CASE

OF THTC

UNIVERSITY OF CALIFORNIA.

Received.-
A ccessions No&&&j0.y_ Shelf No.-.

THE increasing attention given of late years to personal
and public hygiene is one of the most encouraging signs
of social improvement. Books, periodicals, tracts, and lec-
tures, have disseminated information on the subject of great
value ; but it is notorious that most of the cheap and popu-
lar kind are crude compilations of incompetent persons.

Several eminent medical and scientific men of London
accordingly combined to prepare a series of HEALTH PRIM-
ERS, of a character to entitle them to the fullest public
confidence. They are to be brief, simple, elementary in
statement, and filled with substantial information, suitable
for the guidance of grown-up people. Each primer is to
be the work of a specially competent writer ; while the
choice of topics and the critical supervision will be in the
hands of an able and responsible committee. The series
will deal with the chief hygienic subjects of vital impor-

tance, and will form a cheap and compendious popular
library of health-manuals for every household.

As these little books are produced by English authors,
they are naturally based very much upon English expe-
rience, but it matters little whence illustrations upon such
subjects are drawn, because the essential conditions of
avoiding disease and preserving health are to a great degree
everywhere the same.

Volumes of the Series.

EXERCISE AND TRAINING.

'(Illustrated.)

'1HE HEART AND ITS FUNG
TIONS.

ALCOHOL: ITS USE AND ABUSE. I THE HEAD.

THE HOUSE AND ITS SUR- ! CLOTHING AND DRESS.

ROUNDINGS. WATER.

PREMATURE DEATH: ITS PRO- THE SKIN AND ITS TROUBLES.

MOTION OR PREVENTION. FATIGUE AND PAIN.

PERSONAL APPEARANCES IN THE EAR AND HEARING.

HEALTH AND DISEASE. THE EYE AND VISION.

(Illustrated.) TEMPERATURE IN HEALTH

BATHS AND BATHING.

AND DISEASE.

In square i6mo volumes, cloth, price, 40 cents each.

For sale by all booksellers. Any volume mailed, post-
paid, to any address in the United States, on receipt of the
price.

D. APPLE TON & CO., Publishers,

549 & 551 BROADWAY, NEW YORK.

HEALTH PRIMERS.

No. S.

HEALTH PRIMERS.

E D I T O R S'.

J. LANGDON DOWN, M.D., F.R.C.P.
HENRY POWER, M. B., F. R. C. S.
J. MORTIMER-GRANVILLE, M.D.
JOHN TWEEDY, F. R. C. S.

CONTRIBUTORS TO THE SERIES.

G. W. BALFOUR, M. D. St. And., F. R. C. P. Edin.

J. CRICHTON-BROWNE, M. D. Edin., F. R. S. Edin.

SIDNEY COUPLAND, M.D. Lend., M.R.C.P.

JOHN CURNOW, M. D. Lond., F. R. C. P.

J. LANGDON DOWN, M.D. Lond., F.R.C. P.

TILBURY FOX, M. D. Lond., F. R. C. P.

J. MORTIMER-GRANVILLE, M. D. St. And., F. G. S., F. S. S.

W. S. GREENFIELD, M.D. Lond., M.R.C. P.

C. W. HEATON, F.C.S., F. I. C.

HARRY LEACH, M.R.C.P.

G. V. POORE, M. D. Lond., F. R. C. P.

HENRY POWER, M. B. Lond., F. R. C. S.

W. L. PURVES, M. D. Edin., M. R. C. S.

J. NET TEN RADCLIFFE, Ex-Pres. Epidl, Soc., etc.

C. H. RALFE, M. A., M. D. Cantab., F. R. C. P.

S. RINGER, M.D. Lond., F.R.C.P.

JOHN TWEEDY, F. R. C. S.

JOHN WILLIAMS, M. D. Lond., M. R. C. P.

HEALTH PRIMERS.

PERSONAL APPEARANCES

IN

HEALTH AND DISEASE.

BY

SIDNEY COUPLAND, M. D.

rr

•'9iu v

NEW YORK:

D. APPLETON AND COMPANY,

549 & 551 BROADWAY.

1879.

v

BIOLOGY

LIBRARY

G

CONTENTS.

PAGK

INTRODUCTION 5

THE FORM AND SIZE OF THE HUMAN BODY .... 7

CHANGES IN THE FATTY LAYER 24

CHANGES IN THE BONY FRAMEWORK 36

CHANGES IN ORGANS 45

ARTIFICIAL ALTERATIONS IN SHAPE 60

THE COLOUR OF THE HUMAN BODY 64

CHANGES IN COLOUR IN HEALTH 80

CHANGES IN COLOUR IN DISEASE 87

ON 'TEMPERAMENT,' * HABIT,' AND 'TONE' . . . . 92

PERSONAL APPEARANCES

IN HEALTH AND DISEASE.

INTRODUCTION.

IF a person wholly unacquainted with the structure of the
body or with any of its functions could be confronted with
a. number of individuals, some of whom are what we call
healthy and others what we call unhealthy, he would
have very little difficulty in discriminating the one group
from the other. The unhealthy ones might none of
them be suffering from any grave disease, they might
even be pursuing their ordinary avocations, and yet
without putting a single question to them this unskilled,
and possibly not very discerning^ individual would have
but little hesitation in making the broad distinction. He
could not tell why he arrived at that conclusion, he
might only say that these did not " look so well " as those ;
yet he would have gone through the process of picturing
to himself what a healthy man should be, and would
contrast his ideal with the forms before him. It is very
likely indeed that here and there lie might make a
mistake, for being an undiscerning man he might be
deceived by the appearance of health which some dis-

6 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

eases give, or by not knowing the limits to which a body
performing all its functions well enough to be con-
sidered healthy may exhibit a leanness to which he
would feel inclined to apply the term of illness. Still,
with some few exceptions, he would be in the main right.
If he were asked to push his conclusions further, and to
point out among the unhealthy ones those whom he
deemed most and those least ill, and try and construct
a scale of ill-health from the frames before him, it is
likely that he would go very wide of the mark indeed.

Now it is the object of this little book to try and explain
as briefly as possible how and why variations that are so
plain on the surface can be taken as indices of disorder
within, to give the reasons for form-changes which occur
within the limits of health, and for those which mark the
departure from those boundaries. It cannot be denied
that this is a subject of very great importance; but
it is beset with difficulties on all sides, difficulties such
as those which the mere definitions of the terms " health'*
and " non-health " imply.

One great difficulty stares us in the face at the outset,
and it is this : although built up on a definite plan, when
viewed from the standpoint of the morphologist alone,
the individual variations in the form of the body, slight
though they be, are yet so numerous as to dispel once
and for all any notion that there is an ideal of human
form which can be described in so many words. Of

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 7

course there are some who, " framed in the prodigality of
nature," seem to approach to that ideal which we
associate with the beautiful, just as there are others so ill-
fashioned, " cheated of feature by dissembling nature,
deformed, unfinished," as to excite in the beholder feelings
of quite an opposite nature. And yet both may equally
enjoy all that we know as health, and indeed the latter
may, like the mis-shapen Richard, be endowed with a
mental and a bodily vigour far surpassing the former.

Our subject then being " Personal Appearances " in
their widest sense, there is no need to dwell upon indi-
vidual variations ; but dealing with the matter broadly,
we shall have to ascertain what it is that contributes to
the form, size, and colour of the body, and what is the
significance of departures from the normal in these re-
spects. The subject is a wide one. We can but touch
upon its threshold.

CHAPTER I.

THE FORM AND SIZE OF THE HUMAN BODY.

THOSE animals which come nearest to man in physical
conformation have at all times been objects of interest
and of study. Their habits of life, no less than their
bodily structure, have been investigated so far as oppor-
tunities have occurred, and even their mental attributes
weighed in the balance with those shown to be possessed

8 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

by the lowest of mankind, and not always to the advantage
of the latter. In outward conformation the tail-less anthro-
poid ape bears striking resemblance to his human fellow-
creature, and even in details of anatomical structure the
differences are so slight as hardly to amount to generic
distinction zootomically speaking. The precise points
at which the anatomy of man touches that of the lower
animals are very numerous. The grosser and more obvious
differences are those which relate to the hairy covering
of the body in apes as contrasted with man's comparative
bareness, the relative proportions of the limbs to the
trunk, the comparative size of the skull or brain-case, to
that of the face, and, lastly, the erect stature of man and
the consequent modifications in and development of the
lower limbs. The following table, from Professor Huxley,*
shows at a glance the difference between the length of
the bony skeleton of the extremities compared with that
of the spine. The spinal column is taken as i oo : —

Man-
Male Female Gorilla. Chimpanzee. Orang.
Bosjesman. Bosjesman.

Arm 78 80 115 96 122

Leg . no 117 96 90 88

Hand 26 26 36 43 48

Foot . . 32 35 41 39 52

It will be seen that the upper limb in these three
anthropoid apes is relatively longer than the lower, whereas

* * Man's Place in Nature.' London, 1860, p. 71.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 9

in the Bosjesman the reverse holds. In fact, in these
apes the foot is used largely as a prehensile organ, and
the usual mode of progression is, not in the erect posture,
but in the semi-erect, or even on all four limbs.

The erect posture of man largely modifies his form by
calling into play certain muscles which become more
developed in him than in animals. The muscles of the
spine, and all those in front of and behind the thigh which
are employed in moving the lower limbs in progression
are thus markedly developed, and their development
forms an integral part of the contour of the body. But
mere muscularity alone does not suffice to conceal the
angularities of the bony framework to which the muscles
are attached, or at any rate does not lead to the appear-
ance of the fine curves and rounded outlines of the
human form. All the deficiencies in this respect are
supplied by the soft fatty tissue which underlies the skin
filling up spaces left between muscles, and concealing
bony prominences. There are thus three factors contri-
buting to the form of the body — bone, muscle, and fat ;
and a more detailed description of each of these and of
their arrangement is necessary before treating of the
modifications they undergo, and the consequent changes
in the general form of the body.

The regions into which the body is divisible are, head,
trunk, and extremities. The head, containing the brain

10 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

and bearing the sensory organs (which, with the jaws and
mouth, go to form the face), is largely bony, the soft parts
being very slightly developed over the head proper, but to
a greater degree over the face. The trunk, divisible into
neck, chest, abdomen, and pelvis, has its form laid down
in bone, which in the neck and abdomen is represented
in the spine only, in the chest by the ribs, which attached
to the spine behind and the breast-bone in front form the
walls of the thoracic cage in which are contained the
lungs and heart, with the air passages and blood-vessels
connected with them, as well as the gullet passing on
its way to the stomach. The chest cavity is separated
from that of the abdomen by a muscular septum, the
diaphragm ; and contained in the abdomen are the organs
of digestion, assimilation, urinary excretion, and others.
The lateral and front walls of the abdomen are soft and
pliable, being wholly composed of skin, subcutaneous
fat, and muscular layers. Lastly, the pelvis is flanked on
each side by the greatly expanded haunch-bones to which
the bones of the lower extremity are attached. The
four limbs, subdivided into segments and terminating in
the hands and feet, are connected to the trunk by muscles
and ligaments binding the joints.

The Skeleton.— The bony skeleton (Fig. i*) or frame-

* For this and for many of the other illustrations we are indebted
to Mr. H. E. Cree.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. II

work consists of two hundred separate bones, eighty-three
of which are in pairs, JTIG

and those that are single
are symmetrically shaped
and could be divided
into two equal and similar
halves. The bones forming
the head or skull are ar-
ranged into those which
form the cranium proper and
those which enter into the
face. The cranium or brain-
case rests upon the spinal
column by articular surfaces.
Its roof and sides are formed
by several flattened bones,
which in the adult are firmly
interlocked one with another.
Although expanded above,
at the base of the skull, the
bones are compact enough,
and, except for the numerous
perforations to allow of the
passage of nerves from the
brain and of blood-vessels, and a large aperture below
* Adult male human skeleton.

12 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

FIG. 2*

for the upper part of the spinal cord, which is con-
tinuous with the brain, — the brain-case is a closed box.
In front of the cranium is the face, the broad features
of which are laid down in the numerous bones entering
into its composition ; bones to complete the eye-sockets,
to form the foundation of the nose, to give the pro-
minence to the cheek, and to form the upper jaw and
palate ; whilst articulated to the temporal bone is the
lower jaw, which in the adult is squarish in front, and
is acted on by powerful muscles for its closure (Fig. 2).

The spinal or vertebral column,
or backbone, consists of a number
of bones called " vertebrae," joined
together, and capable of a certain
amount of movement, which gives
flexibility to the whole column. In
the neck these are seven in number,
and here their movement 'is greatest.
In the dorsal m region there are
twelve, each of them bearing a rib
on each side ; then come five larger
lumbar vertebrae, and four more fused together into one
bone, the sacrum, and, lastly, three rudimentary bones,
the relic of the tail. The cervical, dorsal, lumbar, and
sacral consist of an anterior solid part or body, and an
* Adult male human cranium.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 13

arch of bone behind, with a projection in the middle
line, so that when united there is a channel through the
whole of them, which lodges the spinal cord, passing
from the brain. The shape of each bone varies slightly
from its fellow, and very much according to the region
in which it is placed, so that the width of the column is
greatest in the lumbar region, where the bones are
larger and deeper. United by fibrous bands or liga-
ments, which yet allow of their movement, they form the
whole column, which is not straight, but is curved slightly
forwards in the neck, backwards in the back, and again
forwards in the lumbar region.

There are twelve ribs on each side of the chest ; each
of these articulates with the spinal column behind, and is
capable of an upward movement at the joint. The first
rib is flattened from above down, and is comparatively
short. It passes from the first dorsal vertebra to join the
upper part of the breast-bone or sternum, a flattened,
sword-shaped bone which completes the chest in front.
The other ribs are flattened chiefly from side to side ; six
of them are in connection with the sternum in front by
means of cartilages which are about two/ inches in length,
and in shape exactly like the bony rib. The next three
ribs are attached by their cartilages, not directly to the
sternum, but to one another; whilst the eleventh and
twelfth ribs — the latter shorter than the former — are quite

14 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

free from anterior attachments, and are hence called
" floating ribs."

The bones of the upper extremity consist in the large
single arm-bone or humerus, the upper extremity of
which is rounded and fits into a socket in the blade-bone
or scapula — a flattened bone, which rests over the upper
ribs on the back, and can move over them for some
distance ; a curved bone forming a prominent feature at
the top of the chest — the " collar-bone " passes from the
scapula to the sternum. The arm-bone is joined at the
elbow by a hinge joint with the bones of the forearm,
or rather with the ulna, which alone enters into the
elbow-joint. The ulna is thicker at its upper extremity,
where it forms the prominence of the elbow, than at its
lower ; its fellow, the radius, on the outer or thumb
side of the forearm, articulating with the ulna above,
and capable of rotation, alone bears the wrist. Then
comes the wrist-joint and a series of small bones, eight in
all, forming the wrist ; to these succeed five long bones
forming the framework of the hand, and upon them are
articulated the finger-bones or phalanges, of which there
are in all fifteen, three to each finger and two to the thumb.
Each successive lower segment is smaller than the upper,
the terminal phalanx being expanded at the extremity
where the nail is borne. The length of the fingers depends
upon the development of these bones, and the long, taper-

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 15

ing fingers, and small hand of the high-born lady owe
their shape to the delicately-formed skeleton ; just as the
broad and short hand and clumsy-looking fingers of the
rustic are due to his coarser and broader bones. Notice
that the second, or middle finger, is the longest ; that as
a rule the third, or ring-finger, is longer than the first,
but not always, and that the fourth is shortest of all.

The bones of the lower extremity resemble somewhat
those of the upper. The great hip bones, which are
united to the sacrum behind, and to one another in front,
represent the shoulder-blades, and each bears a socket
for the reception of the upper end of the thigh bone.
This single bone, called the femur, is succeeded at the
knee joint by two bones, one large and massive, and
prismatic in shape — the tibia — which comes close under
the skin in front and forms the shin. The other is
slender, and passes on the outer side of the tibia, without
entering into the knee joint, and flanks the outer side
of the ankle. Then the bones of the foot, seven in
number, interlocked into one another, one forming the
heel, and bearing on its upper surface the square-shaped
bone which articulates with the tibia to form the ankle
joint. Then in front of this a boat-shaped bone, and
then a series of four small wedge-shaped bones, which
in their turn articulate with five long bones forming the
front part of the foot, and these again with the phalanges
2

1 6 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

of the toes, stunted and small in comparison with those
of the fingers. One other bone should be mentioned in
the lower limb — the knee-cap, which is visible under the
skin, and in front of the knee joint.

In the disease of early life called Rickets, when the
skeleton is unnaturally soft, — the yielding bones of the
thigh and leg give way under the weight of the child when
it attempts to walk, and extreme
and permanent deformity may
result unless the child is kept
off its legs. Thus the thigh
bone curves forwards, and out-
wards, and the leg bones,
especially the larger one, bend
forwards, and bowed legs and
" knock-knees " (see Fig. 3)
result. Happily the soft and
yielding nature of the bones
allows of appliances early had
recourse to effecting the straightening of the limb ; but
unless such measures be taken, and if the child continues
to walk, the deformity will be increased, and as the
bones grow firm will be borne by it throughout life.

Such in merest outline is the bony framework of the
skeleton. . It is completed by the union of the bones in
* Ricketty deformity of bones of lower limbs.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. I 7

joints, which are of various forms and construction in
accordance with the movements they have to subserve.
Essentially, a joint consists in the two ends 'of the bones
which enter into its formation, and which are covered by a
layer of cartilage, a sac, secreting fluid which bathes the
surfaces of the cartilages, and in fibrous bands or ligaments
protecting these structures, and serving to keep the bones
in apposition and to limit their movements. The expanded
ends of the bones entering into the joints add to the
diversity of the form of the body, and alteration in these
joints themselves gives rise to conspicuous deformities.

The Muscles. — The skeleton, bound together and com-
pacted by the ligamentous structures, is clothed with
muscles, which are structures of flesh endowed with the
power of contracting, and by their contraction pulling on
the bones to which they are attached, and thus subserving
the motion of the body. According to their develop-
ment, so do these muscles play a large part in producing
the outlines of the body, and their bold configuration is
well reproduced in the sculptures of antiquity. Those
muscles which are most wanted for the support of life,
and for locomotion, are the most developed, e.g. those
of the lower limbs.

Besides contributing largely to the mere contour of the
frame, the muscles have an important part to play in

1 8 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

maintaining the body in the erect position. The whole
framework of the body is, as we have seen, composed of
a large number of separate parts. Each of these parts
has relations with others, and in many regions one can be
moved on the other by means of muscular action.

There is moreover a state of equilibration between
the muscles performing opposite kinds of movement ;
and so long as the muscles are in a state of tonicity,
and so long as the one set bears its due amount of work
as compared with the other set, so long is this equi-
libration maintained.

This may be readily illustrated by the part played
by the muscles placed before and behind the spine, in
maintaining the erect posture of the body. The position
is kept up without effort, without even consciousness,
by the healthy man whose muscles are well balanced and
in good "tone." It may be, however, that the same
man after a long day's work over a desk, in an, ill-venti-
lated city office, no longer presents that supreme un-
consciousness of his muscles and their action, and
the stoop of his shoulders and bent head demonstrate
to others that the balance is no longer kept, that the
tonicity of the morning has passed off, and the wearied
muscles are no longer on the watch. And so it is when
in sleep the muscles are relaxed and gravity asserts its
force, so that the head falls forward by its own weight,

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 19

no longer restrained by the passive counteraction of its
" extensor " muscles. It may be mentioned in passing,
that so little is there any effort required to maintain the
body erect, that it is a sign rather of weakness than
strength in anyone who exercises an effort to do this.
This may seem paradoxical, but it is nevertheless the
case; and he who walks "bolt upright" with his chin
in the air and his back as rigid as a plank, is often
not a strong, but a weak man.

In consequence of this it happens that various de-
formities arise from the equilibrium between opposing
muscles being destroyed from weakness or palsy of the
one set, or by the over-action of the other set. For
instance u wry-neck," which consists in the head being
permanently fixed in a position inclined to one shoulder^
or its continual spasmodic movement in that one di-
rection, is due to the contraction, or over-action of the
muscle causing that movement not being balanced by its
opponent ; or if the muscles of expression, those of the
face, be palsied on one side, the mouth appears drawn
up and out to the opposite side, an appearance exag-
gerated by calling the muscles into action as in laughing;
or, again, in " squinting," we have an example of weak-
ness or palsy of one or more of the six small muscles
moving the eye-ball preventing the movement of the eye
in their direction of action, so that the two eyes no

20 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

longer move in concert, and lose their parallel action.
Change of form is also obvious enough from wasting of
particular groups of muscles. We may only instance the
flattening of the back of the forearm in lead-palsy, where
the muscles which bend the hand backwards are especially
attacked, so that the hand falls and cannot be raised —
the condition known as " wrist-drop."

Then again, weakening of the muscles of the back (as
produced by enforced sitting on benches without support
to the back) is one cause of what is called lateral cur-
vature of the spine, where the curve to one side which
the spine has in the loins is greatly increased, so much
so, that the shoulder on the side to which the curve is
directed is lower than its fellow; and a curve in the
opposite direction, causing projection of the blade-bone,
forms in the dorsal region.

Club-foot is in a large majority of cases due to mus-
cular defect — a defect which may be present to a' certain
degree at birth, or which may arise from an unnoticed
paralysis in early childhood. The most common form of
this is, that where the heel is raised, and the subject walks
not on the sole but on the toes, or more frequently on the
side of the foot. The strong tendon which passes from
the calf muscle to the heel is in such cases contracted, the
muscles themselves being wasted from their long enforced
inactivity, so that the leg appears small and shrivelled.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 21

Nor simply from bearing weight do ricketty bones give
way. The muscles that are attached to them act as
powerfully in producing their distortion, as may be seen
in the thigh bones (Fig. 3), in the collar bones, and in
those of the upper limbs, the powerful muscle which
passes from the shoulder blade to be attached to the
humerus on its outer surface often causing considerable
distortion of that bone.

Such are some of the changes of form which muscles
give rise to ; those depending upon great muscular de-
velopment are too obvious to be detailed, the fact need
only be stated that the more work a muscle is called on
to perform the larger it grows, and as it. grows, it must
proportionately modify the form of the body.

The Fatty Layer. — Lastly, beneath the skin is the layer
of fatty tissue which is in very variable amount in different
sites, being for instance wanting in the scalp, which is in
contact with the skull, but abundant in the face of a well-
nourished individual, concealing the prominent cheek-
bones. Fat also occurs in the interior of the body around
organs, but this really does not concern us here. How-
ever, it may be mentioned that the eyeball rests on a
cushion of fat ; and the sunken eye of a wasted person is
due to diminution in this cushion. In addition to this, the
natural fulness of the skin is further due to the presence

22 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

throughout it, and the textures underlying it, of blood-
vessels full of blood ; this has a great influence on the
shape— as seen by the shrivelled aspect of a part which
is deprived of blood from any cause, e.g. cold, which
causes contraction of the small arteries, and lessens the
supply of blood to the part.

The general form is dependent on the due relation of
all these parts, and modification in either will lead to pro-
portionate change in shape of the body. The shape of
FlG 4* the head, as a whole, is deter-

mined by the form of the skull,
as is well exemplified in the
negro (Fig. 4), where the pro-
tuberant and prominent lips are
attached to the projecting upper
jaw-bones — - the prognathous
form of skull.

It may be observed that there
is a perfect bilateral symmetry
in the whole body — a symmetry which is not only apparent
on the exterior, but obtains in the skeleton, and to a great
extent in the disposition of the internal organs.

We may now rapidly enumerate the leading changes in
form undergone by the body at different periods of life.
* Skull of negro, showing prognathism.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 23

In infancy the head is large in proportion to the chest,
and the bones of the cranium are not fully ossified, but
are separated from one another by membrane, which,
between the frontal and parietal bones, and between the
latter and the occipital, leaves a considerable interval.
Then the face is small in proportion to the cranium, and
the lower jaw, instead of having an angle at its pos-
terior extremity, which in the adult is F *
almost a right angle, is nearly horizontal
(Fig. 5). The skeleton is incompletely
ossified, the muscles small and ill-
developed, the contour of the body
being chiefly made up by the excessive
fatty layer which underlies the skin.
The neck is short; the chest prominent, narrow, and
short ; and the abdomen large and capacious, whilst the
spine is nearly straight, and the lower limbs propor-
tionately short. In youth the chief change lies in the
greater development of the lower limbs, the greater
proportional increase in the size of the chest, and cor-
responding diminution of the head and abdomen. The
spine now forms a double curve. In adult life, when
all the skeleton is firmly ossified, trie jaw is square, its
angle almost a right angle (Fig. 2), the chest fully ex-
panded, the lower limbs well developed. In old age the
* Skull of infant.

24 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

stature is less, the neck broad, and shoulders rounded ;
the bones are more fragile, the rib cartilages fixed and
hardened; the lower jaw, from loss of teeth, reverts some-
what to the infantile form (Fig. 6), whilst the chin appears
FlG 6 * more prominent and approxi-

mates to the sharpened pro-
jecting nose; and the skin
hangs loosely, and in folds
and wrinkles, in proportion
as the fatty layer has de-
creased and the muscles have
diminished.

Of the differences in the two sexes suffice it to note
that the average stature of women is less than that of
men ; that in the former there is a greater tendency to
the growth of the subcutaneous fat, and that the skeleton
of the pelvic region is modified so that the hips are wider
in the female than the male.

CHAPTER II.

CHANGES IN THE FATTY LAYER.

HAVING thus as it were propounded the bases upon
which the form of the body depends, let us consider

* Skull of aged person. It is unusually long from before back-
wards in the above figure.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 25

the variations which this form undergoes. Some of these
are irremediable in the individual, stamped upon him by
inheritance ; others are the effects of declared disease de-
ranging the economy ; others again arise from the perverse
practices of mankind in the matter of clothing, or by the
equally perverse pursuit of certain modes of life and
labour which cramp and distort the frame, disabling the
individual for the comfort of the community. Such and
many more comprise a long catalogue of effects, some of
which are compatible with good bodily vigour, whilst
others can only be regarded as warning signs, if not
actual indications of defective health.

Perhaps the most convenient way of dealing with the
matter will be to discuss seriatim the effects which arise
from changes occurring in each part of the framework,
and show how deficiency here or redundancy there may
be brought about, and to indicate what it teaches.

We have then first to treat of changes in the Fatty Layer.

It is impossible to say where leanness ends and fatness
begins, just as it is impossible to mark the dividing-point
between any other two opposed states. But all the world
knows what is called a " lean " figure, just as it can point
to a corpulent one, only between the'two there is of course
any amount of gradation. In the absence of any given
standard of proportion between the height of the body
and its girth, we need not attempt a strict definition of

26 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

either one or the other, but must be contented with the
general statement that leanness depends on a deficiency
in the soft parts, and corpulence upon an excess of the
fatty layer especially. Now each of these conditions, even
to a very extreme degree, is compatible with health.
Many, indeed, if not born lean, yet acquire leanness
because they inherit the disposition to it ; these are the
wiry muscular men, and the angular women. To have a
"lean and hungry look" does not by any means ne-
cessarily portend that the. possessor " thinks too much."
It may simply mean that he has inherited the type from
his parents, and were he now submitted to the close
confinement and rich fat-making diet of a Strasburg goose
it is doubtful if the wanting adiposity would ever come
to round the angles of his frame. It must then always
be borne in mind that deficiency in fat is not a sign
of disease, unless the individual has been previously well
nourished, and although there is no doubt that much is
claimed for the influence of heredity which it can hardly
bear, yet this goes for a great deal in the production
of a spare habit of body. Many other factors, however,
help in its production ; continued muscular activity is
a well-known counteracting influence against the over
production of fat, for the muscles in their work require
nutriment, taking it from the food, which unless dis-
posed of in this way would go to add to the general

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 27

store of fat. And accompanying with such exertion there
are the quickened circulation and increased activity of
respiration, by which the blood is more rapidly exhausted
and requires more frequent renewal than when the body
is at rest. When to this is added a spare but sufficient
diet, and especially an avoidance of malt and alcoholic
drinks, the induction of a lean habit is more and more
favoured. There can be no doubt also that equally with
muscular activity, continued mental exercise will hinder
fat production, for although it would be an unfounded
aspersion,* frequently disproved in fact, that fat people
have sluggish faculties, yet there can be no question that
severe mental application tends to a lean habit, and that
the words put into Caesar's mouth by Shakespeare in
speaking of Cassius have some measure of truth in them.

It may be pointed out here that as a rule the inhabi-
tants of tropical climates are leaner than those of tem-
perate or frigid zones, and the probability is that the
former make less flesh. However, there are many ex-
ceptions to the rule; for the indolent life of the first
named, dwelling in a land " where it is always afternoon"
and where nature in her luxuriance i§ always at hand to
supply his physical needs, would favour rather the ten-
dency to fat production when contrasted with the more
active work of the latter.

One more point about lean people and we pass them

28 ' PERSONAL APPEARANCES IN HEALTH AND DISEASE.

by for the more interesting group. It is notorious that
persons of spare habit are not only capable of resisting
more fatigue than others, but they often show far more
resistance to the inroads of disease. This is especially
the case with acute diseases, e.g., fevers. As a rule there
is more vitality, more ability to struggle with the violent
disorders of nutrition in such diseases among spare
people than among the stout, so that a lank ungainly
habit has its compensation, — it is more often tenacious of
existence than the apparently but not really more robust
frame.

When we turn to the opposite condition to leanness
we find ourselves trenching upon the borders of disease,
for that beyond a certain extent corpulence is non-natural
may be admitted, and that it is dependent on defects in
the working of the animal mechanism is highly probable.
In infancy, fat production is paramount ; the food of the
infant is rich in materials for its formation, and although
growth is proceeding with marvellous rapidity, yet a thin
babe is an abnormality, a witness to improper feeding so
common among all classes. The inert, almost vegetable,
existence of the suckling infant favours this storage of fat,
and its plump cheeks, its chubby extremities marked
by deep furrows at their flexures, are indications of this
storage. But as has been pointed out, even in this early
period of existence the production of fat may exceed the

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 29

normal, and trangress the bounds of health; and then all
the forming causes tell with tenfold vigour.

But as growth proceeds, and activity takes the place of
inertness, the tendency to the production of fat is lessened ;
and hence it is that a fat child or youth is rightly regarded
as one whose nutrition is at fault, or whose diet is of a
kind which should not be encouraged. The full exercise
of the body, during its period of growth, is incompatible
with the production of fat, and strongly counteracts what
tendency there may be to its formation. As life advances,
and the period of growth is passed, and maturity is
yielding before the advance of old age, then the lessened
call upon the expenditure of the body favours the accu-
mulation of fat, and we reach that period of the seven
ages when corpulence is regarded almost with reverence,
and even desired as adding dignity and importance.

Of the causes of corpulence that which is predominant
is that to which we have already referred with regard to
leanness. The tendency to obesity is as much under the
influence of heredity as the tendency to spareness. It
" runs in families," and it can as little be avoided as a
man can get rid of his features or the, colour of his hair,
or tendency to early baldness, or any of the thousand and
one proclivities which he derives from his parents. Vain
indeed is the effort to reduce his form to greater comeli-
ness. No amount of abstinence in diet, of regulated or

30 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

even excessive exercise will, except at the expense of
health, rid him of his proclivity, although care may keep
it within limits.

There are, however, many subordinate and favouring
causes to corpulence. The first to be mentioned is that
of sex. Undoubtedly women are more prone to this
production than their hardier brothers. Without seeking
for an explanation of this fact, it is better to accept it as
a fact, true from the beginning, and parallel with the
facts known as to the average stature of the sexes, that
women have more fat than men.

So again, the time of life, as we have already indi-
cated, is a predisposing cause to corpulence.

But there are other causes, not indeed often if ever
sufficient of themselves to increase the amount of the fat
in the body, fat which, be it remembered, is not limited
simply to the exterior as we are now considering it, but
abundant also around certain organs and in certain tissues
in the interior of the body. These are, first and foremost
the continued consumption of rich oleaginous, starchy or
saccharine food, and drinks, such as malt liquors and
alcohol. Who is not acquainted with the typical dray-
man, whose portly figure matches well with the rotundity
of the barrels on his dray, and the plump sturdy horses
between the shafts ? Physiologists have calculated to a
nicety the number of ounces of nitrogenous, carbo-

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 31

naceous, and fluid, material that is necessary to be the
daily food of man, to supply his normal waste, to give
the amount of fuel sufficient to keep the human
mechanism in due working order. All over and above
this is waste, much thrown off, much also stored up as
fat to be called for if occasion ever require it. Hence
regulating diet to a nicety, by cutting off excess of those
foods which most go to " make fat," and such liquors
that do the same, was the gist of that method aiming at
the cure of corpulence propounded to Mr. Banting by
the late Mr. Harvey, and quoted now in learned medical
treatises as the system of " Bantingism."

Another cause, and one which the very possession of
a corpulent habit only serves to perpetuate and extend,
is indolence — indolence of body and indolence of mind.
To take things easily, " to laugh and grow fat," to do
nothing with undue expenditure of force or thought, this
is one of the main causes of fat production. And many
people, already corpulent, cannot help being lazy. It is
a greater effort for them to pursue even the ordinary
avocations of life, how much more its more arduous
and less necessary exertions ! Lack of energy is then
both cause and consequence, and as 'the fat grows the
muscle wastes; and to "make flesh" is a phrase which
often should more properly be used in the opposite
sense.

32 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

Other favouring conditions for the development of fat
are equability of temperament, the cold, impassive
" phlegmatic " rather than the excitable and nervous ; and
an impoverished condition of blood whereby its functions
are ill-performed, and that function of getting rid of waste
material also.

Corpulence is an attribute which is by no means
unmixed with the reverse of blessings. Its greatest evil is
that its possessor when attacked by acute disease is less
fitted to contend against it than his sparer neighbour.
This may be in part because, as we have seen, habits
unhealthy in themselves are so often at the foundation of
the corpulent state. But even apart from this and from
the difficulties the fat man has to. contend with when laid
low by illness, it must be generally admitted that his power
of resistance to acute inflammatory disorder is but slight.

We come now to conditions that are abnormal, both
in diminution and in excess of the subcutaneous fatty
layer. Many diseases, nay most, are accompanied by
"loss of flesh." In some affections this wasting takes
place rapidly — e.g., in the acute febrile diseases ; in others
it is slowly progressive. It depends upon two factors, one
excessive consumption of tissue, the other diminished ca-
pability of assimilation and of nutrition. In a few maladies
both these factors are at work; with a chronic wasting
disease, such as consumption, it is the latter only or

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 33

almost solely. To deal first with the latter cause,
viz., diminished assimilation of food, let us see the
effect that is produced by starvation. It does not re-
quire a visit to a famine-stricken district to become
acquainted with the repulsive details. Examples enough
are unfortunately presented daily before our eyes, where
from ignorance of the simplest rules of diet, infants are
practically starved, although apparently highly fed. And
it is in infants that the effects of deprivation of food,
or of the administration of such food which cannot be
assimilated, and therefore cannot subserve nutrition, is
most plainly seen. The first tissue to "go," and that
which wastes to its largest extent is the fatty layer
beneath the skin. It has been calculated that as much
as 93 per cent, weight of fat can be lost in the process
of starvation — a degree of wasting which far exceeds
that of any other tissue in the body. It is as if this
material is standing in reserve, to be first utilised when
either food is withheld, or when the processes of dis-
integration surpass those of growth.

The rapidity with which the transition from the fulness
and rotundity of health passes into y the more or less
highly attenuated condition is exemplified in several affec-
tions, which, being of an acute character and accompanied
by considerable discharges from the blood, e.g., cholera,
drain the blood-vessels and take away fluid from them.

34 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

And these effects are shown more rapidly and readily,
although perhaps carried to a less extent, in individuals
who previously were well nourished or even corpulent.
For in these the contrast is all the more striking than in
those in whom from the slight amount of adipose tissue
normally present there is already the appearance of
wasting. Hence it is that the appearances of ill-health
are best seen in those who previously had the greater
appearance of robust health, and the sunken cheek and
drawn face show early the inroads of disease.

In acute fevers there is a great call upon the stores of
nutriment, in the body, and much waste takes place
which cannot be made up while the fever process lasts ;
because the functions of digestion and assimilation are
perverted. Hence in a few days or weeks of fever the
body emaciates to a. marked degree. Nor is the wasting
limited to the fatty layer. As in starvation this doubtless
is the first to be used up, but then further call is made
upon the other structures, and muscles grow thin and
flabby too. The recovery of form after , the fever has
passed away, during the stage of convalescence, is chiefly
by the reproduction of fat ; for it requires a long period
of careful exercise to restore the muscles to their
previous natural condition. Indeed, it is frequent enough
that an acute and wasting fever will cause such per-
manent alteration in the nutrition of the body as to lay

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 35

the foundation for a condition of corpulence to which
the subject was previously quite a stranger. The slower
process of losing flesh that occurs in chronic wasting
diseases affects the same parts, and depends either upon
actual starvation, the disease involving the digestive
organs, or upon some interference with the natural
transformation of food into tissue, or the occurrence of
prolonged discharges impoverishing the blood.

Mere modifications in quantity of the subcutaneous
materials are not the only causes of change of form in
the soft parts ; abnormal products may accumulate in
their tissues and lead to change of shape. This is seen,
e.g., after an injury, when a swelling is produced by the
escape of blood into the tissues ; or when a part is
inflamed. Then it becomes swollen by the escape not
actually of blood but of some of the constituents of the
blood, and may even go on to form a limited swelling full
of matter, an abscess. Or tumours of all kinds may give
rise to local derangements in shape. But there is a con-
dition, in dropsy, which may effect a change in the whole
body, or may be limited to one part. Here the serum of
the blood which is unduly watery escapes into the tissues,
and replaces the fat; and the skin becomes stretched
and smooth in proportion to the amount of the dropsy.
Seen to its greatest extent in the dependent lower limbs,
where the fluid naturally gravitates, it may appear in all

36 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

parts, as in the loose tissue under the eyelids. Many con-
ditions give rise to this, some depending on local disturb-
ances of the circulation, others on general blood conditions,
and thus it may be of grave and serious significance.

Lastly, in the subjects of long-standing disease of the
heart or of the chest, there occurs often what is called
"clubbing" of the extremities. It is best seen in the
fingers, the tips of which become broad and rounded,
especially the soft palmar surface. But the same club-
bing may be seen at the extremity of the nose. In all
cases it is dependent on the slowing of the circulation
which takes place in such diseases, so that there is an
almost permanent condition of overfulness of the minute
blood-vessels of these extremities.

CHAPTER III.

CHANGES IN THE BONY FRAMEWORK.

HAVING sufficiently alluded to changes in form produced
by alterations in the muscular structures (see p. 17 and
seg.), and in the fatty layer (see p. 24 and se#.)9 we have
to consider now those due to alterations in the bones
and in the joints. Changes which occur in the shape
of the skeleton necessarily entail very marked deformity.
Some of these are the result of previous muscular failure,
others are due to affections of the joints, others to

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 37

alterations in organs contained within or in contact with
the bony structures, and others, again, to altered con-
ditions of the bones themselves, arising primarily, and
independently of any previous condition of contiguous
parts. When a bone is broken there may or may not be
considerable deformity ; its occurrence depending on the
nature arid extent to which the injury has taken place,
the position of the bone itself and its connection with
muscles. In consequence of this, sometimes most
careful scrutiny will fail to detect that a bone is broken,
whilst at other times the whole limb may be bent and
the injury be manifest at once. Thus a rib may be
broken, but no external change in shape will reveal the
fact to the observer. But the arm or thigh may be frac-
tured, and the amount of deformity be striking. The
more oblique the fracture is, the greater the resulting
deformity j for then the muscles attached to the fragments
will in their traction on each pull them the one over the
other and so lead to shortening of the limb.

Sometimes when the two fragments of a broken bone
do not grow together again naturally, or unite in a dis-
torted manner, the limb remains permanently misshapen.
But even where the union is natural and perfect, an
irregularity in the shape of the bone itself will denote
long after the spot where the junction has taken place.

The main cause of distortions in the shape of the bony

38 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

framework, and therefore of the whole body, is the disease
of infancy called rickets, to which allusion has already
been made. In this affection the whole skeleton, at
its period of most active growth, when the soft carti-
laginous and membranous structures which are ultimately
to become firm bone, still form a large part of the
framework, suffers from lack of proper material for the
formation of bone, and grows exuberantly but yet not
firmly, and the evil results that ensue are due in great
measure to the unnatural softness of these structures
combined with their great abundance. There is abundant
material to form bone, but it is bad material ; there is
active growth, but it is a perverted activity.

Some of its effects have already been mentioned ;
others will be met with later on. One of these effects is a
curvature of the spine, not to one side, as we saw resulted
from muscular weakness, but a bending forwards, giving
the appearance of the spine " growing out," as it is
popularly termed. A sharper angle in this direction,
leading to considerable deformity, is produced by actual
disease of the bones of the spinal column. Such curva-
tures are called " angular curvatures," distinguishing
them from the " lateral" bendings before mentioned.
" Knock-knees " and " bowed legs " are mostly due to
rickets (see Fig. 3) ; their names sufficiently indicate the
deformities they produce.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 39

Any account of the changes of form undergone by the
body would be incomplete, even in a general sketch like
this, without some mention of those partial but frequently
troublesome and permanent distortions which arise from
affections of the joints. All the structures entering into
the composition of a joint may at one time or another be
so altered as to lead to deformity. Thus, the synovial
sac (see p. 17) may become distended with fluid, and
give the joint a swollen rounded appearance, concealing
entirely the natural prominences of the extremities of the
two bones that form it : or the fibrous ligaments surround-
ing the ends of the bones and keeping them together
may be swollen and altered from inflammation, and lead
to similar swelling and alteration of the other soft parts, so
as completely to disguise the joint and render it more or
less fixed. Or these same ligaments may be shortened and
changed by disease so as to cause one bone to pass beyond
the other, and produce what is called a dislocation, or the
dislocation may take place from a violent injury, without any
disease of the joint, and lead to marked deformity of the
limb at the part of the displacement. Or the ends of the
bones themselves may be enlarged and the seat of changes,
which permanently cause an alteration in the shape.

As to simple dislocation from injury, it may be
remarked that in some joints this cannot take place
unless bone or ligament be broken, so intimate is the

40 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

interlocking and union of the normal parts. But on the
other hand there are joints of which the structure admits
of ready displacement. When a joint is dislocated, this
is shown by the appearance of the end of the displaced
bone outside the socket, or separated by an interval from
the extremity of the bone with which it was previously
in contact. There is then such a deformity as results
from the disappearance of the rounded end of the bone
at one place, and its appearance at another, a depression
occurring where formerly there was a projection.

There are, however, affections of the joints which are
common enough to be frequently observed, and concern-
ing which a few words must here be spoken. When
from a twist or a strain the ligaments around a joint are
injured, i.e., when a sprain, as it is called, takes place,
there is always a certain amount of inflammation set up.
This may be, and indeed if the sprain be a severe one, is,
preceded by considerable bleeding into the soft parts
around the joint, and a consequent bruise over the
swollen joint is added to the other evidences of injury.
The amount of force exerted on the joint, or the direction
of the force has not been enough to cause a dislocation,
but has sufficed to stretch or rupture ligaments and give
rise to the inflammatory changes. A joint may become
swollen and inflamed from other forms of injury, as direct
blows or wounds.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 4!

But the inflammations set up by diseases such as
rheumatism and gout, are definite in their characters,
are productive of great alteration in the form of the joint,
and may lead to changes of a permanent or chronic
character. Let us watch the course of an attack of
rheumatic inflammation, say of the knee, in so far as it
causes changes of form.* The pain which foretells and
which indicates the seat of the affection is soon accom-
panied by perceptible swelling; there is a rounded fulness
of the knee, and if the synovial sac, as often happens, has
a large quantity of fluid secreted into it, it is specially dis-
tended, and bulges beneath and on each side of the knee-
cap. The surface is slightly reddened, a redness which
fades on the least touch, under the pressure of the finger.
Or the ankle also may be attacked, and the bony pro-
jections on each side of it, which are formed by the
lower ends of the two bones of the leg, are concealed
in the pufrlness and smoothness of the inflamed tissues.
And here may be mentioned the fact, not, however, without
very many exceptions, that the larger or middle-sized
joints, such as the knee, ankle, wrist, and elbow, are
more liable to be inflamed and swollen in acute rheuma-
tism than other joints. Still frequently enough the

* It must be distinctly understood that the purpose of this little book
is not to give full details of the symptoms of any disease, except in so
far as any change in the normal form is brought about by the disease.

42 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

smaller joints of the fingers, and less frequently those of
the toes, also suffer. In a short but variable time, a few
days or at most a few weeks, the swelling subsides ; with
the subsidence of the inflammation, the joint regains its
natural shape and mobility. But the rheumatism may
become chronic, and then the swelling, although much
diminished in extent, will yet remain a very long time, or
may indeed never wholly disappear. And in this con-
nection we might refer to an inveterate, nay an incurable
and painful malady, one which never loses its hold on
the sufferer, but advances as it were step by step from
joint to joint, cramping their movements, and finally en-
tirely restraining them, and leading to an amount of dis-
vtortion and alteration in and around them which entirely
alters their form as well as their function. Under its
popular cognomen of " rheumatic gout," or its scientific
name of chronic rheumatic arthritis, this affection is known
to many. Happily of not very frequent occurrence, its
inveteracy is its foremost feature, an inveteracy due to
the slow disorganising changes to which it^leads. The
knuckles of the hand become rough and irregular, and the
small bones of the fingers are displaced from their natural
relations one to another. The nodular prominences
which occur over and above the normal outline of the
joint are due to the production of fresh bony substance
in the ligaments and from the bones around them, while

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 43

the articulating surfaces of the bones gradually lose their
cartilaginous covering, and become slowly altered in
shape. In consequence of the fixing of the joints, the
muscles which acted on them are no longer called into
play, and these waste, and lead to a shrinking in the
bulk of the limb itself.

The changes in shape of the joints which gout produces
are somewhat like those of rheumatism. (The joints
affected are as a rule those of the great toe, ankle, fingers,
but even knees, wrists, and elbows.) In the acute form of
gout, if it were not for the particular joint implicated and
collateral evidence, some difficulty might
first exist in determining whether the
joint swelling were due to rheumatism or
gout. The skin over a gouty joint in the
acute stage is glossy and shining, and when
the disease becomes chronic the defor-
mations it leads to are marked and cha-
racteristic. Around the affected joint
spring up nodulated chalky masses, which every acute
attack leaves behind, until hardly a joint of any limb but
is not deformed and rendered unsightly, and to a large
extent unserviceable by the disorder. ' (See Fig. 7.)

There are of course other diseases affecting joints, than
either gout or rheumatism, and resulting in quite as much

* Extreme deformity of hand in chronic gout (after Garrod).

44 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

destruction of the joint itself and distortion of the limb.
To name and illustrate only one of them. The hip-joint
is frequently attacked with inflammation of a particular
kind in children of what is called strumous constitution.
In its early stage, this disease shows itself by the attitude
of .the limb almost as much as by any subjective
pain. The child fears to put its foot down, and stands
with the affected leg raised and turned inwards, so that
only the tips of the toes rest on the ground ; and actually
there may be some shortening of the limb, whilst if the
child be laid on its face, the normal fold of the buttock
on that side will be almost if not entirely obliterated, the
great protuberance itself being flattened out as compared
with the opposite buttock. If the disease run its course,
all these alterations become more marked, and the limb ac-
tually grow shorter, from disappearance of the head of the
bone, and finally even firm union will take place between
the hip and thigh bones. Then in walking the thigh
moves with the hip, the body is bent, and one cause of
spinal curvature is established.

" Housemaid's knee " is a swelling produced by en-
largement of a sac containing fluid which exists beneath
the skin in front of the knee-cap. Its enlargement is
brought about by constant kneeling on hard surfaces
without any protection pad, so that there is much pres-
sure upon this part. Small elastic and occasionally

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 4$

painful swellings sometimes form at the back of the wrist
from enlargement of similar sacs, which occur here in
connection with the cords or tendons passing over the
bones from the muscles which mar the ringers.

CHAPTER IV.

CHANGES IN ORGANS.

WE now come to a very important part of the subject, the
organs of the body, and the influence their various struc-
tural changes exert upon external parts. It will be well to
pass with brevity over the natural disposition of the viscera,
so that we may the more readily appreciate these facts.

The brain which is contained within the cavity of the
skull is not closely applied to the sides of the cavity,
but is invested with certain membranes, one thin and
full of blood-vessels closely applied over the whole surface
of the brain, the other dense and tough, lines the interior
of the skull, but is not in actual contact with the brain.
For the smooth outer surface of the one membrane
and the smooth inner surface of the other are separated
by a small quantity of fluid, and although here and there
as age advances the virtual cavity winch exists between
the two membranes may become obliterated by the
adhesion of the membranes, yet there is seldom complete
blending unless from disease.

46 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

The cavity of the thorax, which extends from the root
of the neck to the lower end of the breast-bone in front, is
separated from the cavity of the abdomen by the midriff
or diaphragm, an expanded muscular structure, which
is dome-shaped, and on contracting tends to descend and
thus to increase the capacity of the thorax. This occurs
every time the lungs are filled with air in the process
of respiration, the descent of the diaphragm being one
main cause of the enlargement of the lungs so as to
allow them to receive more air. At the same time by
virtue of the muscular structures attached to them,
the ribs are raised and turned outwards, and thus the
thorax capacity is increased in a lateral direction. The
lungs are each of them contained in a thin membrane or
pleura, composed of two layers, the outer of which lines
the wall of the cavity of the chest, and the inner is re-
flected around the air-tubes or bronchi, and blood-
vessels entering the lung to cover the whole surface of
the lung itself. Although in the normal state- there is
no actual cavity between the lung and the chest-wall, but
only the virtual space between the smooth surface of the
costal pleura (as it is called) on the one hand and the
pulmonary pleura on the other, it is usual to speak of
the " pleural cavity " when we mean that half of the chest
cavity which contains a lung. The shape of this is roughly
that of half a cone, the apex being upwards behind the

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 47

highest rib and collar-bone, the base being on the surface
of the diaphragm. But between the two pleural sacs, and
encroaching chiefly on the space occupied by the left,
lies the heart, contained in its own bag, the pericardium,
and the large blood-vessels coming off from the heart.

In the abdomen are contained the organs of digestion
and of the urinary excretion, as well as an organ which
probably has something to do with the formation of
the blood — the spleen. The spleen lies behind the
last ribs on the left side in close contact with the
diaphragm ; on the right side behind the ribs, and in
the arch of the diaphragm, extending also beyond the
middle line to the left, and projecting a short distance
below the ribs, is the liver. Partially concealed by its
left lobe lies the stomach, the left extremity of which is in
contact with the spleen. Immediately below and behind
the stomach is the pancreas or sweetbread, which pours
its secretion into the commencement of the intestine at a
spot where the duct of the liver also sends the secretion
of that organ, the bile. The rest of the abdominal cavity
is occupied by the coils of the intestine, and the kidneys,
the latter lying deeply imbedded in each flank. Lastly,
passing down from the thorax through the cavity, and in
close contact with the spine, is the great blood-vessel,
the aorta, sending off branches in its course to the organs,
arid at the lower lumbar region dividing into vessels
4

48 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

for the supply of the pelvis and lower limbs. This great
arterial trunk, taking blood from the heart, is accompanied
in its course by a large venous trunk, the vena cava,
bringing back the blood from the lower extremities to the
heart. Much of. the blood from the viscera passes by
another route to the heart, viz., through the liver.

Confined as it is within a rigid box, it is not likely that
the brain by any change in its shape can in the adult
exert any influence on the shape of the skull and there-
fore of the external configuration of the head. So it
happens that when any growth or tumour occurs in
connexion with the brain, it does not cause the skull to
change its shape, but rather the brain itself, which, being
of less resistance, yields, and is displaced by the new
growth. It is different, however, in infancy, when, as we
have seen, the bones of the skull are but imperfectly
developed, when their ossification is far from complete,
and when, soft in themselves, they are separated by still
softer and more yielding membrane. At this -period of
life if the brain enlarge it causes enlargement of the
skull, and the condition which best shows that is that
unfortunate condition popularly termed "water on the
brain," or technically " hydrocephalus." In this state
the brain is actually enlarged by the secretion of a large
excess of fluid in the spaces, or as they are termed
the ventricles, which exist within the nervous substance.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 49

In proportion as the fluid is formed the capacity of these
ventricles increases, and the whole bulk of the brain is
enlarged. Then also the cavity* of the ^

skull enlarges and the head assumes a
rounded shape, in which the cranial part
is out of all proportion to the small facial
part in a painfully grotesque manner
(Fig* 8). A comparison of this form of
enlargement of the head with that pro-
duced by the perverted growth of the
cranium in rickets (Fig. 9) shows that in hydrocephalus
the skull tends to the globular form, whereas in rickets,
the square-shaped protuberant forehead and
the projecting occiput are surmounted by
almost a flattened vertex. Sometimes, in
consequence of this hydrocephalus, the
cranium attains an enormous size. Nor
does it always, although very frequently,
terminate in early death. The progress may
be arrested, but the enlargement never subsides, and
throughout life the rounded form of the head may be
retained. Often bones not present in the normal skull
are developed to fill up the spaces of membrane.

Here we may turn aside for a moment to glance at

* Outline of hydrocephalic head.

f Outline of ricketty head. The deformity in this instance is not
very pronounced.

50 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

the position assumed by the phrenologist. It is a position
wholly untenable, and we should not have deemed it
worthy of refutation here were it not that misled by the
recent discoveries of physiologists with regard to certain
facts of experiment and disease, it has been reiterated that
not only have certain regions of the brain their special
functions, but that these regions are indicated on the
surface of the skull by prominences which denote similar
development of the brain within. Three distinct facts
converge to utterly explode the phrenologist's standpoint.
The first is that the brain is not in actual contact with
the skull, but is separated from it by a membranous sac
between the inner wall of which and the surface of the
brain there is not any union. The second is that the
inner surface of the skull does not correspond at all in
configuration with the outer surface, for on the vault of
the skull there is interposed between what are called the
inner and outer tables a layer of loose textured bone of
variable thickness, and in the frontal region there is
developed to a very variable extent in different individuals
a series of cavities between these two tables, the size of
which amplifies or diminishes the amount of the forehead.
The third is that even in parts where these cells do not
exist, the thickness of the skull is very variable in different
individuals, and prominences occur in larger number and
extent in some than in others, according to the size and •

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 51

strength of the muscles attached to them. Thus a small
skull with thin walls may contain a comparatively large
brain, and vice versd. But even if the reverse were the
fact, mere size of brain goes for nothing in estimating its
capacity, and more will be learnt by studying the complexity
of its constituent elements than any amount of happy guesses
and shrewd surmises arrived at from a study of the external
surface of the skull, especially when it is remembered that
all the inferior parts of the brain are concealed and have
no relation to the outer regions of the skull.

In the neck an irregular enlargement on each side
results from enlargement of bodies connected with the
lymphatic system, and called lymphatic glands, which,
forming a chain on each side of the neck, as well as
beneath the jaw, may inflame and lead to the formation
of abscesses, which, after bursting and discharging their
contents, leave behind unsightly puckered scars in the
skin. The tendency to the spontaneous enlargement of
these structures, and their ready inflammation, is most
marked in the strumous or scrofulous type of constitution.
Sometimes an enlargement of these neck-glands is shared
in by similar change in the like glands in other parts of
the body, and large irregular tumours may grow up and
conceal the natural shape of the neck. The Derbyshire
neck is the result of the enlargement of a structure the
precise office of which is unknown. This is a fleshy

52 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

organ called the thyroid body situated immediately below
the prominence in part of the neck, known by the name
of " Adam's apple," and consisting of two lobes con-
nected by a narrow isthmus, which passes across the air-
passage, the lobes lying one on each side of the voice
organ or larynx. By its enlargement, which often is
excessive, there ensues a large prominence in front of the
neck, this is the wen or " goitre," frequent in Derbyshire
and in many parts of Switzerland and France.

The size of the chest, as we have said, is ever changing.
It enlarges as the lungs expand, and contracts as they
empty. Its form and dimensions also largely depend
upon the condition of these organs. If they remain from
birth not fully inflated, there is corresponding smallness
in the form of the chest itself. If on the other hand
they are of large size, and unusually capacious, the
thorax is large, broad, and deep. The change in shape
which the chest undergoes during respiration is as
follows-, with inspiration the diaphragm descends, that
is to say, becomes less convex towards the chest; and
the lateral walls of the chest are enlarged by the
ribs being raised by means of certain muscles passing
between them, and the upper ones by-muscles going from
the spine in the neck to the upper rib, and also slightly
everted, this latter action being most marked in the
lower ribs. An elevatory movement combined with one

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 53

of expansion takes place every time we take a breath,
and if the breathing be forced and hurried, other and
more powerful muscles which have attachments to ribs,
act on these bones and increase the area of their move-
ment. But as the ribs are (the six upper directly and the
three following indirectly) connected with the sternum or
breast bone, this bone is, at the same time as the ribs are
raised, thrust bodily forward. There is thus an enlarge-
ment of all the diameters of the chest, the vertical, the
transverse, and the antero-posterior ; the cavity is in-
creased in length, in width, and in depth from before
backwards. When, on the other hand, the lungs are
completely emptied of air, that is, at the close of a number
of forced expirations, the chest is narrowed in all those
diameters, and its circumference is proportionately less.
Contrasting the position of the ribs in the two conditions,
note that at the end of a full inspiration they have a
nearly horizontal direction, whereas at the close of a
de^ep expiration they are sloped downwards and forwards,
and are therefore more Vertical. So that, in fact, the
chest looks longer but narrower when its lungs are less
exp^ided than when they are fully distended. Now it
is not at all uncommon to meet with people the confor-
mation of whose chest approaches what may be called the
" inspiratory type," and quite, if not more common those
in which it is rather of " expiratory type." The small,

54 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

contracted, long and narrow chest is sadly too common.
By no means indicative of present disease, it yet shows a
lessened lung capacity more plainly than any other
surface indication, and is therefore to be regarded as a
warning sign. What produces this expiratory form of
chest ? It may be assumed to be due to no single condition,
but rather the grafting of faults of training, faults of dress,
superadded to those primary defects over which the pos-
sessor has no control, and for which heredity is re-
sponsible, and the artificial existence of the race more
responsible still. The preventable causes ought to be
removed, and all should be done that is possible to
remedy or lessen the unpreventable. A multitude of
errors in our artificial, over-cultured modern life, ought to
be, nay, must be, cleared away; and stricter attention
paid to the laws of health if the tendency to this defect is
to be combatted at all. That it ever can be thoroughly
and completely overcome, would, however, seem almost
impossible, seeing that so many of the essentials of civi-
lisation depend upon the sacrifice of health ; and number-
less trades and occupations of themselves favour the per-
petuation of the defect. Sedentary occupations, especially
such as require constant bending to work ; the evil pro-
duced by close study over books on benches which afford
no support for the back, and the want of complete and
systematic exercise of muscles and of lungs, tend to produce

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 55

this contraction of the chest, and act with greatly increased
force when the organism is young and pliant. The round
shoulder goes along with the narrow chest, and unless
preventive measures are taken in early life, both become
attributes of the individual which cannot be shaken off.

Narrow chests are mainly to be feared as indicating a
diminished lung capacity and breathing space. But it is
wrong to think that they are characteristic of, or predis-
pose to consumption, for if anything, the wide though
flattened chest is more to be feared than the long and
narrow. This terribly fatal form of lung disease often
selects for its victims the broad-chested, even robust
looking ; and whilst on this it may be well to point out
one very striking fallacy in connexion with the shape of
the chest in this affection, — a disease which cripples the
lungs, and proceeds to their destruction. As a portion
of lung disappears the chest-wall falls in, and hollows
appear under the collar-bones. Now it might be thought,
and it often is thought, that when this is extremely marked,
so that the collar-bone seems to stand out one or two
inches from the chest, the disease is advanced and the
result hopeless. It is true that there is advanced disease
at that part of the lung, but as to hopelessness, it is quite
the reverse. The shrinking of the chest shows that the
disease is on the road to recovery at that spot, and is a
sign rather of arrest than of progress. Consumption is not

56 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

wholly incurable. Indeed in many of its forms it is curable,
when measures are early taken to arrest its advance, and
the sign of its arrest is this falling in of the chest.

There is another disease which in its " cure " leads to
considerable deformity of the chest-wall, and that is one
form of a not uncommon result of catching cold — pleurisy.
Here the smooth lining membrane of the chest and
covering of the lung is inflamed, and as a consequence
often fluid is poured out into the chest, and the lung
is squeezed up more or less against the spinal column.
If this last a long time, and no measures be taken to get
rid of the fluid and allow the lung to re-expand and fill
FIG. 10.* tne cnest> the fluid is gradually absorbed
back into the blood. But the lung, unable
to recover itself, remains compressed,
and as the fluid slowly disappears the
chest-wall sinks in, and thus consider-
able deformity is brought arTout. The
deformity shows itself not only in shrink-
ing of the rib, but in a lowering of the
shoulder on that side, and a curving of
the spine (Fig. 10) to the opposite side.
Still, grave as this change is, it is slow in progress, and
although the main work of two lungs has now to be un-
dertaken by one, there is recovery.

* Contraction of right side of chest after pleurisy.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 57

In rickets, the ribs, like the rest of the skeleton, being
soft and yielding, offer less resistance to the pressure of
the atmosphere than if they were firmly ossified, and are
also less able to act as supports to the muscles bearing
on them. The lungs being imperfectly filled with air, the
chest-wall tends to sink in, and a wide groove is pro-
duced on each side of the breast bone from the yielding
of the soft ribs, except at the lower part, where the liver,
stomach, and spleen, the highest organs in the abdJmen
which underlie the diaphragm, or muscular septum be-
tween the chest and belly, prevent their falling in. This
depression, when marked to a full extent, gives the
shape of chest known as the pigeon-breast, the sternum
appearing to be thrust forward like the prominent and
keeled breast-bone of birds. When from any cause
the entrance of air into the lungs is impeded, as, for
instance, in consequence of some obstruction to the
air passage by enlarged tonsils, the tendency to the
formation of the pigeon-breast is greatly increased.

A deep and broad chest — the chest of "inspiratory
type " results from enlargement of the lungs, an enlarge-
ment which may be due to disease, in which as a result
of continued attacks of bronchitis, or>of asthma, or con-
tinued exercise of the lungs 'forcing air through narrowed
apertures, as in the playing of wind instruments, or in hard
manual work, where efforts are constantly made to fix the

58 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

chest when it is full of air so as to give greater support
to the large pectoral muscles going to the arms — the lung
becomes permanently enlarged, arid the ribs maintain
more or less their position of full inspiration, viz.: — the
horizontal. In that way the barrel-shaped chest, as it is
termed, is brought about — it is deep from before back-
wards— and instead of having its external diameter longer
than its antero-posterior, both diameters may be equal, so
that the circumference of such a chest is round. Hence,
although the lungs are so large, breathing is more
laboured and difficult, for the ribs are raised to their full
extent and no longer move in breathing ; and the neces-
sary enlargement of the capacity of the thorax has to be
brought about mainly by the movements of the dia-
phragm, and the forcible raising of the upper ribs by
the muscles passing to them from the neck.

Although the most frequent cause of change in the
form of the chest depends on the condition of the lungs,
yet, especially in childhood, when the ribs are .soft and
yielding, the heart if greatly enlarged will cause a con-
siderable bulging of the chest-wall over it.

The abdomen having only soft and fleshy walls is liable
to any amount of variation from the condition of the
organs contained within it, and as some of these organs —
the stomach and intestines — are very distensable, and vary
in capacity and in amount of their contents several times

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 59

a day, so does the shape of the abdomen alter. On this
point we may only state here, that food which is liable to
much fermentation, which is not readily digested, and
causes the development of much gas, acts chiefly in
causing distension of these organs. Hence it is that
vegetable feeders have large bellies. Continued and
often-repeated temporary causes may thus lead to per-
manent deformity.

Any of the solid organs in the abdominal cavity may
from various causes undergo change in shape, and size,
and lead to departure from the normal form of the ab-
domen. This may be from an enlargement of the organ
in all direcfions, or from its unequal enlargement from
the growth of tumours in it. Swellings in the lower part
of the abdomen or in the groin, may be produced by " rup-
ture," in which a portion of the contents of the abdomen
is protruded through the abdominal wall where it is
weakest. Such swellings will increase under efforts
which bring the abdominal muscles into action, as for
example, when the breath is held and a vigorous attempt
made to lift a heavy body.

But there is one condition in which the abdomen is
uniformly enlarged and assumes a globular form. That
is, dropsy of the abdominal cavity, where fluid derived
from the blood fills and expands the sac in which the
viscera are contained. In proportion as the amount of

6o PERSONAL APPEARANCES IN HEALTH AND DISEASE.

fluid is great, so will the form of the abdomen tend to
become more spherical ; for when it is slight the fluid lies
at the lowest part, and the contour will vary with the
position of the subject — the intestines floating on the
surface of the fluid. But when this reaches the maximum
amount it tests the expansile capability of the abdominal
walls to the uttermost, and they become stretched tightly
and the abdomen gains a spheroidal shape.

CHAPTER V.

ARTIFICIAL ALTERATIONS IN SHAPE.

IT is the prerogative of civilised man to be the slave
of custom and of fashion. Still among savage races
there is often as much adhesion to absurd, irrational,
and almost .harmful observances as among the so-called
cultivated. Setting aside such deformations as have
no great significance, we may speak of two barbaric
customs only, and then turn to civilised communities
and see the analogous instances of ignorant folly, ten
times more foolish and stupid (because there they have
not the excuse of ignorance), that prevail among them.
It is customary among many American races, especially
the Peruvians, to subject their infants to a process of
compression of the skull, which is carried out to such

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 6 1

an extent, that a deformity remains throughout life,
and the frontal region instead of rising boldly up above
the orbits appears as if cut away, and as if a long
but slightly inclined plane were left rising gradually from
the orbit to the middle of the vertex of the skull. The
resulting shape is so peculiar, and the facial angle thus
produced so small and brute-like that there is no wonder
that it should at one time have been regarded as typify-
ing a peculiar race of man. The process, however,
has been now frequently observed and recorded by com-
petent travellers, and it has been shown that in different
tribes various kinds of compression are practised, with
the result of procuring curiously unsymrnetrical crania.
The accompanying figure (Fig. n) is a reduced outline
from an engraving of such a skull pIG x r *

from Titicaca in Peru, in Dr.
Pochard's l Natural History of
Man,' and the author quotes the
opinion of Dr. Scouler as to the
manner in which the compression
is effected. He says, " The pro-
cess is slow and gentle, so that the child does not appear
to suffer in any way from so unnatural a process, nor
do the intellectual qualities of the individual appear
to be in any degree affected by it ; on the contrary, a
* Compressed cranium of a native of Titicaca.

62 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

flat head is esteemed an honour, arid distinguishes the
freeman from the slave."

The Chinese custom of cramping the feet of female
children, consists in so binding them up that the toes
and heel are almost brought into contact, and the sole
of the foot bent upwards in a high arch. The result
FIG 12 * upon the shape and structure of the foot
and of the leg is very marked (Fig. 12),
the bones of the toes and foot itself
being small and atrophied and com-
pressed, whilst the muscles in the leg
which should act on the toes, but which
are never called into action, are wasted and small.

Turning to the " civilised" customs; the high-heeled
boot of modern female fashion does not favour the de-
velopment of calf-muscles, seeing that it throws the foot
forwards on the toes, and normal progression cannot take
place. The wearing of small and tight boots — a far more
prevalent evil — leads, as is well known, to much dis-
comfort in progression and much deformity of the feet.
The toes cramped, distorted, and displaced, become the
seat of thickenings of the skin where pressure is most felt,
and corns and bunions come to disfigure the natural
elegance of a well-formed foot. One other evil resulting
from the wearing of improperly-made boots is the flat
* Foot of Chinese woman (after Humphry).

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 63

foot, in which the strong fibrous ligament that passes
under the bones of the foot and maintains its natural
arch is weakened, and the whole structure yields.

The wearing of tight stays and corsets — the folly of
which is, that they are worn with the avowed object of
distorting the figure — leads to compression of the lower
part of the chest, interfering with its movements in
breathing, and displacing the abdominal organs. Apart
from the foolishness of the practice from an aesthetic
point of view, it is still more unwise in a hygienic, as
there can be no doubt that compression of the chest
must both impair the action of the breathing muscles,
and render the muscles compressed by it weak and in-
effective. But in spite of much attack the practice holds
its ground, and so it will as long as there are foolish
women enough in the world to think that a small waist
is a thing of beauty.

Other pieces of clothing which are worn habitually
tighter than they need be, such as stockings, may not be
productive of much change in figure, though to the last-
mentioned articles must undoubtedly be attributed many
cramped and deformed toes ; that tight garters should
be discarded is obvious, since, by compressing the veins
of the leg, they retard the flow of blood from the limb,
and are a prime cause of enlarged veins in the leg and
swelling of the foot and limb.
5

64 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

The barbaric habit of wearing earrings might almost be
considered a harmless one, for it does not much alter
the shape of the ear-lobe, were it not that the act of pierc-
ing the lobe and inserting rings is apt to be followed, in
young children especially, by troublesome inflammation
of the skin at the part pierced. It is no uncommon thing
to find, among the lower classes, mothers nursing infants
a few months old who are already in the possession of the
coveted ornament.

But it is time to turn from this section of our subject,
so leaving the question of deviations of form (although
much more might be said of them did space permit), we
pass to those of changes in the colour of the body ; and
in the first place let us make clear upon what this colour
depends.

CHAPTER VI.

. THE COLOUR OF THE HUMAN BODY.

WHAT is the cause of the red colour of the blood? It
took a long time to answer this question. Men had to
wait until the microscope was first applied to the investi-
gation of the blood by Malpighi, about two hundred years
ago, before it was answered. And then it was found that
this blood— this red fluid was really, so far as its fluid part
went, colourless, but that with the colourless fluid or serum

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 65

were mingled a number of small round bodies to which
the name corpuscles were given. Then it came to be
found that of these corpuscles there were two kinds, some,
and these formed the large majority, were of a pale
yellowish red colour, hence called " red corpuscles ; "
whilst others, larger, less regular in shape, were pale or
devoid of colour. Ever since that time attention has
been largely directed to the nature and properties of
these constituents of the blood, and we must describe
them in slightly more ample detail, limiting our remarks
only to the red corpuscles. If a drop of blood be
placed on a glass slide and examined under the micro-
scope, the field will be seen to be in great part occupied
by small circular bodies, in which a faint yellowish tint
indicates their possession of some colouring matter.
They are not only circular, but are flattened from side to
side, and careful observation will show that their
flattened surface is really depressed
(Fig. 13). They are in fact small
discs with a slight concavity on
each surface, a character which is
perceived at once when a corpuscle
happens to roll over whilst it is
being observed, and the observer
sees it edgeways. A single cor-

* Blood corpuscles, all with one exception being red.

66 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

puscle when viewed alone seems to have very little colour
at all, a mere faint tinge, and if a drop of water be added
to the blood the corpuscle will swell up and become glo-
bular, and its colour will become even fainter than before.
But, even under the microscope, it will be seen how the
corpuscles are sufficient to account for all the colour the
blood possesses, for the little bodies have a great tendency
to collect in groups, especially forming rows like a pile of
coins, and then the colour of the whole group is more
manifest. If further proof be needed that the colour of
the blood is due to these little particles, it may be found
by collecting a small quantity of blood and exposing it
to the air. After a short time the fluid will set — it under-
goes what is called coagulation- — the resulting solid mass
being called a clot. This clot is formed by the pro-
duction of a substance from the fluid part of the blood
known as fibrine, which does not exist as such in the
blood when circulating through the body. The fibrine
is formed in short and fine threads which entangle the
corpuscles in their meshes. Now the red corpuscles
being relatively heavier than the fluid part of the blood
sink to the bottom of the vessel during the process of
coagulation, and more of them will sink the slower this
process takes place. Hence it comes to pass that
whereas the lower part of a clot so formed is of a dark red
colour, the upper layers may be. almost colourless ot

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 67

only just tinged by reason of the entanglement of a few
of the red corpuscles, which have not had time to sink to
the bottom of .the vessel before the clot set. A micro-
scopical examination of a portion of the lower part of
the clot will show that there the fibrine has entangled
nothing but red corpuscles, whilst hardly any of these
corpuscles will be found in the upper strata. Again it
has been found that pale blood, or the blood of pale
persons, contains fewer red corpuscles than the average
quantity in health, and even quite recently it has been
ascertained that the red corpuscles themselves may contain
less colouring matter than the normal. The physiologist
has long since succeeded in separating this colouring
matter in bulk, and obtaining it in the crystalline state.

The chief constituent of the blood pigment or hcemo-
globin, is carbon, which forms more than one-half of it ;
oxygen, nearly a quarter; nitrogen and hydrogen make
up all but a small fraction of the remainder, which
yields sulphur and iron. The most important property it
possesses is the power of combining with oxygen, and
when this combination occurs the colour of the blood
changes ; it becomes brighter and more scarlet. If, how-
ever, the oxidised blood be exposed to carbonic oxide or
carbonic acid, the colour changes to dark purple. This
readiness to combine with oxygen and to give it up again
appears indeed to be the essential property of the red cor-

68 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

puscles, and the difference in colour thus produced con-
stitutes the essential difference between the* blood which
flows/w;2 the heart in the arteries to all parts of the body,
and that which is returned to the heart from the tissues by
the veins. When ah artery is divided the blood that
jets forth with every beat of the heart is of a bright red
colour • on the other hand, that which flows from a
divided vein in a constant stream is dark and purple.
The reason of this difference in colour between arterial
and venous blood arises from the fact that before entering
the left side of the heart to be sent through the body by
the arteries, the blood passes through the lungs, and then
the carbonic acid with which the venous blood is charged
is at once exchanged for oxygen by the process of
respiration. Again, the bright arterial blood carrying
oxygen to the tissues, the muscles, glands, &c., receives
carbonic acid in exchange for its oxygen, which goes to
maintain the tissues in their constant process of change,
and the dark carbon-laded blood courses .back to the
heart to be again renewed in the lungs. If from any
cause this process of oxygenation of the blood be carried
on imperfectly, or if the heart be unable to do its work
efficiently, so that the venous blood does not pass on
with sufficient rapidity, then the blood in the tissues is
less bright, and as will be seen later on, the surface of the
body denotes the darkening.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 69

Although much of the colour of the body depends
upon the blood, and although some of the chief
indications of derangement of health may be found in
changes of the colour due to blood conditions, yet there
is also throughout the body a large quantity of special
pigment deposited in different regions. This colouring
matter wherever it occurs is brown or black, and is met
with in the form of minute particles or granules within
the constituent cells which make up the various structures
where it is found. Derived as it probably is from the
blood-colouring matter, its composition is clearly allied to
this substance, only it is even richer in carbon. In some
places where it is deposited it subserves definite uses ;
but for our present purpose we have only to consider
it as affecting the colour of the body, and we are thus
limited to its consideration in influencing the colour of
the skin, of the hair, and of the eyes, or, more strictly
speaking, of the "irides."

Regarding then, for our present purpose, the skin only
as the seat of colour, and leaving for others* to deal with
its more important functions as an excretory organ of the
body, it will suffice to describe the structure of this
integument just so far as is necessary to give a clear
conception of the cause of its colouration.

* For full details as to structure of skin, see work in this series
on the Skin.

70 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

The skin, which serves as the protective covering
of the body, is a tough membranous structure, con-
sisting of three parts, an external layer of epidermis or
scarf-skin, an internal, sensitive and vascular layer called
cerium or true skin, and an intervening soft, spongy layer
called the rete mucosum^ or, after its discoverer, rete
Malpighii. This middle layer is the seat of collections
of fine pigment granules, which are the primary cause of
diversity of colour. In dark persons this layer is thicker,
more spongy, and contains more pigment than in fair
ones, whilst in the Ethiopians it is very thick and very
black, so that the colour of the blood in the underlying
corium is never seen at all. There are some diseases,
one especially, and that of rare occurrence, which are
marked by a gradually increasing deposit of this pigment,
so that a previously fair skin may become gradually more
and more bronzed,* the regions which are naturally the
seat of most pigment being those which suffer most.

A "bruise" is the name given to the effect . produced
on the skin by an injury which does not suffice to break
the skin but only to contuse it. The blood escaping
from such blood-vessels as are torn in the injury ^ collects
under the skin, and the gradual variation in tint that a

* So marked is this that the affection in question has been styled
" Bronzed-skin Disease," although the coloration of the skin is only
a part, and that a small part, of a deep-seated disorder.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 7 1

bruise undergoes, from purplish-red to green, orange, and
yellow, is due to the changes taking place in the colouring
matter of the effused blood, whilst this is being very
gradually absorbed. All schoolboys must have enjoyed
opportunities of observing these colour-changes in the
familiar " black eye."

Tattooing consists in the insertion into the true skin of
some pigment as charcoal, gunpowder, &c., by means of
punctures made in the skin and the rubbing in of the
particles. Once inserted there the pigment remains, and
the tattoo-mark cannot be removed by any means short
of excision. The accompanying sketch (Fig. 14) is from
a microscopical specimen of a piece of skin from a
highly-tattooed arm. Observe that the pigment is not
contained in the epidermal cells, but is collected in little
heaps and masses between the bundles of tissue that form
the dense cutis. To remove them by simply rubbing the
cuticle off, or raising a blister, will not suffice ; and as a
considerable amount of tissue would have to be taken
away, a scar must ensue. Hence it may be laid down as
a rule, without exception, that no tattoo-mark can be
removed without leaving a scar to indicate the place it
formerly occupied.

The whiteness of scars depends on the fact that the
middle layer of the skin (or at any rate those constituents
of it which contain pigment), is not reproduced with the

72 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

healing of the wound ; and, further, the new tissue formed
in the corium contains fewer blood-vessels than the old
tissue which it replaces. A curious but interesting fact
in connexion with scars is their growth with the body ;
that is to say, if a wound or injury sufficient to leave a
scar be inflicted in early life, the scar formed will retain

FIG. 14.*

*-<

its comparative size to the rest of the body, although this
may have become three or four times as large as at the
time of the infliction of the wound.

The nails and hairs are structures, which, in truth, are

* Microscopical section of tattooed skin : a is the surface layer or
epidermis, in the deeper layers of which the true pigment of the
skin is lodged ; b is the cutis, and imbedded in its texture will be
seen black masses of the tattoo-pigment.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 73

nothing more than modifications of epidermis. The
former consist of a transparent, horny substance, firmly
imbedded in the true skin, the pink colour of which can
be seen through them. Constantly growing by additions
at their posterior ends they project over the ends of the
fingers and toes, and if uncut may attain extraordinary
dimensions. The nails are never coloured by the natural
pigment of the skin. They are narrow, long, sharply-
curved and pointed on the delicate fingers of the finely-
formed, clear-complexioned inheritant of a tendency to
consumption; whilst after acute illness they frequently
show ragged transverse lines and fissures denoting that
nutrition has been gravely affected. The hairs which
exist over nearly the whole of the body and attain their
greatest development on the scalp, are horny, fibrous-
looking structures which spring from little pits or follicles
imbedded in the true skin. The colour of the hair
depends upon the accumulation of fine granules of pig-
ment in its substance.

In the accompanying sketch (Fig. 15) will be seen a
minute portion of three varieties of hair from the heads
of different individuals. One (a) is a portion of a white
hair from the head of an old man ;, the fibrous and scaly
character is well seen. It is absolutely devoid of pigment
in any part. Then comes a piece of a light yellow
hair (£), and the main difference between this and the

74 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

preceding will be seen in the presence in the former of
dots and linear streaks of pigment which had an amber
colour, although of course they appear dark in the engrav-
ing. Lastly we have a black hair (*:), and this will be seen
studded with pigment granules in all parts. We learn
from this then that the colour of the hair depends on the
presence of pigment particles more or less widely dissemi-

nated throughout its substance, whilst a purely white hair
is distinguished by the negative character of the absence
of all such pigment. That men's hairs have Been known
to turn " white in a single night," through sudden fear, or
some equally powerful emotion, is perfectly true. Several
well-authenticated instances are recorded. Not that the
pigment actually disappears from the hair ; it is probably

* Hairs of different shades of colour.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 75

only concealed by the development of air or gas which
suddenly takes place at the roots of the hair and penetrates
the structure. Nor do such changed hairs always remain
invariably white ; as they grow, the pigment may still be
formed, so that the same hair may become half white and
half black.

Before leaving the subject of the colouration of the skin,
one word must be said as to the colour of those structures
called the mucous membranes. Where the skin is said to
end — that is, at the orifices of the body, at the eyelids,
at the ears, nose, mouth, &c. — it is replaced by a mem-
brane which in its minute structure differs but little from
the skin itself. Like the skin it consists of several layers,
but the colour of these mucous membranes is red or
pinkish red, the very vascular tissue beneath showing
through the thin membrane. Hence it is that the lips
are red, and the same " vascularity " prevails throughout
all the canals and passages into which these orifices open.

Finally, no description of the colour of the body would
be complete without reference to the colour of the eyes.
Of the general structure of the eyeball and its constituent
parts it does not concern us to speak here.* The
anterior part of the organ is all that/ is visible to us. We
see. between the eyelids, a central convex, glassy struo

* For more ample details see the work in this series on the Eye.

76 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

ture set, as it were, in front of a white or bluish-white
surface, " the white of the eye," but little of which is
visible between the lids when the eye is directed straight
forwards. This white part is well furnished with small
blood-vessels, which when the eye is rubbed or irritated
by particles of dust, &c., become visible and give it a
reddened or " blood-shot " aspect. The round aperture
seen behind the centre of the glassy structure and called
the pupil appears black to the observer ; it is bounded by
a circular membranous or rather muscular curtain called
the iris, and the pupil can increase in size or diminish
by reason of the muscular fibres which compose the chief
thickness of the iris ; fibres going round it, being for the
purpose of diminishing the size of the pupil, and others
radiating on all sides, for the purpose of increasing its
size. It is this membranous curtain that is coloured,
and gives the colour to the eye, that colour depending
upon collections of pigment 'granules in a layer of cells
which covers its hinder surface. In dark brown eyes
this pigment is very abundant ; in " blue " and " grey "
eyes it is very scanty. There is also a large amount of
pigment in the cells composing the middle membrane of
the globe of the eye, the choroid coat as it is called.
The choroid is really an extension of the membrane
forming the iris. In dark-haired and dark-complexioned
people this choroidal pigment is very abundant, in fair

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 77

people it is less abundant, and in the curious type of
"albinoes" there is no pigment at all in the choroid.
As this choroidal pigment subserves a definite use in
vision, causing the absorption of extraneous rays, such
people are unable to see in strong direct light, and
consequently in the bright light, or even in the simple
diffused light of day, they are obliged to keep their eyes
half closed in order to see anything.

The glassy cornea sometimes becomes opaque, or the
seat of opaque white patches from inflammation. The
glazing of the eye in death is produced by the shrinking
of this same structure. Another change affecting the
cornea, as old age approaches, is the formation of an
opaque white line around the margin of the cornea, and
travelling round it, so that it does not at first make a
complete circle ; it is known as the arcus senilis. It is
part and parcel of the degeneration of tissues which is the
natural accompaniment of age. Another old-age condi-
tion, which sometimes takes place, is the hardening and
opacity of the crystalline lens — known as cataract, such
opacity being visible to the observer through the pupil.

Having just mentioned the case of " albinoes " it' may
be convenient to sum up their characters now and have
done with them. A true " albino" is one whose skin,
hair and eyes are wholly devoid of pigment from birth
onwards. The skin is thin and fair, the delicate flesh-

78 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

tints due to the colour of the blood showing through the
cuticle are very manifest; the hair is a pure white, on
the scalp, the eyebrows, eyelashes, &c. ; the pupil looks
red, like a white rabbit's eye, from the absence of any
pigment on the choroid at the back of the eyeball, so
that the colour of the blood in that vascular membrane
is reflected through the transparent media of the eye;
and the iris also is destitute of colour, or rather its colour
is pinkish or red for the same reason as the choroid is.
This condition of "albinism" is said to be less common
among the white races than among the black, so that a
* white negro " is a verity. There are instances also
where this albinism instead of being general is partial,
the result being a sort of piebald.

Among the white races, the Indo- European stock,
there are two well-marked types of colouration of the
body. From each of these there are numerous departures
and variations, still even in common parlance it is custo-
mary to speak of a person being "fair" or "dark"
according as he falls under one or the other description.
The typical fair-complexioned blonde has ^a delicate soft
skin, through which the emotional disturbances of the
circulation are readily seen, fine yellow flaxen hair, and
irides of a bluish or greyish tint. The dark-complexioned
or brunette has a coarser skin, with more pigment in it
in the usual seats of this pigment — black hair, or shades

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 79

of brown verging on black, and irides of a nut-brown
colour.

The difference in coloration of the skin between inha-
bitants of hot climates and those of temperate races, is
probably due to an exaggeration of the conditions which
are undergone by white-skinned men after prolonged
exposure to heat. The cause of the colour of the negro,
rests in the great accumulation of pigment in the deep
layers of the epidermis ; that pigment is derived from the
colouring matter of the blood, and the reason of its
excessive production perhaps depends upon some deeper
seated changes in blood formation about which we can only
form conjectures. It is suggested that the liver, which is
the organ most readily influenced by changes in tempera-
ture, and which secretes a product largely pigmented, viz.,
the bile, may have its function so modified that an excess
of pigment is, as it were, left in the blood. At any rate
there is a reason for the coloration of dark skins, since
they serve as a protection from the effects of heat to the
delicate structures beneath.

The " tanning " of the skin of exposed parts, which
occurs after a few days' exposure to the air and solar
rays, is due doubtless in part to increased vascularity and
escape of pigment from the blood, just as any irritant
applied to the skin will produce pigmentation from the
congestion it causes. Other and deeper influences may
6

8o .PERSONAL APPEARANCES IN HEALTH AND DISEASE.

be at work, but we can hardly invoke here the hypothesis
that derangement of hepatic function, gravely as this
is affected by heat, has anything to do with it, seeing
that the result is only shown upon those parts of the skin
which are exposed to the air. The influence of light in
this connexion should not be lost sight of; for those
who work in dark places are pallid, just as plants kept in
the dark are ; and though we may not be able to explain
the modus operandi, yet we must think that light has
some effect. Fair skins are especially liable to pigmenta-
tion from exposure to air and light, as is seen in the
production of " freckles " or " sun-spots " on the face and
neck, and hands. These are nothing more than limited
collections of pigment, and as is well known they often
disappear when youth is passed.

CHAPTER IX.

CHANGES IN COLOUR IN HEALTH.

HITHERTO we have spoken only of changes in colour due
to alterations in the amount of pigment in different
regions of the body. Many of those changes are of but
slight importance, for depending upon local influences
they have no direct relation to the general health of the
individual. It is far otherwise with the colour changes
we have now to deal with; foj although, as we have

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 8 1

before pointed out, it is probable that all pigment owes
its primary origin to the colouring matter of the red
blood corpuscles, yet variations in degree of pigmenta-
tion of parts are not necessarily associated with any
marked change in the blood itself. It will be remem-
bered also that the colour of the skin depends upon two
factors, the chief being that of the blood circulating
in the deep layers, that gives the " flesh-tint " which
artists aim so strenuously to reproduce in all its delicate
and varied hues — a colour too, the intensity and delicacy
of which must largely depend on thickness of cuticle ;
and the other being the presence of pigment in the
cuticle — a very varying condition, but one which in-
fluences largely the predominant colour, and which, if
in excess, as in the negro, will suffice to completely
disguise the flesh-tint. However, even in the negro there
are still regions which show the blood colour, e.g., the
mucous membranes ; and observation of the colour of the
lips, of the nails, or of the conjunctiva of the eye, will
reveal more accurately than any change that may be
noticed in the skin, the change that has taken place in
the vascular regions beneath.

The difference in colour produced by difference in the
quantity of blood in a part may be shown by a very simple
experiment. If one hand be held above the head whilst
the other is allowed to hang down by the side for a few

82 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

minutes, and then the two hands compared, the one will
look pale and white, the other flushed and red. The first
is white, because by holding it up the return of blood from
it by the veins has been aided by the action of gravity; in
the other it has been retarded for the same reason. Thus
temporarily there has been produced a condition of com-
parative bloodlessness or anczmia in the one hand, and a
condition of plethora or congestion (hypercemia) in the
vessels of the other. The experiment may be varied by
pressing out the blood from one hand, when you will get a
white spot where the pressure was applied, and conversely,
if the part be rubbed violently, it becomes red and warm.
The reason of the pallor in the first instance is obvious
enough, the pressure squeezes the blood out of the
vessels of the part. The reason of the redness in the
latter example is not so obvious, and requires a little
further explanation. All the blood-vessels, the arteries
more particularly, have muscular walls, which can contract
when the nerves which go to them are irritated, just as
the muscles of the arms contract if the nerves going to
them be stimulated, as they always are when by an act
of the will the brain sends its message down them to
exert a particular movement. The modus operandi
however in connection with the blood-vessels is different
from that of the muscles of the arm, or any of those
which are under the control of the will ; for the muscular

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 83

walls of the arteries are not under voluntary control.
The nerves which go to them do not pass directly from
the brain or spinal cord, but are connected with a part of
the nervous system, which, although in part dependent on
the cerebro-spinal, is distinct enough, both in its arrange-
ment and structure, as well as in its functions. This is
the system of organic nerves, or, as it is also called, the
sympathetic system, and it consists essentially in collec-
tions of nervous cells called ganglia, connected by
bundles of nerve fibres down each side of the spine,
and from which proceed other nerves to the involuntary
muscles all over the body ; to the muscle of the heart, to
those of the intestines and stomach, &c., the movements
of all of which are not under voluntary control, but are
essential to the performance of the function of these organs.
The nervous system is then in its central parts duplex ;
there is the brain and spinal cord from which nerves
of voluntary motion and sensation arise, and there is the
sympathetic system from which nerves of organic life,
of involuntary movement arise. Going back to our illus-
tration, we find that the arteries of the body are kept in a
state of contraction by the sympathetic nerves. It has
been shown that when the sympathetic nerve in the neck
of a rabbit is paralysed, the ear on that side becomes red
and hot, and increases in size. There is in fact an in-
creased flow of blood to it, and this flow is due to greater

84 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

enlargement of the blood-vessels, i.e., they are dilated.
The influence of the sympathetic nerve has been taken
off their contracting walls, and just as a limb is para-
lysed when its nerves are injured, the coats of the blood-
vessels are paralysed. But when the nerve is stimu-
lated, the vessels contract, and the previously engorged
ear becomes cold, pale, and white, less blood passing
through it. And now we come to another fact which
must be accepted before we can explain the reason why
the hand gets red when it is vigorously rubbed. It is
this : although the cerebrospinal nervous system has no
direct influence over the involuntary muscles supplied by
the sympathetic nerve, it has an indirect influence. It
possesses the power of arresting, or diminishing, or, as
it is called in scientific phrase, " inhibiting " the action of
the sympathetic nerves. Now the act of rubbing the hand
stimulates the fine sensory filaments of the sensory nerves
in the skin ; their stimulation exciting them to increased
function, they inhibit the action of the sympathetic nerves
governing the blood-vessels in that part ; and the control
of the sympathetic being temporarily suspended, the
arteries dilate, and becoming capable of receiving more
blood than usual, the part they supply becomes tem-
porarily red and hot. The same explanation holds for
the effects of other kinds of irritation or stimulation of
sensory nerves, e.g., the red blush produced Ity the ap-

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 85

plication of a mustard poultice, and carried further still,
the first effect of a % blister is to cause reddening of the
skin, and later as the blister rises exudation of fluid
from the blood in the dilated vessels of the cutis. In
speaking of pigmentation of the skin due to the effect
of heat, we said that the first effect was an increase in
the flow of blood, and no doubt it is due to this that
there comes to be increased formation of pigment. For
a brown stain is often long left after the application of
mustard or a blister, or after the skin has been inflamed
for some time.

We are now in a position to explain the phenomena
of blushing and of pallor of the surface from fright. In
blushing, which is always most marked in thin-skinned,
fair people, and which is by no means limited to the
face, but may extend over the neck, shoulders, and
chest, the arteries are temporarily dilated. The sense of
shame acts through the medium of the brain in an
involuntary manner, and there is a temporary arrest of
the function of the nerves going to the blood-vessels.
The blood seems to " rush " to the cheeks, and the
individual feels hot and uncomfortable, whilst to the
observer the rosy flush will be seen mantling the cheeks,
ears, and forehead, and reaching to the roots of the hair.
The heart beats quicker, and the whole circulation is
temporarily excited. Then as the emotion sinks, the

86 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

blood tint fades away, and matters return to their previous
state of quiescence.

In the opposite condition, that of pallor, which is as-
sociated with the emotion of fear, especially sudden
shock, the skin becomes pale, the lips lose their bright-
ness, and often a sense of coldness even to shivering is
felt. Here we have a temporary diminution in the flow
of blood — the brain acting upon the heart — and the
surface being less supplied with blood. A similar
effect is produced in fainting. The rationale of the
fainting state is a temporary failure in the action of the
heart, and the brain failing to receive its full supply of
blood, unconsciousness supervenes. The bloodlessness
of the surface typifies the bloodlessness of the brain.
The return of blood to all these parts, and the resto-
ration from the fainting state is accompanied by a sense
of heat and fulness.

And so again the final hue of death, in all time obvious
and striking — "pallida mors" — is due to the final beats
of the heart, and dying contractions of the arteries send-
ing the life-stream slowly on its way to stagnate in the
veins. The emptiness of the arteries and the capillaries
gives a pallor to the surface, which the laden veins do
not overcome.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 87

CHAPTER VIII.

CHANGES IN COLOUR IN DISEASE.

PASSING from conditions giving rise to pallor, which are
physiological, and therefore not departures from healthy
action at all, we are confronted with a set of causes of
undue paleness of the surface which depend on more or
less grave alterations in the constitution of the blood.
The pallor in such cases is general and more or less
lasting. It may be due to a general diminution in the
quantity of the blood, with or without any alteration in
its quality. Great losses of blood are obvious causes of
this anaemia, and in such cases it comes on rapidly.
Or a long and tedious illness gradually interfering with
the nutrition of the body, and therefore with the for-
mation of the blood, will be denoted on the surface by
the paleness of the skin dependent on the diminished
and altered condition of the fluid in the blood-vessels.

More common than all, and striking enough in its
effects, is the pallor produced by unhealthy trades and oc-
cupations ; by life in badly-ventilated, ill-lighted, and over-
heated rooms. Then just as the plant grows pale when
kept from the light, so the man or woman loses the tint
of health and presents a blanched appearance. This is
the state of general bloodlessness or anaemia which is so
prevalent in so many of our townsfolk and factory hands.
The lips lose their natural redness and become pale,

88 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

as do the gums also, and the other visible mucous mem-
branes. A white line on the thin part of the gum, where
this stretched over the prominent canine teeth, is an
indication of this anaemia. The skin is white and no
longer has the flesh tint natural to it. Many troubles
arise out of this condition of impoverished blood ; for,
being poor in corpuscles and deficient in colouring matter,
the functions which these subserve are impaired, and
shortness of breath on exertion, caused by the demand of
the tissues for oxygen being greater than the small num-
ber of oxygen carriers can supply, disturbed and im-
perfect digestion, disorders of the mental faculties, sen-
sorial derangements, &c., all follow in the train.

But it may be said that numbers of persons are naturally
pale, and apparently bloodless, but yet enjoy good health,
with none of these grave discomforts. That is true,
but it is only true because their pallor is not the pallor
of true anaemia ; it may be dependent upon the condition
of the circulation in their skin ; or the skin may be
thicker in them than in other folk, who, with no more
blood, are yet red-faced and healthy-looking. Then
these people do not exhibit the unnatural paleness of the
lips or nails, or the mucous membrane under the eyelids —
the only places where in dark-complexioned thick-skinned
people the objective signs of anaemia can be with con-
fidence ascertained.

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 89

As to this state of anaemia, all its causation may be
summed up in derangement of those processes which
are concerned in blood-making ; of these, digestion and
oxygenation are the chief; and of the causes, con-
sequently, ill digestion and bad oxygenation, in other
words improper food and bad air, are the predominating
circumstances contributing to this state. Various as
are the diseases of which anaemia plays a part, the pro-
duction of the anaemia itself always comes back to this.

Apart from its association with' any grave disease this
poorness in the quality of the blood is common among
young women ; especially those who, accustomed to out-
door life, are called upon to work from morning to
night within the house — and often in them the pallor of
the surface is not merely paleness, but a greenish tint of
skin replaces whiteness. The period of the growth of
the body when great demands are made upon the func-
tions of assimilation and nutrition is a favouring time
for the occurrence of anaemia ; and the debility and pale-
ness of young people who " grow too fast " find here an
explanation.

Increase in the quantity of blood may be considered here
only in its local relations from overfilled blood-vessels,
or what is called congestion of parts. It is seen in the
cheeks in the "hectic flush" of fevers, and in the early stage
of an inflamed part, redness being one of the classical

90 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

signs of inflammation. The cause of the red rash in scarlet
fever is congestion of the vessels of the skin, and its ready
paling on pressure of the skin shows that the blood can
be displaced from the vessels of the surface. Permanent
congestion, leading to permanent redness of parts, are
not at all uncommon ; and the enlarged congested vessels
can be traced on many a weatherbeaten face, or in the
bloated, reddened features of the habitual drinker. Tem-
porary flushing of the cheeks — apart from blushing, but
doubtless conveyed through the medium of the nervous
system — is seen frequently in indigestion, and is the usual
result of the ingestion of stimulants, as alcohol ; and an
aggravated degree of this produces what is known as
" nettle-rash."

When the blood cannot be perfectly oxygenated in
the lungs, or when from any cause the return of blood
to the heart is hindered, then the surface assumes more
or less of a bluish or livid tint. This is seen best in the
parts which are most vascular, e.g., the mucous mem-
branes, as the lips, or the regions most remote from the
centre of the circulation, as the tips of the fingers, or toes,
ears or nose. Simple exposure to cold will do as much,
causing temporary stagnation of the blood in these remote
regions of the body. Prolonged chilling of the surface is
always followed by reaction ; the blood flows back to the
part with increased vigour, and redness replaces pallor,

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 91

and not only the redness of mere congestion of vessels,
but that denoting inflammation ; and the tender, swollen,
reddened "chilblain" is thus related to the graver "frost-
bite," where the effect of cold is seen in its severest form.

Jaundice is due to the pigment of the bile finding
entrance into the blood, either because too much bile is
manufactured by the liver than can be got rid of, or else,
and more frequently, because the escape of the bile into the
intestines is hindered. This colouring matter then stains
all the tissues yellow, and the skin and the white part of
the eye show the colour most plainly. If the cause cannot
be removed, then the colour changes gradually from a
deep orange-yellow to a more or less greenish or olive-
green tint. But in such cases the cause is probably
beyond removal. Young infants frequently, in the first
few days after birth, before their respiratory and cutaneous
functions are fully established, pass through a slight attack
of jaundice. This seldom has any grave significance.

Passing to other forms of change of colour, we may
note the curious, muddy or tawny, complexion of people
who have suffered from ague or marsh fevers, a com-
plexion which goes with them through life, and is pro-
bably dependent on the change whidi the spleen — an
organ intimately connected with blood formation —
undergoes in such diseases.

Lastly, certain substances when taken into the blood

92 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

will stain the skin and tissues. Of these, silver is the
most notable example ; and people who have taken this
metal medicinally for a long period, are liable to have the
skin of their face changed to a bluish leaden hue from
the action of the light upon the silver. And one of the
most marked effects of chronic lead poisoning is the
appearance of a line of bluish discoloration along the
thin part of the gums where these border on the teeth.

Then many disorders of the skin which give rise to
irritation, congestion, or inflammation, leave behind them
permanent yellow or brownish marks of discoloration.
There is one common affection which is accompanied by
a yellowish pigmentation. It is due to the presence of a
fungus on the skin, and occurs on the body favoured by
clothing and uncleanliness. It is readily removable.

CHAPTER IX.

ON < TEMPERAMENT/ ' HABIT/ AND i TONE.'

FROM the earliest times it has been matte;* of faith among
writers on medicine that all mankind can be subdivided
into a few groups, each with sharply-marked charac-
teristics, and each with certain tendencies to particular
affections. How much truth underlies this doctrine it is
needless to inquire. Let it suffice that even now we
recognise the types of constitution which so long ago

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 93

were first pointed out. Like all generalizations, however,
these types or temperaments require to be dealt with
liberally in drawing conclusions ; and in the majority of
cases, an approximation to the characters can alone be
found, and when found are not of much practical value.
They are four in number, and the terms denoting them
have crept into current use as descriptive of mental as
well as bodily qualities, viz., sanguine, lymphatic or
phlegmatic, bilious or melancholic, and nervous.

The sanguine is characterised by healthy vigour, ac-
tivity of body, and of mind; with ruddy cheek, well
developed muscles which are used with delight. There
is a great deal of tone about the tissues, which are well
braced up, and the bright aspect of the face is repre-
sentative of the hearty condition of the mind, and the
cheerfulness with which life is regarded. Reverses do
not sadden, nor sorrow damp the brightness of the walk
in life. This and more might be said of this happy,
healthy condition, which is happy because healthy. The
lymphatic person, however, is less carried above his life-
conditions. He is pale, and generally fair in feature ;
slow, and rather dull in mind. The bilious is typified by
dark hair, a thick, dull skin, a sluggish mind, rather easily-
provoked temper, and a liability to disorders of digestion
which cloud the mind as well as affect the body. The
nervous on the other hand is easily roused, constantly

94 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

occupied, but seldom continuously — ever seeking fresh
fields to work in, without in any of them pursuing his
work to the end. Highly intelligent, often precociously
so in youth, the mind is not well-balanced, so that the
individual is excitable in temperament, and both unduly
depressed by failure or unduly exalted by success.

Another term, also handed down to us from antiquity,
and far too widely employed, is " habit," or its correlative,
" constitution." For example, we talk of people being of
a " gouty constitution," or a " rheumatic habit," or as
being of a " strumous type," or u consumptive tendency,"
judging in these and many other instances from appear-
ances, but meaning no more by the phrases than that the
individuals in question are disposed to such and such
particular class of disorders. In a broad and general
sense no doubt — as in the above-quoted instances — true
conclusions may be arrived at simply from such observa-
tion, for the affections they denote are generally de-
pendent upon some inherited constitutional defects, and
are stamped upon the individual. But too rigid re-
liance upon certain prominent characters as indicative
of such tendencies is liable to lead to much erroneous
inference, and it is noteworthy that even the same
" habit " may be presented under wholly different cha-
racters. For example, the " gouty " man is quite as
often pale, thin, and flabby-textured, as plethoric and

PERSONAL APPEARANCES IN HEALTH AND DISEASE. 95

heavy in build ; and the strumous child as frequently fair-
haired, oval-faced, and thin-skinned, as coarse-featured,
and thick-lipped.* When, again, the term " habit " is
applied to such diseases as " apoplexy," the error is very
great ; for it is notorious that the prevalent idea that
individuals with thick, short necks and sanguine tempera-
ment are the more liable to apoplexy is wholly unfounded
in fact, that disease depending on causes equally at work
among the lean and long-necked as among the former.
Far better to erase the word " habit " from the vocabulary
than run the risk of such misapplications.

We have more than once spoken of loss of " tone,"
and vague as the expression is, it is well to dwell on this
as indicating perhaps better than anything else the state
or condition which of all others is to be found on the
side of unhealthiness. Everyone knows how much dis-
comfort and inconvenience to themselves and to others
is experienced by those who, suffering from no definite
derangement of any organ, are yet in a state of ill health
during the greater part of their lives. Unable to resist
even the slightest influences, and feeling " well " only at
rare intervals, there is something in their constitution
which baffles definition. Their aspect is generally more
or less pallid; for they take but little exercise, and

* It is usual to regard the strumous state as comprising these two
distinct types.

7

96 PERSONAL APPEARANCES IN HEALTH AND DISEASE.

undergo but few exertions, so that the circulation is slow,
and cold extremities with consequent want of sleep are
their bane. The skin is flabby, often moist, and the
dark shadows under the eyes denote that the relaxed
condition of the skin is sufficient to obscure its natural
colour. The same flabbiness belongs also to their
muscles ; all exertion is painful and wearisome, as well
as irksome, and a general debility and languor accom-
panies them. How many does not this typify, and how
often is it largely the result of want of personal effort, and
personal hygiene? Contrast such habits of body with
those of the sturdy and vigorous, and it will be seen that
in one the tonicity is deficient, in the other marked.
Well-regulated, but not over-violent, open-air exercise,
careful diet, frequent cold bathing, and above all some
definite pursuit to engage the mind, will do more to
restore the balance in the former than a course of me-
dicinal treatment however tonic and however prolonged.
Our highly-artificial lives have much to do' with the
prevalent valetudinarianism of the present day ; and the
customs of society which run counter in so many ways to
the teachings of common sense, have done more evil in

this respect than can well be estimated.

c p
THE END. °' ^

14 DAY USE

RETURN TO DESK FROM WHICH BORROWED

This book is due on the last date stamped below, or

on the date to which renewed.
Renewed books are subject to immediate recall.

TIRE.

i-

er as to
:o disci-

h by an
es some
of each

rvation.
tbellish-
all trea-

>e found
Primers
tout the
bs.

s.

•EWART.

GEIKIE.

FOSTER.

. I)CKYER.

IKVQNS.

PENCER.

AYLOR.

[EVONS.

rork.

GR

RO
EU
OLI
RO
GE(

health ana c

isease

UD

J

B/OLO6Y

J irjrj, _

z

fcfoitftfiy

G

fp, .

PI
CI

SI
GI

H(
El

UNIVERSITY OF CAIylFORNIA LIBRARY

I ) . A P PI , K T ( ) N &" ". ," F UBLisiKb,

549 & 551 Broadway, New York.