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Kishori Sharan and Adam L. Davis

Beginning Java 17 Fundamentals

Object-Oriented Programming in Java 17
3rd ed.
Kishori Sharan
Montgomery, AL, USA

Adam L. Davis
Oviedo, FL, USA

ISBN 978-1-4842-7306-7 e-ISBN 978-1-4842-7307-4

https://doi.org/10.1007/978-1-4842-7307-4

© Kishori Sharan and Adam L. Davis 2022

This work is subject to copyright. All rights are reserved by the

Publisher, whether the whole or part of the material is concerned,
specifically the rights of translation, reprinting, reuse of illustrations,
recitation, broadcasting, reproduction on microfilms or in any other
physical way, and transmission or information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.

The use of general descriptive names, registered names, trademarks,

service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general
use.

The publisher, the authors and the editors are safe to assume that the
advice and information in this book are believed to be true and accurate
at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the
material contained herein or for any errors or omissions that may have
been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Apress imprint is published by the registered company APress
Media, LLC part of Springer Nature.
The registered company address is: 1 New York Plaza, New York, NY
10004, U.S.A.
Introduction
How This Book Came About
My first encounter with the Java programming language was during a
one-week Java training session in 1997. I did not get a chance to use
Java in a project until 1999. I read two Java books and took a Java 2
programmer certification examination. I did very well on the test,
scoring 95%. The three questions that I missed on the test made me
realize that the books that I had read did not adequately cover details of
all the topics necessary about Java. I made up my mind to write a book
on the Java programming language. So I formulated a plan to cover
most of the topics that a Java developer needs to use the Java
programming language effectively in a project, as well as to get a
certification. I initially planned to cover all essential topics in Java in
700–800 pages.
As I progressed, I realized that a book covering most of the Java
topics in detail could not be written in 700–800 pages. One chapter
alone that covered data types, operators, and statements spanned 90
pages. I was then faced with the question, “Should I shorten the content
of the book or include all the details that I think a Java developer
needs?” I opted for including all the details in the book, rather than
shortening its content to keep the number of pages low. It has never
been my intent to make lots of money from this book. I was never in a
hurry to finish this book because that rush could have compromised
the quality and the coverage of its content. In short, I wrote this book to
help the Java community understand and use the Java programming
language effectively, without having to read many books on the same
subject. I wrote this book with the plan that it would be a
comprehensive one-stop reference for everyone who wants to learn
and grasp the intricacies of the Java programming language.
One of my high school teachers used to tell us that if one wanted to
understand a building, one must first understand the bricks, steel, and
mortar that make up the building. The same logic applies to most of the
things that we want to understand in our lives. It certainly applies to an
understanding of the Java programming language. If you want to master
the Java programming language, you must start by understanding its
basic building blocks. I have used this approach throughout this book,
endeavoring to build each topic by describing the basics first. In the
book, you will rarely find a topic described without first learning its
background. Wherever possible, I have tried to correlate the
programming practices with activities in our daily life. Most of the
books about the Java programming language available on the market
either do not include any pictures at all or have only a few. I believe in
the adage “A picture is worth a thousand words.” To a reader, a picture
makes a topic easier to understand and remember. I have included
plenty of illustrations in the book to aid readers in understanding and
visualizing the contents. Developers who have little or no programming
experience have difficulty in putting things together to make it a
complete program. Keeping them in mind, we have included over 290
complete Java programs that are ready to be compiled and run in the
book.
I spent countless hours doing research for writing this book. My
main source of research was the Java Language Specification,
whitepapers and articles on Java topics, and Java Specification Requests
(JSRs). I also spent quite a bit of time reading the Java source code to
learn more about some of the Java topics. Sometimes, it took a few
months researching a topic before I could write the first sentence on
the topic. Finally, it was always fun to play with Java programs,
sometimes for hours, to add them to the book.

Introduction to the Third Edition

We are pleased to present this edition of the Beginning Java 17
Fundamentals book. It is the first book in the three-volume Beginning
Java series. It was not possible to include all JDK features in this
volume. We have included version-specific changes at appropriate
places in three volumes. If you are interested in learning only JDK 9–
specific topics, we suggest you read Java 9 Revealed. To learn more
about Java 17, we suggest you read More Java 17. There are several
changes in this edition, and they are as follows.
We have added a separate chapter (Chapter 2) on setting up your
environment, such as downloading and installing JDK 17, verifying the
JDK version, etc.
In this edition we have added some introductions to lambda
expressions, method references, and Streams throughout the book
where they are referenced. We’ve also included many of the more
recently introduced features of Java such as local variable type
inference, switch expressions, sealed classes, multiline text blocks, and
Records.
Chapter 3 provides a comprehensive introduction to the module
system. We provide a step-by-step process on how to write, compile,
package, and run your first Java program using a command prompt and
the NetBeans integrated development environment (NetBeans IDE).
Chapter 10 contains an in-depth coverage of the module system.
JDK 17 ships with a very valuable tool called the JShell (short for
Java Shell) tool. It lets you explore the Java programming language
interactively by entering chunks of code, rather than writing a full-
fledged program. We strongly encourage you to use this tool to play
with snippets of Java code when you are writing a Java program. We
introduced this tool in Chapter 2, and we have covered it extensively in
Chapter 23. The reason we did not cover it in one of the first few
chapters of the book is because, as a beginner, you need to know the
basics of Java programming first.
The first edition contained a chapter entitled "Classes and Objects,"
which was over 120 pages long. This edition has divided this chapter
into three chapters titled “Classes,” “Methods,” and “Constructors”
(Chapters 7–9).
We have updated Appendix B to cover Javadoc features of JDK 17. In
the previous edition, Appendix B included frames, but they have since
been removed from Javadocs.
We received several emails from the readers about the fact that the
first books in this series did not include questions and exercises, which
are needed mainly for students and beginners. Students use this book
in their Java classes as a Java textbook, and many beginners use it to
learn Java. Based on this popular demand, over 60 hours was spent
preparing questions and exercises at the end of each chapter of this
book.
Apart from these changes, we have updated all chapters that were
part of the previous edition. We have edited the contents to make them
flow better, changed or added new examples, and updated the contents
to include features specific to JDK 9–17.
It is our sincere hope that this edition of the book will help you
learn Java better.
Structure of the Book
This book contains 23 chapters and two appendixes. The chapters
contain fundamental topics of Java such as syntax, data types,
operators, classes, objects, etc. The chapters are arranged in an order
that aids learning the Java programming language faster. The first
chapter, "Programming Concepts," explains basic concepts related to
programming in general, without going into too many technical details;
it introduces Java and its features.
The third chapter, "Writing Java Programs," introduces the first
program using Java; this chapter is especially written for those learning
Java for the first time. Subsequent chapters introduce Java topics in an
increasing order of complexity. The new features of Java are included
wherever they fit in the chapter.
After finishing this book, to take your Java knowledge to the next
level, two companion books are available by the authors: More Java 17
and Modern Programming Made Easy.
At the end of each chapter, you can find questions and exercises that
challenge you with the knowledge you gain in the chapter. Questions
and exercises are geared toward students taking Java classes and
beginners. Answers to all questions and solutions to all exercises are
available at www.apress.com.

Audience
This book is designed to be useful to anyone who wants to learn the
Java programming language. If you are a beginner, with little or no
programming background, you need to read the first chapter to the last
in order. The book contains topics of various degrees of complexity. As a
beginner, if you find yourself overwhelmed while reading a section in a
chapter, you can skip to the next section or the next chapter and revisit
it later when you gain more experience.
If you are a Java developer with an intermediate or advanced level of
experience, you can jump to a chapter or to a section in a chapter
directly. If a section uses an unfamiliar topic, you need to visit that topic
before continuing the current one.
 If you are reading this book to get a certification in the Java
programming language, you need to read almost all of the chapters,
paying attention to all the detailed descriptions and rules. Most of the
certification programs test your fundamental knowledge of the
language, not the advanced knowledge. You need to read only those
topics that are part of your certification test. Compiling and running
over 290 complete Java programs will help you prepare for your
certification.
If you are a student who is attending a class on the Java
programming language, you need to read the first ten chapters of this
book thoroughly. These chapters cover the basics of the Java
programming language in detail. You cannot do well in a Java class
unless you first master the basics. After covering the basics, you need to
read only those chapters that are covered in your class syllabus. I am
sure you, as a Java student, do not need to read the entire book page by
page.

How to Use This Book

This book is the beginning, not the end, for you to gain the knowledge
of the Java programming language. If you are reading this book, it
means you are heading in the right direction to learn the Java
programming language that will enable you to excel in your academic
and professional career. However, there is always a higher goal for you
to achieve, and you must constantly work harder to achieve it. The
following quotations from some great thinkers may help you
understand the importance of working hard and constantly looking for
knowledge with both your eyes and mind open.
The learning and knowledge that we have, is, at the most, but little
compared with that of which we are ignorant.
—Plato

True knowledge exists in knowing that you know nothing. And in

knowing that you know nothing, that makes you the smartest of
all.
—Socrates
 Readers are advised to use the API documentation for the Java
programming language, as much as possible, while using this book. The
Java API documentation is the place where you will find a complete list
of documentation for everything available in the Java class library. You
can download (or view) the Java API documentation from the official
website of Oracle Corporation at www.oracle.com. While you read
this book, you need to practice writing Java programs yourself. You can
also practice by tweaking the programs provided in the book. It does
not help much in your learning process if you just read this book and do
not practice by writing your own programs. Remember that “practice
makes perfect,” which is also true in learning how to program in Java.

Source Code
Source code for this book can be accessed by clicking the Download
Source Code button located at
www.apress.com/us/book/9781484273067.
Any source code or other supplementary material referenced by the
author in this book is available to readers on GitHub via the book’s
product page, located at www.apress.com/9781484273067. For
more detailed information, please visit
http://www.apress.com/source-code.
Acknowledgments
I would like to thank my family members and friends for their
encouragement and support: my mom, Pratima Devi; my elder
brothers, Janki Sharan and Dr. Sita Sharan; my nephews, Gaurav and
Saurav; my sister, Ratna; my friends Karthikeya Venkatesan, Rahul
Nagpal, Ravi Datla, Mahbub Choudhury, and Richard Castillo; and many
more friends not mentioned here.
My wife, Ellen, was always patient when I spent long hours at my
computer desk working on this book. I want to thank her for all of her
support in writing this book.
My special thanks to my friend Preethi Vasudev for offering her
valuable time for providing solutions to the exercises in this book. She
likes programming challenges—particularly Google Code Jam. I bet she
enjoyed solving the exercises in each chapter of this book.
My sincere thanks are due to the wonderful team at Apress for their
support during the publication of this book. Thanks to Mark Powers,
Editorial Operations Manager, for providing excellent support. Last but
not least, my sincere thanks to Steve Anglin, Lead Editor at Apress, for
taking the initiative for the publication of this book.

—Kishori Sharan
Table of Contents
Chapter 1:​Programming Concepts
What Is Programming?​
Components of a Programming Language
Programming Paradigms
Imperative Paradigm
Procedural Paradigm
Declarative Paradigm
Functional Paradigm
Logic Paradigm
Object-Oriented Paradigm
What Is Java?​
The Object-Oriented Paradigm and Java
Abstraction
Encapsulation and Information Hiding
Inheritance
Polymorphism
Summary
Chapter 2:​Setting Up the Environment
System Requirements
Installing JDK 17
The JDK Directory Structure
Verifying the JDK Installation
Starting the JShell Tool
Installing NetBeans 12
Configuring NetBeans
 Summary
Chapter 3:​Writing Java Programs
The Goal Statement
Using the JShell Tool
What Is a Java Program?​
Writing the Source Code
Writing Comments
Declaring a Module
Declaring Types
Package Declaration
Import Declarations
Class Declaration
Types Have Two Names
Compiling the Source Code
Packaging the Compiled Code
Running a Java Program
Playing with Module Options
Listing Observable Modules
Limiting the Observable Modules
Describing a Module
Printing Module Resolution Details
Dry-Running Your Program
Enhancing a Module Descriptor
Running Java Programs in Legacy Mode
Duplicate Modules on a Module Path
Syntax for Command-Line Options
Other documents randomly have
different content
the respiratory movements and was regarded by Sir George
Humphry, who tested for it by estimating the elasticity perceived
when gentle pressure is exerted on the lower part of the sternum, as
a bad omen for the future.
The teeth are usually, but not invariably, few in the aged, for
care or lack of it, the accumulated effect of long-continued
mechanical injuries, altered calcium metabolism, and diminished
resistance to infection will necessarily influence the amount of decay.
Statistics, especially Humphry’s, show that in extreme old age very
few teeth are present, and it is tempting to correlate the diminished
provision for mastication with the lessened need for food. Sir Isaac
Newton, however, at the age of 85 was said to have lost one tooth
only. The numerous reputed instances of a third dentition can be
explained only by the appearance of a previously buried tooth
through the atrophying gums, for a genuine third dentition would
necessitate the presence of dental germs which do not exist.
The gastro-intestinal tract shows atrophy of the muscular coat
and its secreting glands, so that dilatation of the thin-walled, pale
stomach and colon occur on less provocation than in adult life and
digestion is impaired; from lack of mucous secretion combined with
loss of motor vigour constipation is common. It may be added that
hypertrophy of the prostate by interfering with peristalsis of the
151
colon has been thought to cause gerontal constipation (Hollis ).
The pancreas shows fibrotic atrophy and becomes smaller and
harder. From the loss of fat and muscular atrophy visceroptosis is
not uncommon.
The liver diminishes in size and weight by about one half;
atrophy of considerable areas may expose the vessels and ducts on
the surface of the organ. Boyd’s tables show a difference of 18 oz.
between the weights in persons in the decade 20–30 and in those
over 80. Microscopically atrophy of the lobules and of the cells in the
152
centres of the lobules have been described (Luciani ), but the
latter change is not constant, for in a woman of 93 Salimbeni and
153
Gery definitely noted that the cells were not atrophied. That such
atrophy of the liver cells is pathological is perhaps supported by D.
154
Symmers’s observation that in the pancreas of such cases the
islands of Langerhans may show moderate enlargement, as if to
compensate for failure of the glycogenic function of the liver.
Pigmentation of the cells by a lipochrome is excessive, and the name
brown atrophy has been applied to the condition which is seen in the
other viscera of the old.
The lungs become smaller, lighter, and the elastic tissue
degenerates; this is atrophous emphysema, and the chest capacity
155
diminishes. Roussy and Leroux found that these lungs commonly
show endarteritis obliterans and fibrosis, conditions which favour
infarction, infection, and the terminal bronchopneumonia to which
the aged are so prone.
156
The voluntary muscles, according to Durante, contain many
157
fibres with large globules of fat; but Jewesbury and Topley, who
describe coarse fat globules mingled with brown pigment in the
immediate neighbourhood of the muscle nuclei in 50 per cent of
cases of various kinds, and almost constantly in old subjects, regard
this condition as independent of true fatty degeneration, and are
doubtful if it has any pathological significance. Excessive fatty and
fibrotic change is found in cases of senile paraplegia without any
lesion in the spinal cord or brain.
Heart.—Some difference of opinion exists as to the condition of
158
the heart; Parkes Weber says that the only true senile change is
diminution in size and weight; this as it is worded is no doubt
correct; but pure atrophy is less rare in the heart than in most parts
159
of the senile body. Charcot indeed stated that it does not atrophy
in old age, but preserves the dimensions of middle life. The heart
may even hypertrophy in old people; this is pathological;
160
Councilman found it in 248, or 43 per cent, of 580 persons over
60 years of age, and could not refer it to aortic or renal
arteriosclerosis or to the diminished capillary area in the skin; but
the average blood pressure 158 systolic/88 diastolic of the cases
with cardiac hypertrophy was higher than that 130/78 of the others.
Fatty degeneration of the myocardium is very frequent; Charcot
stated that at the Salpêtrière it was almost constant in old women,
but according to Councilman there is no clear evidence that it
produces permanent injury or functional insufficiency; he noted
some fibrosis in 15 per cent of his cases. Atrophy of the epicardial
fat—serous atrophy—is common, and increase of the so-called
lipochrome pigment in the muscular fibres which become smaller
and fewer—brown atrophy—is frequent as it is in the other organs in
old age.
Chronic valvulitis and subendocardial fibrosis are, like
arteriosclerosis, common morbid changes.
Arteriosclerosis, contrary to what has been stated by Huchard
and others, is not constant in a considerable degree in old people,
and therefore cannot, as Demange and others considered, be
regarded as the cause of the atrophic changes seen in old age.
Arteriosclerosis is due to several factors, namely, infection and
intoxication of various kinds and to damage caused by long-
continued high arterial blood pressure. The primary changes are
degeneration and weakness, however brought about, in the middle
161
coat. Ophülz has recently discussed the question whether the
degeneration is entirely or largely a senile change; if it were so, the
curve of the incidence of arterial sclerosis would begin gradually
about the age of 40 years, so as to include premature cases, and
rise slowly until the age of 55 years, when there would be a sudden
increase to 80 or 90 per cent, and at the age of 70 it would be
improbable that any one would be free from well-marked
arteriosclerosis. He found that the curve of incidence was very
different from this; beginning much earlier its rise is gradual all the
way without any sudden increase, and indeed seems, if anything, to
be retarded by old age. Old persons may have practically healthy
arteries, so, although arteriosclerosis may undoubtedly produce
atrophy and senile changes in the tissues and organs by diminishing
the blood supply, for example in the case of the red granular kidney,
it cannot be regarded as the causal factor in healthy old age.
The primary calcification of the middle coat, sometimes called
Mönckeberg’s sclerosis, which leads to the formation of regular rings
in the degenerated muscular media and the “pipe-stem” arteries
associated with senile gangrene, may be independent of, or
combined with, endarterial sclerosis. It follows fatty degeneration of
the media, which is the commonest form of medial degeneration in
162
the aged, and specially picks out the elastic fibres. The femoral,
tibial, radial arteries and the aorta are most often affected. It is
difficult to estimate its incidence, but that it is not very common, at
any rate in a high degree, seems probable from the comparative
infrequency of its detection in x-ray examinations of the lower limbs
in old people. It would be natural to associate its occurrence with
the rarefaction of bone that goes on in advanced life, and so to
consider it as in some respects different from the secondary
calcification in endarteritic sclerosis; in answer to an enquiry
Professor W. T. Councilman of Harvard kindly wrote to me that he
did not regard calcification as characteristic of any particular type of
arterial disease, lime salts being in certain cases more easily
deposited in any pre-existing lesions. Klotz describes fatty and
calcareous change in the middle third of the media of the aorta as
quite characteristic of senescence.
Cazalis’s famous aphorism “man is as old as his arteries” is true
in so far that the state of the arteries is a good index of the general
condition, for they are extremely prone to suffer as the result of
infection, toxaemia, and strain; strictly speaking, therefore, the state
of the arteries is not so much an index of the individual’s age as of
his adventures.
Phlebosclerosis, analogous to arteriosclerosis, is common, and
dilatation, often due to stagnation and lack of the normal vis a tergo,
of the veins is a familiar change in the aged.
The capillary area is diminished in the skin and elsewhere, but
not uncommonly there are dilated venules or angiomas on the skin;
the latter, commoner on the trunk and upper limbs and in men, were
formerly known as “de Morgan’s spots” and were thought to
accompany cancer, but the association is only due to a rough
correspondence of their age incidence.
The blood of healthy octogenarians may not show any departure
from that of the earlier periods of life as regards the number of the
163
reds and the amount of haemoglobin (Hansen ), though some
have described a secondary anaemia. Thus in a female centenarian
164
Macnaughton found slight secondary anaemia with a normal
number of leucocytes, the differential count showing a relative
lymphocytosis. The red bone marrow diminishes, its place being
taken by fat cells.
The lymphoid tissues undergo atrophy all over the body
including the leucoblastic bone marrow, but though it does not
appear that the blood shows any definite change in the leucocyte
count it is tempting to correlate the diminution of resistance to acute
infections, such as pneumonia and erysipelas, with the atrophy of
the lymphoid tissue. The alimentary canal often shows lymphoid
atrophy in a high degree, but two normal Peyer’s patches were
165
present in a man reputed to be 106 years old (G. Rolleston ).
The spleen, in common with the lymphoid tissues elsewhere,
shows atrophy, sometimes to an extreme degree, so that instead of
the normal weight of 7 oz. it weighs a few drams only. The capsule
is thrown into folds, and is somewhat opaque; from atrophy of the
pulp and Malpighian corpuscles the vessels and fibrous trabeculae
become prominent. The thymus, contrary to the general opinion that
it undergoes involution long before puberty, has been found by
166
Hammar to increase in size up to puberty when involution begins,
but proceeds so gradually that even in old age it is functional.
The thyroid, unless there is cystic change, is smaller than
natural; thus out of 40 thyroid glands from individuals between the
ages of six months and 77 years the smallest was in a woman aged
167
77 (Hale-White ). In colour it is darkish brown and on section
rather dry. Dr. Donaldson, Lecturer on Pathology at St. George’s
Hospital, has specially examined 19 thyroid glands from patients
between the ages of 57 and 93; of these five showed cystic change;
they all showed increase in the amount of fibrous tissue which was
progressive with age, and in the absence of cystic change the size of
the vesicles and amount of colloid material were diminished.
The Parathyroids.—From examination of a number of specimens
Dr. Donaldson finds that in old people the parathyroids appear to be
free from retrogressive changes, but he cautiously requires further
experience before concluding that this is the rule.
The adrenals show involutionary atrophy in common with the
body as a whole, but sometimes the cortex is enlarged from excess
of lipoids, usually associated with considerable atheroma, and may
also show adenomas. As the increase in size of the adrenals is
cortical its relation to high blood pressure, if any, is that of a remote
result, namely from arteriosclerosis, and not causal as has been
168
suggested. According to G. M. Findlay the amount of lipochrome
in the cells of the adrenals increases with advancing years and is
accompanied by the appearance of melanin in their nuclei.
169
The kidneys show definite atrophy, and Councilman, who has
recently made a study of them in 580 persons over 60 years of age,
calls the condition chronic atrophic nephropathy. The fat in the renal
pelvis is more obvious than usual, the capsules are slightly thickened
and occasionally but by no means always adherent, the surface
finely rough and sometimes showing small cysts, but the large and
irregular depressions characteristic of a granular kidney are not
common. There are, however, areas of fibrosis, and the cortex and
medulla are equally atrophied. Microscopically some glomeruli are
fibroid, others smaller than natural. In three-fourths of his cases the
renal vessels showed arteriosclerosis due to primary atrophy of the
media with compensatory hypertrophy of the intima; but Councilman
gives reasons for hesitation in accepting the obvious conclusion that
the senile kidney is the result of the vascular change.
 The prostate shows some degrees of enlargement after the age
of fifty in the vast majority of men, but in only a percentage of these
170
are there symptoms referable to it. Kenneth Walker finds that the
maximum size is reached at the age of 60 and that from then
onwards there is a slow diminution in size; among 340 men between
80 and 90 there were 11, or 3·2 per cent, and among 92 men
between 90 and 100 one only with hypertrophy of the prostate
(Humphry). The causation of prostatic hypertrophy has been much
171
discussed; that its association with arteriosclerosis (Launois ) is
anything more than a coincidence, the two conditions being common
in the later years of life, seems improbable; Walker found the two
associated in 10 per cent, and he regards the change as part of a
general enlargement and thickening of the peri-urethral, sub-
cervical, and sub-trigonal glands, and, as the interstitial cells in the
testes become fewer and degenerated, he considers that the
prostatic enlargement is possibly a degeneration connected with a
172
disturbance of the endocrine balance. Nemenow argued that
prostatic enlargement was due to proliferation of the interstitial cells
following senile atrophy of the seminal tubules of the testes, but K.
Walker found that in prostatic enlargement the interstitial cells are
diminished rather than increased in number. An interesting parallel
has been drawn between the involutionary changes in the mamma
and the prostate, and it is probable that the same underlying factor
173
is at work in both (Walker, Paul). Hertoghe regarded some cases
of prostatic hypertrophy as due to senile dysthyroidism, and recently
benefit has been reported from thyroid medication and also from
prostatic extract. Dr. Leonard Williams has told me of cases, as yet
unpublished, showing well-marked relief of symptoms and
diminution in the size of prostatic enlargement after doses of thyroid
extract (½ grain once) and colloidal iodine (one dram three times)
daily. The prostatic plexus of veins is often enlarged and may contain
phleboliths.
The testes become smaller, softer, and commonly show some
atrophy of the tubules with disappearance of the epithelial lining and
thickening of the basement membrane; but the testes of old men
may be free from any such change and the spermatozoa in the
vesiculae seminales may be active. According to K. Walker the
interstitial cells gradually diminish in number from the age of 30, but
174
they may be present in men over 80, and Mott remarks that their
persistence may account for an increased and perverted sexual
appetite, due to stimulation of the desire without the power to
perform the sexual act.
The penis becomes smaller, often retracted, the glans harder,
and the scrotum smaller.
The ovaries become shrivelled and fibrotic; the ova disappear or
small cysts may form. It is difficult to find statements about the
presence or absence of interstitial cells in the senile ovary. Professor
Turnbull has kindly informed me that in old women an occasional cell
which might be, but is not certainly, an interstitial cell is visible, and
that if they are interstitial cells their number must be small and their
development poor.
The uterus becomes small, its cavity round, and the cervical
canal may be obliterated. The external genitals atrophy.
The mamma in women shows involution changes and when
175
excessive (cystic disease) these may, as Paul has pointed out, be
compared with prostatic enlargement in the male.
 VII

PHYSIOLOGY OF OLD AGE

The basis of the physiology of old age is progressive diminution

in functional activity, which corresponds to the characteristic
structural atrophy of the organs and tissues. Thus the lowered
functional activity of its glands is manifest in the dry skin; according
176
to Haneborg there is usually a fall in the percentage of
177
hydrochloric acid in the gastric juice, though Bell disputes this.
The lessened amount of mucus from the intestine probably plays
some part in the tendency to constipation. Other evidences of
lowered metabolic rate are seen in the diminished efficiency of the
178
acid-base equilibrium (MacNider ) and the increased degree of
urea-nitrogen in the blood, as shown in 50 per cent of 41 persons
179
between 70 and 88 years of age examined by Rappleye.
Temperature.—Before the era of the clinical thermometer it was
supposed that the body temperature of the aged was below normal.
This belief was part of the ancient view that the cause of old age
was exhaustion by the natural heat of the radical moisture which,
like lamp oil, supported the innate heat and with the passage of
years could not be supplied as perfectly as before; as a result of this
loss of radical moisture the body was thought gradually to dry and
180
cool. But it is now known that the internal temperature is almost
constant at all ages, and Charcot proved that the only real difference
is that the axillary is lower than the rectal reading; this is due to the
diminished vascularity of the skin and to the corresponding fall in the
loss of heat, which again may be correlated with the lower metabolic
181
rate of old age. Aub and Dubois’ observations on six men
between 77 and 83 years of age, mainly with arteriosclerosis,
granular kidney, and emphysema, showed that the basal metabolism
was 12 per cent below the average for men between 20 and 50.
Blunting of sensibility to pain is a beneficent process, suggesting
that with the gradual process of involution and approach to a
physiological death the need for the warning normally conveyed by
symptoms is no longer needed. This is connected with the
simultaneous atrophy of the nervous tissues which look after the
conduction, perception, and reference of pain. The latency of
disease, as shown by an absence of the characteristic symptoms
observed in earlier adult life, is often remarkable in the aged. Thus
death may occur suddenly from extensive but entirely unsuspected
pneumonia; the passage of biliary or urinary calculi may be
unaccompanied by the violent colic of these events in ordinary
cases, and extensive malignant disease may exist without any
definite localizing discomfort. This failure in the power to react is
also shown in fevers and infections (vide p. 142).
Cutaneous sensation is little affected, and indeed the aged are
very sensitive to cold. Taste and smell are impaired, and presbyopia
is due to changes in the crystalline lens. The pupils are contracted
and the iris sluggish. From weakness of the orbicularis palpebrarum
muscle ectropion and epiphora may noticeably change the facial
appearance. With advancing years hearing commonly becomes less
acute from various causes, and after 60 there is a successive
decrease in the number of persons with normal hearing. According
182
to Albert Gray there is probably a characteristic form of deafness
for the higher notes of Galton’s whistle in all old people, even when
for all practical purposes there is no obvious defect or tinnitus; this
he regards as due to progressive atrophy of the ligamentum spirale.
Chronic progressive labyrinthine deafness, due to atrophy of the
auditory nerve and fibrosis of the ductus cochleariae, is the most
common condition in persons over 60. Fixation of the stapes
frequently causes deafness, and the sequels of middle-ear disease
accumulate with advancing years. Gouty eczema of the external
auditory meatus and collections of wax may seriously interfere with
hearing. Tinnitus in the elderly is commonly associated with high
blood pressure and arteriosclerosis.
Appetite for food is sometimes capricious; old people may eat
excessively, possibly because the pleasures of the table are the only
ones to which they feel equal.
Muscular movement is slow and somewhat uncertain, and the
reflexes are diminished except in the presence of sclerosis of the
spinal cord. According to Moebius the knee-jerk is often absent in
normal old persons, but Sternberg, by employing methods of
reinforcement not available in Moebius’ time, found that it was
invariably present even in the tenth decade.
The sleep of the aged is less continuous, and from interruptions
often appears to them to be much less than it really is. There is
often a tendency to irregularity, bad and good nights alternating. But
too much attention to disturbed sleep in the aged must be avoided,
as hypnotics are inadvisable, and it has been urged by Sir Hermann
Weber and others that too much sleep is more harmful than too
little.
In old age the mental condition varies in different individuals
according to their previous character and their present physical
state. Freedom from sexual and other perturbations often renders
the minds of old people calm, tolerant, less susceptible to
disappointed ambition, and philosophic when the part of spectator
has been accepted in place of that of actor in life’s drama. In what
may be regarded as normal old age psychical activity diminishes; not
only do initiative, elasticity, and originality fail, but new ideas and
fresh lines of thought are assimilated with difficulty; hence the old
are commonly conservative and laudatores temporis acti. Mental
fatigue occurs more readily and the power of concentration and
attention is impaired so that the old may appear deaf; the mind
begins to show disintegration and a return to the primitive condition
in which each act demands individual care; it has indeed been said
that old age is nothing but progressive fatigue. A less agile memory
for names is commonly one of the early symptoms of senescence,
and long precedes the characteristic loss of memory for recent
events while that for the remote past remains, as if the nerve cells
were photographic plates which in course of time have all become
occupied with impressions. With commencing failure of memory
there is often a tendency to make the same remark or tell the same
story repeatedly, to mislay things, and unconsciously to become
careless about personal appearance and habits. As a kind of protest
against the inevitable there may, in the early stage of old age, be a
tendency to ape the young and to conceal the true age; thus a man
may remove the date of his birth from Who’s Who and books of
reference, and a mother may delay the “coming-out” of her
daughter. On the other hand, at a later stage there may be the
opposite desire to appear a wonderful prodigy of senescence. The
old are notoriously less subject to feel the loss of relatives and
friends by death; they become more self-centred; this may be
because retirement from active work switches their minds on to their
own feelings, and possibly in part depends on loss of touch with the
external world, resulting from failure of the sense organs. This when
exaggerated develops into selfish dependence and demands on
183
relatives. Senile vanity is not uncommon, and Eden Phillpotts
remarks that all old people love to be in the centre of the stage, one
of the pathetic things in life being that they are seldom allowed to
be there. The ego-centric frame of mind may lead to
hypochondriasis with fads and meticulous attention to details of
personal health and to experiments in diet and patent medicines.
Loss of control, due to failure of the higher centres, engenders
restlessness, garrulity, emotional weakness, and peevishness. There
may be considerable variation in the moods, so that the deep
depression of one day may vanish the next, and irritability and
apathy may alternate.
Regression, which closely corresponds to the “devolution” of
Hughlings Jackson, who argued that in disease the organism tends
to retrace the steps of its development, accounts for the phenomena
of “the second childhood.” Thus the old are prone to nervous
apprehension, and liable to suggestion and to hysteria which
184
Rivers defined as a protective mechanism representing a
recrudescence of the reaction to danger in an early stage of animal
development. Will power, like their gait, becomes hesitant and
uncertain. This devolutionary change progresses partially and not
universally; memory for personal names, as mentioned above, is
often the first to fail, because, like the mathematical faculty, it has
from the attendant difficulty a high place in the order of mental
processes; hence forgetfulness of personal names is a criterion of
185
psychical fatigue and neurasthenia (Dupuis ).
In old animals it is natural for the instinct of self-preservation to
fade, as is exemplified in the day-flies which in their larval stage are
well endowed with this property, and as their end draws near
animals seem to acquire an instinct for death comparable to that for
sleep. But in human beings, although they usually dislike old age,
186
there is generally what Matthew Arnold called “a passionate,
absorbing, almost bloodthirsty clinging to life.” Metchnikoff specially
investigated this point and found hardly any instances in which
death was anticipated with the same feelings of pleasure as is sleep
by the weary. Considering the discomforts of many old people it is
rather remarkable how very seldom they endorse the words of the
burial service: “We give thee hearty thanks for that it hath pleased
thee to deliver this our brother out of the miseries of this sinful
world.” Various explanations have been offered for this want of
harmony between the mental and physical states of the old; it has
been ascribed to the idea of eternal punishment, and to the
presence of pathological conditions which bring on senility and death
prematurely and thus alter what should be the normal mental
attitude of healthy old age. In speaking of the usual fear of death in
old people it should be mentioned that shortly before death this
187 188
commonly disappears and, as G. E. Day, R. W. Mackenna, and
Thompson and Todd point out, the aged when seriously ill commonly
regard death as a welcome release; the famous William Hunter’s last
words in his sixty-fifth year expressed his sense of resignation: “If I
had strength enough to hold a pen, I would write how easy and
pleasant a thing it is to die.”
The Cardio-Vascular System.—The pulse rate is usually rather
increased in frequency as compared with that in adult life; extra-
systoles are so common in persons who appear otherwise normal
that they cannot be regarded as having any important significance.
Among Sir George Humphry’s collection of 824 persons over 80
years of age one-fifth had an irregular or intermittent pulse.
Although, like arteriosclerosis, a well-marked high blood pressure
without evidence of renal disease, to which Sir Clifford Allbutt has
given the name of senile plethora or hyperpiesia, is common in the
decline of life, it is a pathological and not a physiological change;
and a distinction must be drawn between the gradually rising blood
pressure seen from birth onwards and an increase above that normal
to an arterio-vascular system that has been active for over half a
century. In the same way the venous pressure increases with age
189
(Hooker ). That a definitely high blood pressure in the aged is
pathological appears to be shown by observations quoted by
Councilman from the Peter Bent Brigham Hospital, Boston; among
94 patients (male and female) averaging 66 years of age, 44 per
cent with cardiac hypertrophy as shown by necropsy, had an average
blood pressure of 158 systolic / 88 diastolic, whereas the 56 per cent
without cardiac hypertrophy had an average blood pressure of
130/78. In both series the differences between males and females
were never more than 7 mm. Hg. From observation of 102 Chelsea
pensioners over 75 years of age Thompson and Todd found that the
average blood pressure was 145 systolic / 80 diastolic, estimations
varying from 190/100 to 115/70, and that the average pulse
pressure, or difference between the systolic and diastolic pressures,
was 67 mm. They came to the conclusion that it was not possible to
arrive at a normal blood pressure for old people on account of the
190
varying conditions of the heart and arteries.
 The urine, in consequence of the lowered metabolism and
general atrophy, is somewhat diminished in quantity with a fall in the
solids, though the specific gravity remains about normal. The
chlorides are stated to be normal and the phosphates and urea to be
diminished. Slight glycosuria as a result of a low sugar tolerance
191
(vide Spence ) is not uncommon, especially in obesity. Prolonged
confinement to bed has been thought to be responsible for casts in
the urine. A trace of albumin is not rare; this may be due to various
factors, and in itself is not a cause for anxiety; but a well-marked fall
in the specific gravity is a sign of renal inadequacy which may be
preceded and anticipated by the discovery of nitrogen retention in
the blood.
Sexual activity in man wanes generally speaking after 50, but
there are great variations in this respect, and sometimes there are
periods of considerable excitement in old men, often thought to be
associated with prostatic enlargement.
It would naturally be expected that wounds and fractures of
bones would heal more slowly in the old than in the young, and,
192
according to Carrel and Ebeling, the cicatrization of human
wounds varies inversely, if accurately measured, with the age of the
patient; Humphry, however, found that, provided sloughing did not
occur, wounds and ulcers in the aged heal as quickly as in middle
life, and that the failure of union in intracapsular fracture of the neck
of the femur is due to want of apposition and not to the age of the
patient.
In some respects the reaction to drugs in the senescent body is
different from that in ordinary adult life. In old people absorption
from the alimentary canal is slow and this is particularly so with
gelatin-coated pills and drugs, such as cinchona, containing tannin,
which should therefore be avoided. The physiological response to
drugs is slower and more prolonged than in early life, so that for this
reason and from the frequency of constipation an accumulated
action is thought to be more likely to occur in the aged. It is
sometimes said that large doses are not borne well by the old and
 193
that morphine is dangerous as it is in infants, but Nascher states
that if, in order to obviate the paralysing effect of morphine on a
weakened respiratory centre, atropine is given before the morphine
so that their action can be timed to coincide, instead of giving them
at the same time when the effect of the atropine comes later,
morphine can be given in the same doses as in maturity. Purgatives
may be required in larger doses than in ordinary practice. According
194
to Leonard Williams bromides are likely to produce mental
confusion in old people and if persisted in, even in ordinary doses,
may be followed by vascular thrombosis and permanent impairment
of the intellectual powers. Sedatives and hypnotics when necessary
should be given in small doses and discontinued as soon as possible;
but they may be necessary for restlessness which would otherwise
seriously exhaust the failing strength.
 VIII

THE DESCRIPTION OF OLD AGE IN THE

TWELFTH CHAPTER OF ECCLESIASTES

When first approaching the subject of old age every one must
recall the famous description in the first six verses of the twelfth
chapter of Ecclesiastes beginning “Remember now thy Creator in the
days of thy youth while the evil days come not, nor the years draw
nigh when thou shalt say I have no pleasure in them.” Formerly
ascribed to King Solomon (977 B.C.) the book of Ecclesiastes (in
Hebrew Koheleth = the preacher) has been shown by the higher
criticism to date only from the end of the third century B.C., and from
internal evidence, namely references to the brain, spinal cord, and
other anatomical structures, though expressed with poetic imagery,
it may fairly be assumed that a medical man was concerned with its
195
construction. In his attractive work, A Gentle Cynic, the late
Professor Morris Jastrow, jun., of Philadelphia explained that the
book of Ecclesiastes as it appears in the authorized version, consists
of (i.) the original, cynical, but good-natured obiter dicta of the
unknown dilettante who preferred to veil his identity under the name
of Koheleth, and (ii.) additions and modifications made by various
hands to render it more orthodox and compatible with the tradition
that it was written by Solomon; thus the admonition “of making
books there is no end and much study is a weariness of the flesh”
may very probably have been intended as a hint that Koheleth’s
views should not be taken too seriously. Following this conception
Jastrow reconstructed the text of the book of Ecclesiastes to what he
argued was its original form, and compared it with the more modern
writings of Omar Kháyyám and Heinrich Heine. As we all must have
speculated over the correct interpretation of the various metaphors
in this description of the last stage of life, the explanations offered
196
by others, such as Andreas Laurentius (1599), Master Peter Lowe
197
(1612), founder of the Faculty of Physicians and Surgeons of
198 199
Glasgow, Bishop J. Hall (1633), John Smith (1665), Richard
200
Mead (1775), and Jastrow may be very briefly mentioned. The
second verse, “While the sun, or the light, or the moon, or the stars,
be not darkened, nor the clouds return after the rain,” is regarded by
Laurentius, Lowe, and Hall as referring to the ocular disabilities of
old age, whereas Smith and Mead consider that mental failure and
depression are meant. As regards the third verse, “In the day when
the keepers of the house (the hands) shall tremble, and the strong
men (the legs) shall bow themselves (become bent), and the
grinders (teeth) cease because they are few, and those that look out
of the windows (the eyes) be darkened,” there is general agreement,
Lowe specially designating cataract as meant in the last sentence.
“And the doors shall be shut in the streets,” is regarded as referring
to the mouth by Laurentius and Mead, and to the various orifices
including the results—constipation and dysuria—by Smith; “when the
sound of the grinding is low,” is considered by Jastrow to mean
impaired hearing, and by Smith as a lowered rate of metabolic
processes, such as assimilation, blood formation, and various
secretions. “And he shall rise up at the voice of the bird,” implies,
according to Smith and Mead, the early waking of the elderly; “and
all the daughters of music shall be brought low” signifies to
Laurentius the failure of voice, to Mead deafness, and to Smith all
the organs concerned with sounds, namely the lips, tongue, larynx,
and the auditory apparatus. “Also when they shall be afraid of that
which is high, and fears shall be in the way” is regarded by Smith as
describing the general mental attitude of anxiety for things both
small and great and a bad head for height, but a more modern
commentator suggests that “afraid of that which is high” refers to
dyspnoea on climbing a hill. “And the almond tree shall flourish” is
by Laurentius, Hall, and Smith thought to refer to the white hair or
“churchyard flowers” of the old, but Mead argued that loss of smell
is meant. “And the grasshopper shall be a burden” has been very
variously interpreted: Hall is content to accept the literal meaning
that the least weight is a nuisance; Laurentius and Lowe understand
oedema of the legs; John Smith that the aged body undergoes the
reverse change of shrivelling, hardening, and angularity; Mead
suggests scrotal hernia, and Jastrow, as according to the Talmud the
grasshopper is a symbol for the male sexual organ, considers that
the sentence refers to the loss of sexual activity. In the sixth verse
the words “Or ever the silver cord be loosed,” refers, according to
Laurentius, Lowe, Mead, and Jastrow, to kyphosis, but Smith
translates them into paralysis of the spinal cord and nerves. “Or the
golden bowl be broken,” signifies cardiac failure to Laurentius and
Lowe, but cerebral haemorrhage to Smith, who thus explains the
next line, “or the pitcher (the veins) be broken at the fountain (the
right ventricle), or the wheel (the arterial circulation) broken at the
cistern” (the left ventricle), and therefore concludes that King
Solomon was perfectly acquainted with the circulation of the blood
discovered by William Harvey in 1616. “The pitcher” is regarded as
the vena cava by Laurentius, and as the urinary bladder by Mead
and Jastrow; “the wheel broken at the cistern” suggests the kidneys
and bladder to Laurentius and Lowe, cardiac failure to Mead, and
intestinal and hepatic insufficiency to Jastrow.
 IX

DISTINCTION BETWEEN HEALTHY AND

MORBID OLD AGE

In any individual instance the exact line which separates healthy

old age (senescence) from old age complicated by a morbid process,
i.e. by some factor other than the gradual atrophy and restriction of
functional activity, or senility, may be difficult or impossible to draw.
The dictum of Terence, Cicero, and Sanatorius that old age is a
disease probably still finds acceptance with many. It is indeed clear
that exposures to infections and poisons would produce changes
more easily in cells that are beginning to fail in vitality. Healthy old
age should be a normal process of involution with progressive
atrophy and loss of vitality, and free from any morbid change due to
other factors whether extrinsic, such as infection, or intrinsic and
due to abnormal metabolism. As the bodies of the aged usually
show a number of changes additional to those of normal involution,
some of which, such as arteriosclerosis, are so frequent that they
have sometimes been erroneously regarded as part or even the
cause of old age, it is essential to recognize and to try to draw a
distinction between physiological old age and senility from the
effects of disease (Senium ex morbo). But about the anatomy and
physiology of normal old age much remains to be learnt; more
indeed is known about the pathology of the aged, a subject which
includes the damage done in the past, perhaps in youth, and morbid
processes starting during advanced life.
 In attempting to decide when old age should be regarded as a
disease or merely as a process of involution or retrogression which
naturally follows the earlier and progressive stage (youth) of
development, it may be well to refer to the meaning of “disease”
and “health.” Disease, or want of ease, has been variously defined as
evidence of imperfect function, as discord, and as maladjustment
201
between the individual and his environment (Moon ), and Health
as the indication of perfect functional activity, as harmony between
the individual and his environment. In the different stages of life’s
cycle there should be a correspondence between the individual’s
desires and his powers so that there is harmonious co-ordination;
this should hold good in normal old age as it does in youth.
The frequent complaints of old people show that there is
maladjustment and disease, for if the decline of vitality were uniform
throughout the body the equilibrium would, though altered as a
whole, still be maintained, and there would no longer be a
discordant desire for activity, for which other parts of the body are,
from a more advanced state of atrophy or morbid change, unable.
Thus it would appear that the conscious disabilities of old age are
not the necessary results of a true physiological involution, and that
the late Sir Andrew Clark’s definition of Old Age as “the period at
which a man ceases to adjust himself to his environment” should be
regarded as true of senility or morbid old age but not of senescence
or healthy old age.
The organs of the body do not all start to grow old at the same
time or progress at the same time. That such variations in involution
may be so exaggerated as to become morbid without any very
obvious cause is highly probable, but the latter event is clearly a
departure from the progress of normal old age. The precocious
atrophy of some tissues or organs may be ascribed to several
factors, such as inherent weakness, the effects of overstrain, though
without producing gross changes, or to the influence of a definite
infection or intoxication in the past. Thus deafness may be
hereditary, senile paraplegia has been known to occur in energetic
walkers, and thyroid deficiency may be the outcome of a past attack
of enteric fever. These errors in the chronometry of life, as Sir James
202
Paget termed the different ageing of organs, cannot be regarded
as a physiological process.
 X

DISEASES IN AND OF OLD AGE

Strictly speaking, it cannot be said that there are any diseases

special to length of days, for premature senility shows the changes
and diseases usually correlated with ordinary old age. Inherent want
of vitality and the resulting degenerative atrophy, or Gowers’s
abiotrophy, may imitate the results of prolonged wear and tear of
203
the tissues, and thus it appears that Charcot’s group of diseases
special to old age, namely senile marasmus, senile osteomalacia,
senile atrophy of the brain, senile heart weakness, and
arteriosclerosis, are not confined to senescence. Old age, however, is
prone to the incidence of diseases which are chiefly but not
exclusively seen in the evening of life, such as those due to the
degenerative changes resulting from the accumulated effect of past
infections and from metabolic disturbance. Thus arteriosclerosis,
granular kidney, cardiac failure, cerebral haemorrhage, emphysema,
hepatic cirrhosis, prostatic enlargement, and carcinoma commonly
appear in the sixth decade. In a series of five publications dealing
with the diseases of the age of fifty, which he calls the critical age,
204
Leclercq describes, in addition to some of the above, gout and
paragouty affections, obesity, diabetes, cardio-aortic diseases, and
albuminuria. Old age, moreover, modifies the manifestations and
course of infections, notably of pneumonia and erysipelas. It would
be unnecessary and from reasons of space impossible to refer to all
the diseases that may attack the aged, but a few remarks will be
made about some disorders that appear to call for special notice.
 Senescence has some nosological compensations; thus some
acute infections, such as measles, scarlet fever, enteric fever, and
diphtheria, are very rare, probably because immunity has gradually
been developed in the course of time; pneumonia and erysipelas,
however, are notable exceptions in being specially prone to occur in
the aged. Migraine usually becomes less troublesome or disappears
with the march of years. As mentioned on p. 86, malignant disease
is comparatively rare in very advanced age; lymphadenoma and
leukaemia are rarer than in early life; and as pathological, like
normal, processes are slower, carcinoma, especially of the breast,
may become stationary.
Diseases of the Skin.—From atrophy of the skin and its secretory
glands the skin is less resistant to infection and accordingly has been
thought to be more susceptible to parasitic attack, such as pityriasis
versicolor. The aged who are often less scrupulous in cleanliness
than their juniors are more prone to skin affections, such as eczema,
erythema, and erysipelas. The so-called senile prurigo is largely due
to the presence of lice. From the atrophic condition of the skin the
cutaneous nerves are more exposed, and this has been regarded as
playing a causal part in senile pruritus, which is an exception to the
general rule that sensory impressions are less prominent in the aged
than earlier in life. It may, like prurigo, be due to an external cause,
such as pediculi, or it may be metabolic in origin. In almshouses and
institutions for the aged epidemics of scratching may develop from
imitation of a genuine case of pruritus. Senile pruritus is usually
general and from its obstinate resistance to treatment may be a
terrible affliction. Sir Gilbert Blane (1749–1834) suffered from it for
the last 13 years of his life, and was obliged to take opium in
increasing quantities until his daily dose reached the equivalent of a
dram of the solid drug.
Erysipelas, like pneumonia, with which or with
bronchopneumonia it may be combined, is less obvious in its
symptoms than in ordinary adult life on account of the diminished
power of reaction, as shown by the slight degree of leucocytosis in
the aged in erysipelas (Lamy) and by its longer course. From want of
resistance and arteriosclerosis, especially Mönckeberg’s form with
calcification of the media, senile gangrene may follow slight accident
or injury, such as occurs in cutting the toe nails. Absorption from the
gangrenous area may cause toxic glycosuria, and such cases, when
they come under observation at this stage, are sometimes regarded
as diabetic gangrene. It is remarkable how well amputations for
diabetic gangrene do; in July 1922 I saw with Professor F. H.
Edgeworth a man with double amputation of the legs perfectly
healed, and in good health though the glycosuria persisted.
Herpes zoster, though far from confined to advanced life, has in
the old the unfortunate tendency to leave persistent pain in its site.
Rodent ulcer, although sometimes seen comparatively early in life, is
specially common in advanced years. It often supervenes on the dry
yellow or brown spots (senile keratosis) seen on the face in persons
over 60 years of age.
Vertigo is extremely common in later life and may be due to
various causes; the most frequent form is that of aural origin, such
as labyrinthine or nerve lesions and chronic changes in the middle
ear. Increased blood pressure and cerebral arteriosclerosis are
frequently responsible. Attacks of giddiness may occur in Stokes-
Adams disease or follow exertion in the aged, as if from cerebral
anaemia; and gastric disturbance may apparently also be a
determining factor. In rare instances epilepsy or migraine may be
represented or initiated by vertigo.
Senile tremor, rare under the age of 70, begins in the hands,
especially in that most used, and spreads to the neck and head,
rarely occurring in the lower limbs. It is a slow intention tremor, from
4 to 5 per second, and is distinguished by its relation to movement
from that of paralysis agitans which is continuous but diminished on
muscular contraction. The tremor of the jaw resembles that of
munching food; that of the lips is fine. It is compatible with good
health.
Paralysis agitans, described by James Parkinson, surgeon and
palaeontologist, in 1817 as “the Shaking Palsy,” has now about a
century later been shown, largely as a result of S. A. K. Wilson’s
work, to be one of the forms of the extra-pyramidal symptom
complex and due to degenerative changes in the efferent motor
system of the globus pallidus system. Although juvenile forms occur
and encephalitis lethargica may show the Parkinsonian syndrome,
paralysis agitans is a disease of the early part of the later period of
life, the great majority of the cases beginning between 50 and 70
205
(Gowers ), after which there is a small incidence only. It is twice as
common in males as in females. Though unfortunately, from the
degenerative nature of the lesion, incurable, it is a chronic disease;
206
thus Maclachlan refers to a Chelsea pensioner aged 107 years in
whom it was known to have existed for 47 years.
Vascular lesions, haemorrhage or thrombosis, are the most
important factors in the production of grave nervous disease
between the ages of 50 and 70; among 500 cases of cerebral
haemorrhage 321, or 64 per cent, and of 110 cases of cerebral
thrombosis 67, or 61 per cent, occurred in the sixth and seventh
207
decades (Michell Clarke ). Cerebral haemorrhage increases with
frequency from the fourth decade and the largest number of cases
occur between 50 and 60. From analysis of 154 cases at St.
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Bartholomew’s Hospital F. W. Andrewes found that the apparent
maximum is in the middle of the sixth decade, but that correction for
the age distribution of the population shows that the liability of the
individual to this form of death increases steadily up to old age.
Thrombosis of atheromatous vessels is an accident of later incidence
than cerebral haemorrhage, and thus contrasts with hemiplegia due
to syphilitic endarteritis which occurs about the prime of life.
The physiological involution of the mind and accompanying
organic changes in the brain gradually shade off into senile
dementia. A regression to the mental state of childhood, which
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Dupré called puerilism, may occur in widely different conditions,
such as structural change of the brain, hysteria, and toxaemia. It
may be acute and be transient or come on slowly and be permanent.