illness were, a judicious moderate use of food and wine, and very wise and gentle nursing.

This erysipelas, it may be believed, was part of the effects of the poison of the dead body-an issue of the blood-poisoning. Not such, I think, was a pneumonia with which I suffered twice, and which added greatly to the risk and length of my illness. This was, probably, personal; due only indirectly, if at all, to the poison-due rather to a susceptibility of my lungs to the inflammatory process. For I had had acute pneumonia five times during the eighteen years before this illness. All these attacks occurred after severe over-work, with deficient food and exposure to cold; and the manner in which they have cleared-off, leaving my lungs unimpaired in structure, has made it nearly certain that they were rheumatic or gouty. But, however this may be, the pneumonia, of which one attack commenced only two days after the infection, and the other a week after the disappearance of the erysipelas, must be ascribed to me rather than to the poison. They passed through their usual course, and left my lungs sound again; but I ask your attention to them as an illustration of one of the ways in which a specific disease may be complicated or modified by the personal constitution of the patient. Here was an instance of what one may call a specific poisoning; and one of the first things following it was pneumonia. Associated as this was with evidence of poison in the lymph-glands, it might have been thought pyæmial, or in some way due to the specific poison in the blood. Yet it was only such a pneumonia as I might

have had without having been poisoned, or such as might occur in me in any feverish illness from whatever source.

Keep such facts as this in mind. They show that there is no disease so specific but that its signs may be confused or complicated with the things that are peculiar to the patient. Syphilis is a specific disease as sharply defined as any, but its course and appearance in a scrofulous man and in a gouty one are very different. Vaccination produces a well-marked specific disease; but in one patient it may be followed by inflammation of lymphatics, in another by eczema, in others by various other troubles : but all these are due in only a minor degree to the vaccination; they come out from the personal constitutions of the several patients which are disturbed by the vaccination, as they might have been by anything else producing some slight fever.

This is not a mere question of doctrinal pathology. It is among the first necessities for success in practice that, in the total phenomena of a disease observed in any patient, you should be able to estimate what belongs to the disease and what to the man. A farmer may as well expect success if he sows his fields without regard to their soils or to the weeds that may of themselves' come up in them, as one of us may expect it if we treat diseases without exactly studying the constitutions of those in whom they occur.

6

Thus I have given a sketch of my three months' illness, and some of the thoughts which it suggested to me. But I ought to say that my case showed only one of many forms of disease that may be produced by the poisons of dead bodies. The suppuration of lymph-glands,

which I had many years ago, is another. But besides such as these, you may find cases of trivial local inflammation; of direct and simple erysipelas; of spreading, suppurating, or sloughing inflammation of the cellular tissue of the hand and arm; of pyæmia; and of the fiercest septicemia. And it is remarkable that different effects may be produced by the same poison acting on different persons. Mr. Erichsen mentions a case in which six students were infected by the same body; two had suppuration of the areolar tissue under the pectoral muscles and in the axilla; one was seized with a kind of maniacal delirium; a fourth had typhoid fever; and the other two were seriously though not dangerously indisposed.' I advise you to read-up the subject in his Art and Science of Surgery.' He has given an excellent account of it; and so has Billroth in his and v. Pitha's Handbuch der Chirurgie.'2

1

Sir William Lawrence used to say that he had not known any one recover on whose case more than seven had consulted. Our art has improved. I had the happiness of being attended by ten: Sir Thomas Watson, Dr. Burrows, Sir William Jenner, Dr. Gull, Dr. Andrew, Dr. Gee, Mr. Cæsar Hawkins, Mr. Savory, Mr. Thomas Smith, and Mr. Karkeek. In this multitude of counsellors was safety. The gratitude I owe to them is more than I can tellmore than all the evidences of my esteem can ever prove.

1 Vol. i. p. 151, 5th edit. 1869.

2 Bd. i. Abth. ii. Heft. ii. p. 79; Erlangen 1867.

QUIET NECROSIS.

THE ordinary phenomena attending and following necrosis are well-known and described: the inflammation of all the textures about the dead bone, inflammation attaining an extreme intensity, spreading far, leading to suppuration, and attended with fever as acute as itself. In the midst of local inflammation, and with general feverish disturbance, the exfoliation of the dead bone begins, and usually suppuration continues till the exfoliation is complete and the dead piece is removed.

But all the essential parts of the process of necrosis, the death of the bone and its exfoliation, and the formation of new bone, may take place without any of the attendant phenomena of either inflammation, or fever ; and the cases in which this happens, the cases of ' quiet necrosis' as I would call them, are of great interest in both pathology and diagnosis.

My attention was first fixed on these facts by a case which I communicated to the Clinical Society, and which is published in the Society's Transactions,' vol. iii.

p. 183.

Emma L aged 19, a general servant, was admitted into St. Bartholomew's Hospital under my care, on October 12, 1869. She was well nourished, and muscular, and, except in

being rather pale, looked healthy. Her complaint was of severe pain in the left knee, for which she had been under treatment for a month. Her mother died of heart-disease, her father was rheumatic, she herself had been healthy till this pain in the knee set-in.

The knee-joint was very slightly swollen, with fluid in its cavity, but not hot or tender. What seemed more important was that a hard swelling of which the patient knew nothing nearly surrounded the middle of the shaft of the femur. This swelling felt of nearly oval form, about six inches in length; it was in every part very firm, and tense; hard pressure on it was very painful, especially at its middle part. All the textures of the thigh appeared quite healthy; no part of it felt hotter than another; no veins or lymph-glands were enlarged. The pulse was rather quick; but the breathing and temperature appeared natural; there were no signs of fever or general disturbance, and, but for the pain of her knee, the patient would have thought herself well. She could give no account of the swelling round the femur, except that it might be due to her frequently breaking thick pieces of wood across her thigh.

In the belief that the swelling round the femur was due to periostitis, the patient was directed to remain always in bed, to take three grains of iodide of potassium three times a day, and meat diet; blisters also were to be applied over the swelling often enough to maintain a constant slight inflammation of the skin.

At first some benefit seemed to be derived from the treatment; the swelling became rather less, and was not so tender on pressure. But the improvement was of short duration, and on December 2, the doses of iodide of potassium were increased to six grains, and a fortnight later to nine grains, three times a day. On each of these occasions the pain and swelling were for a few days diminished; but no real advantage was gained, and after being under treatment for three months the condition of the affected parts was almost exactly the same as when the patient was admitted. The pain in the knee had continued with very little change, but the swelling of the joint had sub