medicine (Allbutt and Rolleston),
1905, i. 185, London.
159
Charcot, J. M., Clinical Lectures on Senile and Chronic
Diseases, p. 28, New Sydenham Soc., 1881.
160
Loc. cit.
161
Ophülz, W., Stanford Univ. Publications, Med. Sciences,
1921, vol. i. Part I. p. 31.
162
Turnbull, H. M., Quart. Journ. Med., Oxford, 1913–14, viii.
201.
163
Hansen, K. M., Ugsek. f. Laeger, Copenhagen, 1919, lxxxi.
1281.
164
Macnaughton, F. G., Brit. Med. Journ., 1922, ii. 14.
165
Rolleston, G., Brit. and For. Med.-Chir. Rev., 1863, xxxi.
505.
166
Hammar, A., Endocrinology, Los Angeles, 1921, v. 543.
167
Hale-White, W., Med.-Chir. Trans., 1888, lxxi. 181.
168
Findlay, G. M., Journ. Path. and Bacteriol., Cambridge,
1920, xxiii. 482.
169
Councilman, W. T., Contributions to Medical and Biological
Research, Dedicated to Sir William Osler, 1919, vol. ii. p.
919, New York.
170
Walker, K., Brit. Med. Journ., 1922, i. 297.
171
Launois, “Appareil urinaire des vieillards,” Thèse de Paris,
1885.

172
Nemenow, M., Ztschr. f. Urol., Berl. und Leipz., 1921, xv. 45.
173
Hertoghe, “L’Hypothyroidie bénigne chronique,” Bull. Acad.
roy. de Belg., 1899.
174
Mott, F. W., Brit. Med. Journ., 1919, ii. 658.
175
Paul, F. T., Lancet, 1910, ii. 294.
176
Haneborg, Acta Medica Scandinavica, 1921, Supplement I. p.
117.
177
Bell, Lancet, 1922, i. 715.
178
MacNider, Science, 1917, xlvi. 643.
179
Rappleye, Boston Med. and Surg. Journ., 1918, clxxviii. 191.
180
A Discourse Of The Preservation Of The Sight: Of
Melancholic Diseases: Of Rheums and Of Old Age,
composed by M. Andreas Laurentius, Ordinarie Phisition to
the King and Publike Professor of Phisicke in the Universitie
of Montpelier. Translated out of the French into English
according to the last Edition by Richard Surphlet,
Practitioner in Phisicke, p. 170, London, 1599.
181
Aub and Dubois, Arch. Int. Med., Chicago, 1917, xix. 823.
182
Gray, A. A., Diseases of the Ear, p. 335, 1910.
183
The Gray Room, p. 261, 1922.
184
Rivers, W. H. R., Instinct and the Unconscious, p. 148, 2nd
edition, Cambridge University Press, 1922.
185
Dupuis, Journ. de psychol., Paris, 1921, xviii. 481.
186
Arnold, M., Essays in Criticism, Preface, p. x. 1886.
187
Day, G. E., Domestic Management and Diseases of Advanced
Life, p. 5, 1849, London.

188
The Adventure of Death, p. 63, 1916, London.
189
Hooker, D. R., Amer. Journ. Physiol., 1916, xl. 43.
190
Thompson, R. J. C., and Todd, R. E., Lancet, 1922, ii. 503.
191
Spence, J. C., Quart. Journ. Med., Oxford, 1920–21, xiv.
314.
192
Carrel and Ebeling, Journ. Exper. Med., Baltimore, 1921,
xxxiv. 599.
193
Nascher, I. L., Geriatrics, p. 60, London, 1919.
194
Williams, L., Minor Ailments, p. 332, 1920.
195
The Gentle Cynic, being a Translation of the Book of
Koheleth, commonly known as Ecclesiastes, stripped of later
Additions, also its Origin, Growth and Interpretation, by
Morris Jastrow, junior, 1919, J. B. Lippincott Co.
196
Laurentius, A., A Discourse of the Preservation of the Sight;
of the Melancholic Diseases; of the Rheums; and of Old Age,
translated out of French into English by Richard Surphlet,
1599.
197
Lowe, P., The Whole Course of Chirurgerie, 1612.
198
Hall, J., Paraphrase upon the Hard Texts of the Whole Divine
Scripture, 1633.
199
Loc. cit., vide p. 8.
200
Mead, R., Medica Sacra, translated from the Latin by
Thomas Stark, 1775.
201
Moon, R. O., The Relation of Medicine to Philosophy, p. 217,
1909, London.
202
Paget, J., Studies from Old Case Books, p. 93, 1891, London.

203
Charcot, J. M., Clinical Lectures on Senile and Chronic
Diseases, New Sydenham Society, 1881, p. 33.
204
Leclercq, A., Les maladies de la cinquantaine, 5 vols., 1922,
Paris.
205
Gowers, W. R., System of Medicine (Allbutt and Rolleston),
1910, viii. 473, London.
206
Maclachlan, D., A Practical Treatise on the Diseases and
Infirmities of Advanced Life, p. 213, London, 1868.
207
Clarke, J. M., Brit. Med. Journ., 1915, ii. 665.
208
Andrewes, F. W., St. Barth. Hosp. Rep., London, 1912, xlviii.
9.
209
Dupré, E., Nouv. iconograph. Salpêt., Paris, 1905, xviii. 88.
210
Clouston, T., System of Medicine (Allbutt and Rolleston),
London, 1910, viii. 935.
211
Marie, P., et Léri, Séméiologie nerveuse, Traité de médecine
(Gilbert et Thoinot), p. 450.
212
Quesnel, M., Thèse de Paris, 1920, No. 258.
213
Charcot, J. M., Clinical Lectures on Senile and Chronic
Diseases, New Sydenham Society, 1881, p. 239.
214
Roussy, G., et Leroux, R., Ann. de méd., Paris, 1921, ix. 161.
215
Allbutt, Clifford, System of Medicine (Allbutt and Rolleston)
London, 1909, vi. 455.
216
Nunneley, F. P., Aneurysm of the Abdominal Aorta, p. 8,
London, 1906.
217
Peabody, Trans. Assoc. Amer. Phys., Washington, 1891, vi.
170.

218
Osler, W., Journ. Canad. Med. Assoc., 1911, N.S., i. 919.
219
Fenwick, W. S., Lancet, 1909, ii. 1346.
220
Hollis, W. A., Brit. Med. Journ., 1916, i. 677.
221
Miles, W. E., Surg., Gyn., and Obstet., 1919, xix. 497.
222
Roberts, W., System of Medicine (Allbutt and Rolleston),
1907, iii. 124, London.
223
Llewellyn, L. J., Gout, 1920, London.
224
Jardini, Nouv. iconograph. Salpêtr., Paris, 1906, xix. 553.
225
Garrod, A. E., Brit. Med. Journ., 1904, ii. 8.
226
Hale-White, W., Quart. Journ. Med., Oxford, 1907–1908, i.
47.
227
Lannelonge, Bull. Acad. de méd., Paris, 1903, 3e sér., xlix.
299.
228
Fournier, Ibid., 1903, 3e sér., xlix. 522.

INDEX

Abernethy, J., 84
Abiotrophy, 139
Acquired characters, 35, 75, 79
Activity. See Functional; Muscular
Adam, age of, 14
Adami, J. G., 87
Adolescence, termination of period of, 17
Adrenals, 110
Age, the “critical,” 140
the “dangerous,” 26
exaggeration of, by elderly people, 20, 21
Albuminuria, 126
Alcohol, abuse of, 57
action of, on the tissues, 57
influence on longevity, 33, 34, 57
Alimentary canal, lymphoid atrophy of, 109
Allbutt, Clifford, 37, 55, 59, 150
Allen treatment of diabetes, 56
Amputation, for diabetic gangrene, 142
Anabolism, cellular, 67
Anaemia, secondary, 108
Anal orifice, narrowing of, 152
Anatomical changes, 60, 63, 90–114
Andrewes, F. W., 145
Aneurysms, 150, 151
Angiomas, 108

Animal life, duration of, 17, 18
experimental modification of life cycle and growth of, 11
natural death in, 13, 14
rejuvenation and senescence in, 9–11
Aortic stenosis, 149
Aphasia, transient attacks of, 151
Appetite, 56, 118
Arcus senilis, 98
Arnold, M., 123
Aron, 75
Arteries, degenerative changes in, 97, 105–107
“pipe-stem,” 106
Arteriosclerosis, 97, 105–107, 149
age incidence of, 105, 140
causes of, 105, 142
hereditary transmission of, 37
influence of smoking on, 59
prostatic hypertrophy and, 112
spasm associated with, 151
thyroid prevention of, 73
Arthritic affections, 154
Arthritis, chronic infective, 155
Atheroma. See Arteriosclerosis
Athyroidism, 73
Atkinson, Edward, nonagenarian, 51
Atrophy—
brown, 103, 105
cardiac, 104, 140, 149
degenerative, 46
general, 62, 91, 139
causes of, 137, 138
genital, 114
lymphoid, 108
muscular, 103

of auditory nerve, 118
of skin and secretory glands, 141
of thymus, 109
precocious, 138
renal, 111
splenic, 109
testicular, 113
Atropine, 127, 128
Aub and Dubois, 116
Auditory nerve, atrophy of, 118
Auto-suggestion, 48

Bacon, Francis, 17, 95
Bacon, Roger, 17
Baddeley, J. J., 51
Baldness, 95
causes of, 96
thyroid extract in, 96
Barclay-Smith, E., 82
Baronsdale, W., 5
Bell, B., 75
Bell, J. R., 115
Benjamin, H., 77
Berman, L., 71
Biedl, A., 71
Biochemistry of old age, 64–68
Biological aspect of old age, 10, 11, 23, 63
Biotripsy, 93
Birth, expectation of life at, 13, 41, 42
Birth control, 24
Bladder, 133, 153
Blane, G., 142
Blood, condition of, 108, 115

increase of urea-nitrogen in, 115
Blood pressure, 125
and heredity, 37
high, 55, 124
longevity in relation to, 37
senile, 104, 124, 125
Blood supply, diminished, 106
Blood transfusion, 66
Bodily vigour, sex gland activity as manifestation of, 69
Body, cells of. See Cells
conformation of, 60
fibrous framework of, 92
structural changes in, 90
temperature of, 116
water content at birth and adult life, 64
Boerhaave, 91
Bone marrow, atrophy of, 108
Bones, injuries to, healing of, 126, 127
Paget’s disease of, 156
rarefaction and absorption of, 99
arterial degeneration with, 107
Bony changes, 98, 99
Bouin and Ancel, 73
Brain, changes in, 96, 146
degeneration of cells of, 97
organic changes in, 145
senile atrophy of, 139
shrinkage of, 100
weight of, 97
Brain cells, activity of, influence on longevity, 35, 36
Brampton, Lord, nonagenarian, 51
Bromides, intolerance to, 128
Bronchiectasis, simulating tuberculosis, 149
Bronchitis, disposition to, 147

simulating tuberculosis, 149
Bronchopneumonia, 148
and pneumonia, confusion between, 148
tendency to, 103
Brown atrophy, 103, 105
Brown-Séquard, 70
Browne, T., 14, 47, 95
Brownlee, J., 33
Buffon, 17
Butler, Samuel, 35

Calcification, of arteries, 106–107
of cartilage, 100
Calendar, length of, in the patriarchal era, 15
California, centenarians in, 41
Cambridge University, influence of John Haviland on the study of
medicine, 6
Cameron, C., 95
Campbell, H., 65
Cancer. See Carcinoma
Carcinoma, 141
age and sex incidence of, 86, 140
and senescence, 86–89
rarity of, in extreme old age, 87
Cardio-vascular system, 36–38, 103–108, 124, 133, 149
Carlisle, Anthony, 8
Carrel, A., 65, 66, 127
Cartilages, calcification of, 100
Castration, phenomena of old age and, 79
secondary sex-characters following, 79
Cazalis, 107
Cell-memory, 35
longevity in relation to, 35

Cells, 62
activity of, relation to connective tissues, 68, 88, 89, 92
ageing of, 67, 88
carcinoma in relation to, 86–89
causes and significance of, 67
senility in relation to, 86, 88
changes in, infections causing, 43, 44
changes in old age, 64
colloidal changes in, 64, 68
cultivation of, 66
degeneration of, 62, 92, 135
intestinal bacteria causing, 82, 83
infections and intoxications producing changes in, 44
life cycle of, 63, 65, 88, 89
factors influencing, 65
on what dependent, 68
thyroid deficiency influencing, 72
limited vitality of, 62
sequels of, 64
products inimical to life of, 65
senile changes due to injury to, 30, 31, 67
time-rate of, 36
vital phenomena of, 63, 88, 89
Census returns, 41, 43
Centenarianism, 19
heredity in relation to, 19
Centenarians, 20, 33, 34
age exaggeration by, 20, 21
among Churchmen, 50
among doctors, 52
among professional men, 50
census returns of, 20, 21
family incidence of, 32, 33
in California, statistics, 41
in England and Wales, statistics, 40, 41
in Ireland, statistics, 40

medical, 52
personal habits of, 56, 57
rarity of cancer among, 87
sex statistics of, 21, 22
smoking among, 58
statistics of, 21, 24
deaths among, 21, 22, 41
Cerebral arteries, changes in, 97
Cerebral degeneration, 97
Cerebral haemorrhage, 145
age incidence of, 145
Cerebral thrombosis, 145
Chaderton, Laurence, centenarian, 51
Charcot, J. M., 8, 104, 116, 139, 148
Cheatle, G. L., 93
Chest capacity, diminished, 103
Cheyne, G., 55
Child, C. M., 10, 14, 56
“Childhood, second,” 122, 145
Chromophages, 94
Chromosomes, 88
Churchmen, centenarians among, 50
Cicero, 135
Circulatory system, 38
Clark, Andrew, 29, 60, 137
Clarke, E., 85, 98
Clarke, J. M., 145
Climacteric, ancient conceptions of, 27
senile, 30
Climacteric disease, 28
Climate, influence on longevity, 26, 39
Coke, Sir Edward, octogenarian, 51
Colloidal dehydration, leading to old age, 64, 65

Colon, destruction of putrefactive bacteria in, 83
Constipation, 101, 152
age incidence of, 152
gerontal, 102
tendency to, 115
Cornaro, on the duration of life, 18
writer on old age, 8
Costal cartilage, calcification of, 100
Councilman, W. T., 37, 92, 104, 107, 111, 125
Cranial bones, changes in, 100
Crosby, T., 51
Cushny, A. R., 81
Cutaneous sensation, 117
Cystitis, 154

Darwin, C., 53
Deafness, causes of, 118
senile, 118
Death, causes of, 13, 38
mental attitude to, 123
natural, 13, 14, 16, 91
from old age, 14, 91
in animal kingdom, 13, 14
probable cause of, 36
Weissmann’s conception of, 9, 16
phenomenon of, 9, 10
sudden, causes of, 117
latent pneumonia causing, 148
Death-rate, in various countries, 42
sex incidence, 22
Deaths, among centenarians, 41
Decrepitude, 30
Delirium, 146
Delusions, 146

Demange, 91, 105
Dementia, senile, causes of, 146
onset of, 145
varied features of, 146
“de Morgan’s Spots,” 108
Dental decay, 101
an accompaniment of old age, 44, 45
Dentition, third, explanation of, 101
Depression, senile, 146
de Salis, Cardinal, centenarian, 50
Descartes, 7
Desmond, Countess of, centenarian, 20
Devolution, course of, 122
Diabetic gangrene, 142
Diet, restricted, influence of, 56
Digestion, impairment of, 101
Digestive system, 38
Disabilities of old age, 90–114, 137
Disease, associated with old age, 30, 44, 139
chronic, freedom from, in old age, 44
definition of, 136
influence of, on longevity, 43
latency of, 117
old age as a, 49, 136
Doctors, duration of life of, 52, 53
centenarian, 52
Donaldson, R., 110
Drew, A., 68
Drinkwater, H., 52
Drugs, reaction to, 127–128
reaction to, during senescence, 127
Dryness of elderly bodies, 64
Ductus cochleariae, fibrosis of, 118

Dupuytren’s contraction, 155
Dysbasia, functional, 146
Dyspepsia, frequency of, 152

Early rising, 59, 60
Ears, disorders of, 143
Easton, J., 20, 47
Ebstein, 18
Eccentricities of old age, 120, 121
Ecclesiastes, interpretation of, 129
Eczema, 118, 141
Emphysema, 147, 149
Endarteritis obliterans, 103
Endocrine glands, in relation to old age, 12, 68–81
Endomixis, 9
Environment, influence on longevity, 33, 34, 39–46, 55
Erysipelas, 141
disposition to, 140
senile, course of, 142
Erythema, 141
Eunuchs, duration of life of, 79
Expectation of life, 13, 41
in various countries, 42
Extra-systoles, 124
Eyes, senile disorders of, 117

Facial appearance, 93
changes in, 93
causes of, 118
Fads, 121
Faintness, 151
Fat, reduction of, 92
subcutaneous, disappearance of, 94

Fatigue, excessive, danger of, 54
physical and mental, 119, 120
psychical, 122
Fatty degeneration of arteries, 106
of heart, 104
of muscles, 103
Femur, fracture of, 99, 127
Fertility, age limit of, in women, 26
average, estimation of, 24
old age in relation to, 23, 24, 26
social conditions influencing, 24
Fibrosis, 91, 92
Fibrositis, 155
Fibrous tissues, atrophy of, 91
Finot, J., 49
First-born, handicapping of, 38
longevity in relation to, 38
Flourens, on the duration of life, 18
Food, excess of, 56
Fractures, delay in healing of, 126, 127
tendency to, 99
France, longevity in, 40
Functional activity, danger of excess of, 54
influencing longevity, 46, 55
progressive diminution in, 115, 119, 135

Gait, disordered, 122, 147
Galileo, 53
Gallstones, 153
Gangrene, diabetic, 142
senile, 142
pipe-stem arteries with, 106
Garrod, A. E., 155
Gastric juice, composition, changes in, 115

lack of, 101
Gastro-intestinal tract, changes in, 101
Generation. See Reproductive power
Generative organs, internal secretion of, 70, 73–80
Genitals, external, atrophy of, 114
Giantism, 19, 20
Giddiness, 143
causes of, 151
Gilford, H., 30, 72, 88
Gisborne, Thomas, Linacre lecturer, 5
Gland activity, functional, diminution of, 115
senility in relation to, 69
Gland atrophy, 109, 110
Gland cells, life cycle of, 67
Gland secretions, influencing activity of body cells, 68, 69
Gland, endocrine, metabolism stimulated by, 81
rejuvenescence in, in relation to, 12, 73–80
Gland, endocrine, theory of old age, 70, 71, 72
Gland, endocrine, therapy during old age, 71
of prostatic enlargement, 113
rejuvenescence in relation to, 12, 73–80
See also Endocrine, Pituitary, etc.
Glycosuria, 126
toxic, cause of, 142
Goethe, 53
Goodpasture, E. W., 88
Gout, 154
acquired, age incidence of, 154
Gowers, W. R., 139, 144
Graves, R. J., 95
Gray, A. A., 118
Greenwood, Major, 24
Gregory IX., centenarian, 50

Growth, 60
experimental modification of, 11
influence of endocrine gland therapy on, 12, 72, 80
retardation by vitamine deficiency, 13

Habits, influencing longevity, 55
Haemoglobin, 108
Haemorrhage, 144
cerebral, 145
Hair, changes in colour of, 94
excessive growth of, 96
of the body, loss of, 96
Hale-White, W., 109, 155
Hall, Bishop, 131
Hall, Stanley, 8, 27
Haller, 91
Halsbury, Lord, nonagenarian, 51
Hands, appearance of, 93
atrophic changes in, 94
senile tremor of, 143
Harrower, 80
Haviland, John, influence on the Cambridge medical school, 6
Regius Professor of Physic, 6
Linacre lecturer, 5
Head, senile tremor of, 143
Health, definition of, 136
Hearing, impairment of, 118
Heart, atrophy of, 104
condition of, 92, 103, 104
diseases of, 149
failure, 149
age incidence of, 140
hypertrophy of, 55, 104
and blood pressure, 104

longevity in relation to, 37
senile changes in, 104, 139, 149
Heberden, W. (the elder), 4, 54
Heberden’s nodes, 155
Height, cause of loss of, 100
Hereditary tendencies, correction of, 34
Heredity, firstlings in relation to, 38
influence on longevity, 19, 32–39
Hernia, tendency to, 153
Herpes zoster, 142
Hertoghe, 113
Hetero-suggestion, 48
High altitudes, influence on longevity, 39
Hippocrates, age of, 52
Holland, Henry, 28
Holmes, O. W., 49
Hopkins, G., 13
Hot climates, influence of, on senescence, 26, 36, 39
Huchard, 59, 105
Hufeland, C. W., 17, 23, 70
Humphry, G. M., 8, 22, 32, 34, 39, 43, 58, 60, 87, 98–100, 112, 124
Hunter, W., 124
Huxley, J. S., 11
Hygiene of old age, 55–61
Hyperpiesia, 37, 124
Hypertrichosis, following the menopause, 96
Hypnotics, 128
Hypochondriasis, 121
Hypoplasia, 63, 64
Hypothyroidism, in relation to old age, 72

Idleness, inimical to old age, 46, 47

Individuation, phenomenon of, 10
Infant mortality, sex incidence and causes, 22
Infantilism, premature senility with, 31
Infections, 140
cell changes due to, 43, 44
disposition to cardiac failure during, 149
focal, tendency to, 155
gout in relation to, 154
Insomnia, 119
Interstitial cells, 73–81
Intestinal stasis, as cause of premature old age, 82, 85
Intoxications, cause of senescence, 82
influence on body cells, 44, 55
Invalidism, auto- and hetero-suggestion producing, 48
Ireland, centenarians in, 40
Iris, sluggish, 117
Iverex, Dr., centenarian, 32

Jackson, Christopher, 3
Jackson, Hughlings, 122
James, R. R., 52
Jastrow, M., 130
Jaw, changes in shape of, 99
tremor of, 144
Jenkins, Henry, centenarian, 20
Jews, longevity of, 40
Johnson, S., 46
Joints, fractures of, disposition to, 99

Keratosis, senile, 143
Kidneys, 126
degenerative changes in, 111
granular, age incidence of, 140
King, G., 20

Klotz, O., 107
Knee-jerk, 119
Koheleth, 139
Kuntz, A., 74

Labyrinthine deafness, 118
Labyrinthine vertigo, 143
Lacassagne, A., 30, 55
Lane, W. Arbuthnot, 84
Lankester, E. Ray, 14, 19, 23
Laryngeal cartilage, calcification of, 100
Laurent, O., 41, 87
Laurentius, Andreas, 29, 46, 116, 131
Lazarus, 59
Lazarus-Barlow, W. S., 86
Leclercq, A., 140
Léri, 83, 146
Leroux, 103, 148
Lessius, Leonardus, 55
Leucocyte count, 108, 109
Leucodermia, 93
Leukaemia, 141
Leydig, interstitial cells of, 73–81
Lichtenstern, 77
Life, animal and human, duration of, 17, 18
chronometry of, 138
climacterics of, 27, 30
duration of, 9
among professional men, 50–53
chemical theory of, 66
early theories of, 17
estimation of, 18
in vitro, 66

various writers on, 17, 18
variation in different countries, 39
modern theories of, 18
expectation of, at birth, 13, 41
prolongation of, experimental, 12, 13, 77
following cessation of reproductive function, 23
See also Longevity
Life cycle, experimental modification of, 11
Ligament, spinous, ossification of, 99
Ligamentum spirale, atrophy of, 118
Linacre, Thomas, 2
family history of, 2, 3
Linacre Lectures, 3–6
Linacre Lectureship, 1
Lips, tremor of, 144
Lipschülz, 74
Liveing, G. D., 7
Liver, atrophy of lobules and cells of, 102
changes in size and weight of, 102
cirrhosis of, 140
Llewellyn, L. J., 154
Longevity, alcohol influencing, 57
among professional men, 50, 53
auto- and hetero-suggestion influencing, 48, 49
“cell-memory” in relation to, 35
climatic conditions influencing, 39, 41
conditions favouring, 7, 33
diseases inimical to, 45
endocrine atrophy in relation to, 68–81
environment influencing, 33, 34, 39–46, 55
factors influencing, 32
fertility in relation to, 23, 24
functional activity influencing, 46, 55
hereditary aspects of, 19, 32–39
idleness inimical to, 47, 48

in the medical profession, 52
influence of past diseases on, 43
influence of blood pressure on, 37
influence of brain cells on, 36
integrity of cardio-vascular system necessary to, 36
of nations, compared, 39, 40
of the patriarchs, 15, 16
personal habits influencing, 55
potential, on what determined, 67
sex incidence of, 21, 22
smoking in relation to, 58
syphilis preventing, 45
vitality of central nervous system essential to, 36
See also Old Age; Senescence
Lorand, A., 70
Lowe, Peter, 131
Luciani, 18, 102
Lungs, changes in, 103
diseases of, 147, 148
Lydston, G. F., 71
Lymphadenoma, 141
Lymphoid tissues, atrophy of, 63, 108

Maclachlan, D., 144
Maignon, Abbé, centenarian, 50
Malignant disease, 87, 141
cell senility in relation to, 88
Mammae, involution changes in, 114
Mania, senile, 145, 146
Mansell-Moullin, C. W., 78
Mansfield, Lord, octogenarian, 51
Marasmus, senile, 139
Marie, P., 146
Marinesco, 64, 78, 83, 97

Marx, K., 47
Mead, Richard, 131
Medical men, centenarians among, 52
duration of life of, 52, 53
Melancholia, senile, 146
Memory, impairment and loss of, 120, 122
Menopause, onset of old age at the, 26
ovarian changes at, 63, 79
Mental activity, influence on old age, 47, 48, 50, 54
unimpaired, in advanced age, examples of, 50, 51, 53
Mental deterioration, 49, 119, 122, 145, 146
causes of, 47, 48, 49
onset of, 53
Mental fatigue, tendency to, 120
Mental state, 119, 122, 123
and the physical, want of harmony between, 123
influence of, 48–50
Metabolism, disordered, 115, 116, 117, 154
gland therapy stimulating, 72, 81
Metchnikoff, E., 8, 13, 18, 82–86, 91, 97, 123
Methuselah, 14
Michael Angelo, mental activity at advanced age, 53
Micturition, disorders of, 153
Middle ear lesions, 143
Migraine, 140
Miles, W. E., 153
Mind, 121
and body, in old age, 47, 50
disintegration of, 120
disorders of, 122, 145, 146
See also Mental
Molière, 53
Mönckeberg’s sclerosis, 106

causes of, 142
Montaigne, 14, 56
Moon, R. O., 136
Moore, Norman, 5
Morbus coxae senilis, 155
Morphine, 127, 128
Mott, F. W., on functions of cells of testes and ovaries, 75
Muscles, voluntary, changes in, 103
Muscular activity, danger of excess of, 54
impaired, 99, 119, 135
Muscular atrophy, 99, 119, 135
among workmen, 54
Myocardium, degeneration of, 104, 149
Myxoedema, as secondary senilism, 72

Nails, condition and appearance of, 96
Nanism, senile type of, 31
Nascher, I. L., 30, 98, 127
Nathan, 68, 74
National habits, influence on longevity, 40
Natural death. See Death
Neck, senile tremor of, 143
Nemenow, 112
Nephropathy, chronic atrophic, 111
Nerves, cutaneous exposure of, 141
Nervous apprehension, tendency to, 122
Nervous disease, 145
Nervous system, 38
vitality of, hereditary factor in longevity, 36
Neurasthenia, 122
New growths, rarity of, 87, 89
Newton, Isaac, 53
Nicotine, effects of, 59

Nunneley, F. P., 151

Obesity, 60
Occupational neuroses, 54
Octogenarians, among active professional men, 51
census statistics of, 21
Oertel, H., 88
Old age, acceleration of, factors favouring, 26
anatomical and physiological changes in, 63
as a disease, 47, 136
attainment of, on what dependent, 6, 7, 10
biochemistry of, 64–68
biological aspect of, 10, 11, 23
bodily conformation in, 60
causes of, 62–89
cell changes leading to, 64, 65
“cell-memory” in relation to, 35
comparative freedom from chronic disease in, 44
death during, common causes of, 38
disabilities of, 137
disease in relation to, 44
diseases associated with, 93–114, 139–156
fertility rate in relation to, 23, 24, 26
glandular, endocrine, theory of, 70, 71, 81
healthy and morbid, distinction between, 135
hereditary aspects of, 32–39
hygiene of, 55–61
infantilism and, 31
mental activity during, 50, 54
examples of, 50, 51, 53
natural death from, 14
on what dependent, 10
onset of, 26
signs of, 29
pathological, 30, 82, 90
of septuagenarians, 53

physiological, 26, 90, 135
physiological and pathological confusion between, 90
factors in, 26
physiology of, 115
premature, 30
hot climates favouring, 26, 36
intestinal stasis as a cause of, 85
mental causes of, 48, 49
production of, Metchnikoff’s theory, 83
rarity of natural death from, 14, 91
sex incidence of, 21, 22
stages of, 29
vitality of body cells in, 62–68
writers on, 8, 15, 16
See also Senescence; Longevity
Onychogryphosis, 96
Ophülz, W., 105
Oral sepsis, 44, 155
Orthobiosis, 55, 84
Osler, W., 2, 36, 151
Osteitis deformans, 156
Osteomalacia, senile, 139
Osteoporosis, senile, 99
Ovarian extract, rejuvenescence in relation to, 80
Ovaries, activity and function of cells of, 73, 74
degenerative changes in, 114
fibrotic atrophy of, 63
following menopause, 79
in relation to senescence, 75
internal secretion of, evidence of existence of, 79
senile, 114
Over-eating, 56, 118
Overwork, danger of, 54
Owen, I., 57

Paget, James, 36, 138
Paget’s disease of bone, 156
Pain, blunting of sensibility to, 117
Pallor, 93
Pancreas, fibrotic atrophy of, 102
Paralysis agitans, 144
age and sex incidence of, 144
causes of, 144
senile tremor compared with, 143
Paraplegia, senile, 138, 146
causes of, 146, 147
varieties of, 147
Parathyroids, 110
Parietal bones, changes in, 100
Parkinsonian syndrome, 144
Parr, Thomas, centenarian, 20
Pathological old age, 53, 82, 90
Patriarchal ages, length of the calendar during, 16
Patriarchs, explanation of reputed old age of, 15, 16
Pearson, K., 38, 86
Pecten band, 152, 153
Penis, changes in, 114
Pennington, Isaac, 6
Peristalsis, failure of, 152
Philalethes, Eugenius, on old age, 15
Phlebitis, 151
Phlebosclerosis, 107
Physical and mental states, want of harmony between, 123
Physiological life of man, 19
Physiological old age, 90
and morbid senility, distinction between, 135–138
Physiology of old age, 115–128

Pigmentation, cellular, 103
cutaneous, 93
Piles, 153
Pitman, Henry, medical centenarian, 52
Pituitary extract, influence on weight and growth, 12
rejuvenescence in relation to, 12, 80
Pityriasis versicolor, 141
Planarian flat worms, experimental modification of life cycle and
growth of, 11
Plasma, vital phenomena of, 65–67, 88
Plethora, senile, 124
Pneumonia, 147, 148
disposition to, 140
sudden death from, 117
Premature senility, 30
causes of, 48
hot climates predisposing to, 26, 36
syphilis producing, 45
Presbyopia, 117
Pringle, J. J., 94
Prior, Matthew, 3
Professional men, age of retirement of, 54
longevity of, 50–54
Progeria, 30
Prostate gland, 27
climacterium virile due to changes in, 27
hypertrophy of, 101, 112
age incidence of, 140
cause of, 112
cell changes in, 112, 113
glandular therapy of, 113
vesical disorders due to, 153
senile changes in, 111
Protoplasm, products inimical to vitality of, 65

vital phenomena of, 64, 65, 88
Protozoa, rejuvenation and senescence in, 9–11
Prurigo, senile, 141
Pruritus, senile, 141, 142
Pseudo-paraplegia, 146
Psychical activity, diminished, 119
Psychical fatigue, 122
Puberty, functional activity of cells of testes and ovaries at, 75
period of, 17
“Puberty gland,” 73
Puerilism, 122, 145
Pulmonary changes, 103, 147
Pulmonary tuberculosis, 148
Pulse-pressure, 125
Pulse-rate, 124
Pupils, contraction of, 117
Purgatives, 128
Pyelonephritis, 154

Quinquagenarians, diseases of, 140, 145, 156

Rectum, faecal accumulation in, 152
Reflexes, 119
Regression, 122
Rejuvenescence, 10
associated with reproduction, 9, 10, 64
attainment of old age dependent upon, 9, 10
experimental production of, 76, 77
following vasectomy, 78
gland extracts in production of, 12, 73, 80, 81
in animal life, 9, 10
power of reproduction favouring, 23, 24, 69
restricted diet in relation to, 56
testicular grafts producing, 77

Renal inadequacy, 126
Reproductive power, favouring rejuvenescence, 23, 24, 69
waning of, onset of old age following, 26
prolongation of life after waning of, 23
Retas, Joseph, centenarian, 33
Rheumatism, in old age, 44
Rhizomelic spondylitis, 155
Rhondda, Lord, 49
Richardson, B. W., on the duration of life, 18
Rivers, W. H. R., 122
Roberts, W., 154
Robertson and Ray, 12, 60
Rodent ulcer, 143
Roussy, G., 103, 148
Routh, Martin, centenarian, 50
Roy, D., 32, 95
Russian peasants, longevity of, 40

Salimbeni and Gery, 63, 84, 93, 102
Sand, K., 75
Saundby, R., 8, 44, 85
Savage, G., 34
Sclerosis, arterial, 105–107
Mönckeberg’s, 106, 142
spinal, 97
Scrotum, 114
“Second childhood,” 122, 145
Sedatives, 128
Self-preservation, instinct of, 122
Self-reliance, loss of, 48, 49
Seminal tubules, activity and function of, 74
atrophy of, 74, 112, 113
prostatic enlargement following, 112

regeneration of, 74
Senescence, 136
castration not a disposing factor to, 79
causes of, 62–89
Metchnikoff’s theory, 82, 83
pathological, 82
toxaemic, 82
cell changes during, 62–68
in ovaries and testes, 75, 76
colloidal dehydration leading to, 64, 65
diseases associated with, 139
endocrine glands in relation to, 68–81
healthy and morbid, distinction between, 135
nosological compensations of, 140
progress of, 135
rarity of carcinoma in, 87
rejuvenescence necessary to, 10
thyroid deficiency in relation to, 72
See also Longevity; Old age
Senile climacteric, 30
Senile type of nanism, 31
Senility, 136
Senium ex morbo, 136
Sense organs, impairment and failure of, 117–121
Sensibility to pain, blunting of, 117
Septuagenarians, nervous disease among, 145
pathological old age of, 53
Sex characters, secondary, cause of, 75
following castration, 79
Sex glands, changes in, climacterium virile due to, 27
internal secretion of, 70
Sex incidence of old age, 21, 22
Sexagenarians, diseases common to, 140
nervous disease among, 145
Sexual activity, as manifestation of bodily vigour, 69, 70

duration of, 69
leading to rejuvenescence, 69
waning of, 126
Sexual appetite, on what dependent, 75
perverted, 114
Sexual atrophy, as cause of old age and senility, 69–71
Shaking palsy, 144
Sharpey-Schafer, E. A., 63
Sight, impairment of, 117
Sinclair, John, 8, 20, 35
Singer, C., 86
Skeleton, changes in, 98
Skin, 93, 115
diseases of, 141
disposition to, 141
dry, 115
venules and angiomas on, 108
Skull, 100
Sleep, diminished, 119
over-indulgence in, 60
Smell, impairment of sense of, 117
Smith, John, 8, 131
Smith, Lapthorn, 53
Smoking, influence on longevity, 58–59
Sophocles, mental activity at advanced age, 53
Sour milk, destruction of intestinal bacteria by, 83
Spasm of arteriosclerotic vessels, 151
Spastic paraplegia, 147
Spinal cord, degenerative changes in, 97, 147
Spleen, atrophy of, 63, 109
Spondylitis, rhizomelic, 155
Spondylitis deformans, 99, 155
Stapes, fixation of, 118

Starvation, influencing the onset of senescence, 56, 57
Starvation treatment, 56, 57
Steinach, E., 11, 77, 78
Sterne, John, on the attainment of old age, 16
Stevenson, T. H. C., 41
Strachey, L., 47
Structural changes of the body, 90
Symmers, D., 102
Syphilis, influence on longevity, 45

Taste, impairment of, 117
Teeth, decay of, 44, 101
loss of, 44, 45, 99, 101
causes of, 101
Temperance, a characteristic of centenarians, 57
Temperature, and longevity, 26
of body, 116
Testes, atrophy of, 113
cells of, activity and function of, 73, 74
in relation to senescence, 75
changes in, following vasectomy, 77, 78
internal secretion of, 69–72, 74
prostatic atrophy in relation to, 112
Testicular extract, rejuvenescence in relation to, 80
Testicular grafts, rejuvenation by, 71, 72, 77
results of experiments, 76, 79
Thompson, R. J. C., 37, 44, 49, 96, 125
Thompson, W. J., 40
Thrombosis, 144
age incidence of, 145
cerebral, 145
venous, 151
Thymus, atrophy of, 109
Thyroid deficiency, 138

baldness resulting from, 96
effect on activity of body cells, 72
prostatic enlargement in relation to, 113
Thyroid extract, rejuvenescence in relation to, 80
for prostatic enlargement, 113
Thyroid gland, degenerative changes in, 109, 110
Tinnitus, 118
Tissues, connective, relation of cellular activity to, 68, 88, 89, 92
Titian, 53
Tobacco, and arteriosclerosis, 59
influence on longevity, 58
symptoms due to, 59
Todd, R. E., 37, 44, 49, 125
Toxaemia, as a cause of senescence, 82, 86
degenerative changes due to, 44, 55, 56, 86
intestinal, as cause of senescence, 82, 85
over-eating causing, 56
Transfusion, 66
Tremor, senile, 143
Tropical life, influence on longevity, 26, 36, 39
Trousseau, 151
Tuberculosis, senile, 148
Tumours, 86, 141
Turnbull, H. M., 106, 114

Ulcer, rodent, 143
Urea-nitrogen in the blood, 115
Urinary bladder, hypertrophy of, 153
Urine, condition of, 126
Uterine changes, 114

Valvulitis, chronic, 149, 150
Vanity, senile, 120, 121
Variation, correlated, 23

Varicosity, 151
Vascular lesions, 144
Vasectomy, changes due to, 74
changes in testes following, 77, 78
effect on sexual activity, 76
rejuvenescence following, 71, 78
Veins, changes in, 108
Venous thrombosis, 151
Vertebrae, changes in shape of, 99
Vertigo, causes of, 143
Visceral degeneration, 102, 103
Visceroptosis, 102
Vitality, danger of excess of, 54
loss of, 115, 119, 135
waning of, 139
Vitamins, influence on growth, 13
Voltaire, mental activity at advanced age, 53
Voronoff, testicular grafting by, 78

Walker, Kenneth, on changes in the testes, 112
on prostatic enlargement, 112, 113
Walking, functional disturbances in, 147
Waterhouse, B., on the onset of old age, 27
Watson, Thomas, Linacre Lecturer, 5
Weber, Hermann, 8, 34, 43, 57, 119
Weber, Parkes, 35, 104
Weissmann, 9, 16
“Will to live,” 35, 47
Will power, failure of, 122
Williams, Leonard, 61, 113, 128
Wilson, S. A. K., 144
Wounds, healing of, 126
Wrinkles, cause of, 93

Yeo, B., 50

Zorten, Petrasch, centenarian, 20

THE END

Printed in Great Britain by R. & R. Clark, Limited, Edinburgh.

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DISEASES OF THE LIVER, GALL-BLADDER
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Transcriber’s Notes
Punctuation and spelling were made consistent when
a predominant preference was found in this book;
otherwise they were not changed.
Simple typographical errors were corrected;
occasional unbalanced quotation marks retained.
Ambiguous hyphens at the ends of lines were
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