\f
*•
THE NEW SYDENHAM SOCIETY,
Instituted MDCCCLVIII.
VOLUME CLXXIII.
^ SELECTED
ESSAYS AND MONOGRAPHS
CHIEFLY FROM
ENGLISH SOURCES,
BBAXTON HICKS; BODINGTON ; HODGKIN;
PAGET: HUMPHRY : EHLERS.
Wai\} ^Mtnarg ^otitc of llje ^onttg's late STuagum-
DR. SEDGWICK SAUNDERS.
o"^
IToniJOH:
THE NEW SYDENHAM SOCIETY,
MDCCCCI.
R
III
CONTENTS.
Prefatory Note . . . . . . . . vii
Dr. Braxton Hicks on Gynecological Subjects. With
Portrait and Memoir ...... 1
Mr. George Bodington on the Treatment and Cure
OF Pulmonary Consumption. With Memoir . 121
Dr. Hodgkin on Disease of the Lymphatic Glands
AND Spleen. With Portrait and Memoir . .159
Sir James Paget on Symmetry and Disease ; on
Disease of the Nipple ; and on Osteitis
Deformans. With five PLaten .... 185
Sir George Humphry on Unilateral Hypertrophy
of the Gums, <^c. . . . . . . 227
Dr. Ehlers on Danish Lazar-houses in thk Middle
Ages. Illustrated 239
A Portrait of Dr. W. Sedgwick Saunders. With
brief Memoir ....... 315
PREFATOEY NOTE
The present volume is somewhat miscellaneous in its
character, and may in some sense be considered to mark
an epoch in the Society's work. It has been decided during
the next five years to devote the Society's funds almost ex-
clusively to the production of a Clinical Atlas of Illustrations
of Disease, and to abstain from undertaking the translation
of any large works, and also almost wholly from the reprinting
of the works of English authors. Under these circumstances
it has been thought well to include in the present volume
reprints of several short monographs by our own countrymen
which have become matters of historical interest. In this
category we place Dr. Hodgkin's original paper on the gland
affection which now bears his name; Mr. George Bodington's
paper on the open-air treatment of phthisis ; three original
papers by Sir James Paget, and a paper by Sir George
Humphry.
The great loss which the Society has this year sustained
in the death of its treasurer. Dr. Sedgwick Saunders, who
had served it in that capacity for more than twenty years
with great zeal, made the occasion appropriate for the pub-
lication of his portrait, together with a brief biography.
The collected papers of Dr. Braxton Hicks, edited and
abbreviated by Dr. Horrocks, will, it is believed, be very
Vlll PREFATORY NOTE.
acceptable to a large section of our members, whilst the
great interest which attaches to the history of the decline
of Leprosy in Europe affords a justification for the pub-
lication of Dr. Ehlers' important Essay. This last has not
been previously printed, and was generously offered to the
Society by its distinguished author.
SELECTED PAPERS
BY
DR. BRAXTON HICKS,
F.R.S., F.R.C.P., &c., &c.
WITH
MEMOIK AND POKTRAIT.
INTRODUCTION.
The late Dr. Braxton Hicks published a great many
papers in various Transactions and Journals, and the New
Sydenham Society having decided to publish a selection
of them, the following four have been selected by Drs.
CULLINGWORTH, HeRMAN and HORROCKS.
No doubt the facts contained in them have long been
incorporated into Medical Literature and are well known
to the Medical Profession. But it was thought that each
paper marked an epoch in Obstetric Science, and that the
four together would represent Dr. Hicks's best work.
The very elaborate and complete Bibliography of his
works, drawn up by Dr. Cullingworth, will no doubt be
found of use to many.
ON
THE CONDITION OF THE UTERUS
IN OBSTRUCTED LABOUR;
AND AN INQUIRY AS TO
WHAT IS INTENDED BY THE TERMS "CESSATION OF LABOUR
PAINS," "POWERLESS LABOUR," and "EXHAUSTION."
It is not without some hesitation that I venture to bring
the following remarks before the profession, not because the
subject upon which it treats is unimportant in a practical
point of view, but on account of the difi&culty of finding a
title which should indicate the principal matters to which I
desire to attract attention, and on account of the ambiguity
which exists in some authors, and of the difference between
others respecting the conditions to be discussed, the same
term varying in value with each author.
Again, it has been felt that the points which I am par-
ticularly anxious to render prominent have been not alto-
gether overlooked by some ; and that while, for the most
part, the text books have been silent or ambiguous, it is
possible that the facts are already recognised and acted upon
by many of the observant.
Notwithstanding these feelings on my part, I have felt that
the whole train of symptoms comprised under the terms
"Cessations of the pains," ''Powerless labour," and "Ex-
haustion," are so variously considered by authors, and the
B
a DR. BRAXTON HICKS ON
whole phenoma not sufficiently apprehended by us in general,
that if any effort could be made to clear up the matter it
would be valuable as establishing our knowledge on a more
definite basis ; and this, with the additional facts which will
be endeavoured to be brought forward, will, it is hoped, render
considerable assistance in guiding us to the management of
the anxious cases classed under the above quoted terms.
If, when it is asked what is meant by " Powerless labour,"
we turn for answer to authors on the subject, we find that
only a few described it, and that these differ essentially.
Thus, referring to the work of our president. Dr. Hall Davis
(' Parturition and its Difficulties,' 1865), we find that he
understands it as "Defective power in the agents of labour,"
and it is clear from his explanation in Chapter I., where he
points out its various causes and treatment, that he intends it
to be understood as irregular and feeble action, but not
brought on by long and intense activity on the part of the
uterus. Again, if we consult Dr. Churchiirs * Midwifery '
(1867), we find a totally different state intended. Here it is a
uterus worn out by long continued exertion, brought into a
state no longer capable of contracting, attended by symptoms
of increasing seriousness, and tending rapidly to collapse.
He confines it to the second stage of labour, whereas Dr. Hall
Davis does not so restrict it, indeed the cause she mentions
would more frequently occur in the, first stage.
Dr. Hodges alludes to it under the head of Exhaustion.
" Labour complicated with Exhaustion " is the title of the
chapter. "In very many instances," he says, "the delivery
of the child cannot be accomplished in consequence of the
want of power in the uterus, or in the general system. The
uterine pains become more and more inefficient, until they
are completely suspended, so that the child and mother perish
without artificial assistance. This constitutes labour with
exhaustion or syncope, the * Powerless labour ' of the British
accoucheur. It is to be distinguished from inertia, or deficient
excitement, by the fact that although there is a want of action
in both cases, yet where there is a loss of power, stimuli have
either no influence over the uterine functions, or such influ-
ences are transient and ineffectual."
THE UTERUS IN OBSTRUCTED LABOUR. 3
And if we turn to the term " Exhaustion," we find great
variety of description.
Some, as Dr. Osborne, look upon it as the flagging of the
vital powers, and the precursor to collapse. Others, as for
instance Dr. Dewees, would look upon it as rather a condition
of inertia of the uterus from previous over-exertion ; not
looking on the state as one of extreme severity, as Dr.
Osborne does.
Dr. David Davis thinks the term much misapplied. He is
doubtful whether dangerous depression ever comes on within
twenty-four hours from mere labour pains. He had never
seen it, although, possibly from some other evils, symptoms
of exhaustion might arise requiring interference.
Wigand, who has perhaps paid as great, if not greater
attention to the abnormal states of the uterine action as any
one writer on the subject, gives a chapter on Feeble Pains,
wherein he uses the term "Atony," "Asthenia," "Adynamia"
of the uterus in the same sense as Dr. Hall Davis does
powerless labour as above quoted ; not so much referring to
it as connected with powerless labour as described by Dr.
Churchill.
I He divides the case into three classes.
In the first two the pains still exist, but are either feeble or
irregular, or with long interval.
In the third they are entirely absent, which he calls either
Lassitudo, Exhaustio, or Paralysis Uteri.
Again, in looking to other works on midwifery, we find that
the serious symptoms called "Exhaustion," by some, and
" Powerless labour," by Dr. Churchill, are considered to
spring from contusions caused by the pressure of the child's
head. Dr. Blundell so considers it ; and it is evident on
perusing his lectures that he attributes all the formidable
symptoms to the injury done to the soft parts by the bruising
and contusion produced by lingering and laborious labour.
Many authors, on the other hand, make no allusion to the
immediate cause of the untoward symptoms, but merely state
the fact generally as the result of laborious labours.
If now we look into the meaning of the term " Cessation
of the labour pains," or " that the pains had ceased," we find
b2
4 DR. BRAXTON HICKS ON
authors, as a rule, express themselves indistinctly as to the
condition of the uterus. Generally we find it said that, the
pains having continued very severe for some time, the uterine
power becoming exhausted, the frequency of the pains de-
creases, and they become feebler gradually, till at last they
cease altogether, and the patient falls into powerless labour,
or into a state of exhaustion. No very distinctive symptoms
are mentioned whereby the temporary passiveness of the
uterus is to be known from that state which leads on to the
more serious state, though an attempt is by some authors
made to explain, that in one case the exertion has exhausted
the muscular power of the woman, while in the other her
vital powers are exhausted.
Dr. Churchill, in discussing the reason why the former kind
occurring in the first stage is slow in running on to serious
mischief, while in the second stage the dangerous symptoms
ariseso much more quickly, professes himself unable satis-
factorily to explain the reason. "It may be," he says, "that
the first stage is more local, the second a more constitutional
process ; that in the latter, different systems of the body
(vascular, nervous, muscular, &c.) are deeply involved."
Dr. Dewees looked upon the subsidence of the pains, after
long continued labour, as the result of the over-exertion of
the uterus, and that in such a case the failure of the pains
was accompanied by the failure of the general strength, as
shown by the symptoms which are described as "Powerless
labour" by Churchill.
Dr. Osborne looked upon the occurrence of these symptoms
as a sign that the vis vitcB is exhausted and greatly reduced,
if not irrecoverably, and points out their danger, and the
necessity for artificial aid.
This is the general tenor of the observation of authors on
the subject. I have been able to find but two Englishmen
who seem to have observed the real condition of the patient
in obstructed labour, Drs. Murphy and Eigby. Dr. Murphy
in his lectures notices the temporary suspension of the
activity of the uterus when any obstacle prevents the exit of
the foetus ; and he describes the return of the pains at first
with short duration and quickly renewed, then with either
THE UTERUS IN OBSTRUCTED LABOUR. 5
increased force, or with a second subsidence, if the obstacle
be insuperable. If they continue with renewed force, " the
pains are very short, extremely severe, and in their interval
the patient still complains of pain and feelings of soreness."
He then proceeds : "If the uterus be examined through the
abdomen, you will observe a very perceptible difference in the
sensation it communicates. It feels almost as hard and con-
tracted during the interval as during the pain ; the patient
cannot bear the abdomen touched. Besides this alteration in
the character of the pains, we have other symptoms, both
local and general, to guide us." He then describes the
symptoms called by Dr. Churchill " Powerless labour." Dr.
Eigby * describes it in nearly similar words.
In Velpeau and Caseaux I find no allusion to the subject.
A short notice on irregular pains is given, and Velpeau alludes
to Wigand's tetanus uteri.
Having thus, as far as I am able to interpret them, briefly
reviewed the opinions of the principal authors on midwifery
in this country, let me proceed to indicate what appears to
me to be the train of symptoms which occur in a case of
labour when, free from any cause of obstruction, the foetus
cannot be expelled from the uterus ; and to indicate the value
to be placed upon these symptoms as a warning of danger,
and as a guide to our conduct in the treatment of these cases
of dystocia.
But before doing so, I think we shall gain a more distinct
appreciation of the value of the symptoms if, as concisely as
possible, we pass in review, from our present standing ground,
the facts which are admitted to exist in process of natural
delivery. And this must be my apology to the Society if in
so doing I seem to introduce mere commonplaces.
Now, the following are taken to be admitted facts, whatever
may be the immediate cause of labour : —
1st. That when the head of the foetus presses against the
OS uteri, reflex irritation is excited, and the uterus contracts
in a rhythmical manner for a certain period, so long as the
labour is proceeding naturally.
2nd. That when the head escapes through the. os, the
* •' System of Midwifery" in 'Lib. of Prac. Med.'
6 DR. BRAXTON HICKS ON
reflex excitement is increased and more powerful uterine
action results.
3rd. That, in addition to the simple uterine action, the re-
spiratory and abdominal muscles are called into play, whereby
a mechanical pressure is exerted on the outside of the uterus,
increasing the effect of its own efforts to expel the foetus.
4th. That as the foetus descends the reflex excitement in
the same proportion increases, acting on the uterus and on
the external musclt^ just referred to, so that when the head
or presenting part has arrived at the vulva the excitement is
at its greatest, which, continuing its effects after the removal
of the foetus and the placenta, keeps up the uterine contrac-
tion, and thus secures the patient from atony and its effects.
Again, I think it will be by all agreed that, however readily
the constitutional effects of the pains pass off when there is a
fair interval between each, yet there is with every one a
demand on the nervous power of the patient.
Consequently it must follow that the more frequently they
occur, the longer they last, and the more violent they become,
the more readily and completely they drain the nervous
power, and the earlier exhaustion arrives.
Perhaps one is likely to overlook the great demand made
on the system by the action of the uterus. But those who
have suffered from tenesmus of rectum or bladder can in a
slight measure appreciate it, by the recollection of the ex-
haustion and depression thus caused. When therefore the
large area of the uterus is considered, and the enormous
power it puts forth,* it will not be so difficult to apprehend the
nervous force consumed by every vigorous contraction. Dur-
ing the interval, however, in natural cases, no doubt the
system is equal to replenish the loss without showing untoward
symptoms to any serious extent in the generality of constitu-
tions ; but women vary much in this particular : some
suffering from exhaustion much more severely than others,
and at a much earlier period. And this does not seem to be
dependent upon the general muscular power, and what is
- See ' Edinburgh Monthly Keview,' August, 1867 : Dr. Mathews
Duncan's paper.
THE UTERUS IN OBSTRUCTED LABOUR. 7
popularly called strength of constitution ; but rather upon
the natural power of endurance evinced in mental exercise,
and shown by fortitude and vigour of character. Be this as
it may, it is notorious that we find a great difference in our
patients as regards their power of endurance of prolonged
demands on their nervous power.
If, then, the above be admitted as facts, it must necessarily
follow, that if instead of the ordinary intermission between
the pains these latter are repeated so closely as to leave
scarcely any interval, more especially if this rapidly recurring
action be continued over a considerable space of time, we
should reasonably anticipate that all the sooner we should
find that the powers of the system would begin to yield.
Still more reasonably should we anticipate the earlier
arrival of serious symptoms, if, instead of the pains being
intermittent, the uterine action became continuous.
Now, if all these points be received, it seems that we have
a very clear explanation of the fact referred to by Dr.
Churchill and others, namely, that symptoms of exhaustion
come on rather in the second stage of labour, i. e. when the
head is in the cavity and at the vulva, than in the first stage,
i. e. while the foetus is wholly in utero.
As a practical fact, we know that reflex action is but slight
before the os uteri is expanded. This is a wise provision of
nature whereby the ovum is allowed to develop itself in and
to distend the " Corpus uteri " without much chance of its
being expelled.
We also know, as a practical fact, that till the head has
entered the os uteri the foetus may remain in utero in actual
labour for some days before serious symptoms arise; and that
during this time the pains are slight, and as a rule infrequent.
But, notwithstanding this slow development of the reflex
function, and the postponement of the evil hour, I think we
are incorrect if we admit that it does not arrive at all, as
would seem implied when restricting " Powerless labour " to
the second stage. It must surely have been by most of us
observed, and that not infrequently, that the same condition
of uterus and of the system has arisen while the foetus is still
in utero. The only difference which I have been able to
8 DR. BRAXTON HICKS ON
notice being that the exhaustion-symptoms are slower in
arriving ; and that the labour is unaccompanied by the
forcing pains which belong to the second stage.
These remarks apply for instance to cases of hydrocephalic
head ; rigid os uteri ; spasmodic states of uterine walls, and
contracted brim where the head cannot at all enter, &c.
As soon as the os uteri has allowed the head to pass
through it, we then find an increase in the pains, and this, as
before stated, is more ^marked the lower the head descends.
This is partly owing to the more numerous supply of nerves
to the part pressed upon, but also partly to this, namely, that
a larger surface of passage is exposed to the irritant the
lower it descends.
A third reason may be found in the fact that the soft parts
with their nerves are subjected to pressure between two
bones. This position at first increases the reflex irritation,
and consequently the uterine contractions. After a time if
detention ensue the system is affected seriously, first by
nervous exhaustion, and secondly by the bruising and slough-
ing of the soft parts thus compressed.
It is difficult to say how much more effect on the system is
produced during labour by the head in the cavity than whilst
it remained in the uterus, but, judging from the average dura-
tion of full labour with injury accruing, it would probably be
about ten to twelve times greater ; and from eighteen to
twenty times as much when the head is impacted at the
outlet.
Supposing the head did not present, but some softer part
as the breech, arm or leg, then the reflex irritation will be
less, and therefore labour will be longer borne than when the
head presents, as is well known to be the case. Besides, there
is scarcely any injury to the maternal structures done by
bruising in these cases, so that the symptoms observable are
chiefly if not entirely owing to the irritation and demand
made on the nervous system.
As above remarked, it would seem as if in the ordinary
intermission of pains in a natural labour, the nervous force,
whatever that may be, is replenished without any serious
demand on the system ; but that when the pains recur closely
THE UTERUS IN OBSTRUCTED LABOUR. 9
and each one is of long duration ; or if they continue for a
longer period than usual, then symptoms of nervous exhaus-
tion are observable in a greater or less degree sooner or later,
according to the demand upon the patient and her power of
supplying it.
And here it may be remarked that, in calculating the
demand made upon the nervous system by uterine exertion,
there is a tendency to gauge it by the exhaustion produced
by exertion of the voluntary muscles ; whereas we should
consider that in a great measure the process of labour is
carried on by the exertion of the largest involuntary muscle
in the body, the supply of whose nerve-force is directly and
principally from the sympathetic system, the great nerve of
relation whereby the general vital powers are immediately
influenced, and impressions made upon the circulation in a
much more rapid manner than by the exercise of the voluntary
muscles.
That this consumption of nerve-force is the cause of the
rise of the pulse, and of the other earlier symptoms indica-
tive of danger, rather than to bruising or injury to the soft
parts, as was held by Blundell,* seems to be shown by the
fact that in the majority of cases of head presentation, when
exhaustion had seriously appeared, no symptom of any such
injury has subsequently shown itself ; and also that in cases,
as before alluded to, where the softer parts of the child pre-
sented, serious symptoms have arisen notwithstanding ; and
again, where delivery has been effected after their superven-
tion, the complete subsidence of untoward symptoms after
delivery without the evidence of any local mischief is, it
would seem, sufficient to show that the removal of the excitor
of reflex irritation is the cause of the improvement ; and
consequently that the prime cause of the trouble was simply
the presence of the foetus.
From the above considerations, then, it seems fair to
assume that the symptoms of so-called "exhaustion" arise
from an unusual irritation of the reflex function, causing a
greater exaltation of the muscular energy, principally of in-
voluntary fibre ; and thus an excessive demand is made on
* See ' Lectures,' sujpra cit.
10 DR. BRAXTON HICKS ON
the nervous power of the sympathetic system. This applies
to the earlier condition of obstructed labour. It is freely
admitted that, later on, when sloughs and other injuries have
arisen with or without foetal putrescence, the symptoms are
materially increased.
It was remarked above that if we found the intermitting
but rapid action of the uterus liable to produce serious
symptoms, we should fairly expect these would the earlier
arise if the pains were continuous.
It is to this point that I now wish to direct attention.
I have constantly found that in those cases of detained
expulsion of the foetus where serious symptoms have already
risen, or have done so subsequently (I mean such symptoms
as have been tending to the powerless labour of Churchill),
and in which cases it is at the same time said that the pains
have gone off, that the uterine contraction has not really gone
off, but that a state of universal continuous action has been
substituted for the ordinary rhythmical pains. The uterus is
really more active than ever, but its action is grasping, not
expulsive ; and in proportion as the true pains die out, so this
continuous action takes its place.
It has already been mentioned that the only authors I have
succeeded in meeting with who have shown this state of
uterus during the intervals of the pains are Drs. Murphy and
Kigby. But they do not describe it as extending beyond
their cessation of the pains ; nor does it appear that they
attribute the serious symptoms to the nervous exhaustion so
produced, but rather to the injury done to the soft parts and
to the inflammation as a consequence.
Wigand in describing the "krampwehen" or spasmodic
pains describes the universal contraction of the uterus under
the name of tetanus uteri. This, it appears to me, he looks
upon as the cause of the detention of the child, and not as
produced by the prolonged irritation of labour. He says,
among other causes for anxiety, we are to fear when the pulse
rises and becomes small and weak. Inasmuch as he classifies
it with irregular action, and partial spasmodic conditions of the
uterus, as a cause of tedious labour, it is clear that he does not
consider it as the precursor and cause of the serious symptoms.
THE UTERUS IN OBSTRUCTED LABOUR. 11
He makes a remark in his chapter on inertia uteris "that
in the highest grade of this condition the pains are totally
absent, except a small constant universal action in some
exceptional cases." These cases, no doubt, belong to the
condition now under consideration.
Those authors who have made a separate section of the
abnormal condition of the uterine pains have pretty closely
followed him.
But I would go further and say that, by whatever cause the
labour be obstructed, whether by contractions, &c., of the
softer parts or of the bony parts, or by the irregular spasmodic
action of the uterus itself, sooner or later the rhythmical
pains merge into the continuous action till the latter remains
alone ; and that when this takes place it is the precursor to
the symptoms of "Powerless labour," "Exhaustion," &c. ; the
period at which this takes place being, of course, influenced
by the susceptibility of the person to reflex excitement
and other circumstances to be mentioned below. That as
soon as this condition of constant action commences those
symptoms gradually commence which have been held as
indicative of the necessity for artificial delivery, such as the
rise of the pulse, dry tongue, hot skin, &c. And I would also
remark that where, after hard labour, these symptoms have
occurred, and the pains have been said to have ceased, we
shall find the uterus in the state of permanent action ; with
the rare exception of those cases where the uterus has
ruptured or violent mental emotion has subjugated its power.
It must not be from this gathered that the supervention
of the serious symptoms is strongly and decidedly marked ;
on the contrary, as is well known, they are generally slow and
insidious in their approach, but, if we watch carefully, the
coincidence of the occurrence of both is not difficult to
observe ; generally speaking, the first symptom is anxiety of
manner and countenance, somewhat similar to that in reten-
tion of urine. There is generally a great anxiety on the part
of the patient to be relieved by operative help. Then the
pulse rises, tongue is creamy and then brown, and then follow
the other well-known symptoms well described by many
authors, and which need not be here repeated.
12 DR. BRAXTON HICKS ON
How long before death the continuous action of the uterus
relaxes it is uncertain. That it continues to the very verge
of dissolution I have seen in a case of arm presentation to
which I was called after nearly a week's labour, and three
attempts to turn. The patient was scarcely able to articulate ;
tongue very brown ; pulse 150 p. m. Even under the influ-
ence of chloroform no change from its excessive rigidity took
place till a few minutes before death ; so hard was it in all
parts that it bore no resemblance to living contracting tissue.
Now, when hard labour pains have existed some time and
we find the rhythmical action has subsided, we have one of
two conditions, the discrimination of which is very important
as a guide to our proper treatment.
The first and simplest form is well known, and is that in
which the uterus is simply quiescent, resting passively for a
time while the nervous power is being, so to speak, collected ;
after a time the uterus begins to act and the labour is accom-
plished. Now, in this case there is no rise of the pulse ;
generally, on the contrary, it is weak and feeble ; nor are
there any untoward symptoms but languor and possibly some
faintness. In these the reflex function is deficient, and its
action sluggish, and, therefore, the demand on the constitution
to supply nerve force is proportionately small.
How can we further distinguish this class ? Place the
hand on the uterus externally, and through the abdominal
walls it will easily be detected that the uterine walls are lax
and flabby, the foetus readily detected within it floating about
with ease.*
So long as this condition lasts it will very rarely be found
that we have any change from the natural condition of the
patient, consequently but little, if any, cause of anxiety, nor
generally for manipulative interference. There may be rare
exceptions, such as already indicated, in which, with a lax
state of the uterus, we have a failing pulse and other serious
symptoms, collapse, &c. ; but I think that when they do occur
they are an indication of some serious lesion having taken
''- Wigand remarks in these cases, " The foetus is very movable in the
uterus."
THE UTERUS IN OBSTRUCTED LABOUR. 13
place, rather than a state of simply nervous exhaustion or
" Powerless labour," so rare is it that one sees a simply
quiescent state of the uterus attended by symptoms of
" Powerless labour."
The second form of subsidence of the pains is, as already
indicated, of the opposite character. The uterus becomes
gradually irritated, so that, although some of the pains still
occur at irregular intervals, the uterus is really in more
action than before, tightly compressing the child, falling into
the inequalities of its form, whereby the foetus is prevented
from escaping, every indentation of the uterus forming as it
were a ledge past which it is difficult to draw the child, or to
pass the hand if we desire to turn.
When this condition, more frequent than generally supposed,
and not infrequent in primiparae, has once been fairly estab-
lished, it is rare that the rhythmical pains ever occur with
such force as to expel the foetus : as a rule, the continuous
action remains, and sooner or later symptoms set in, telling
one of the necessity for interference.
How can we tell that this condition exists ?
It is seldom requisite to do more than examine the state of
the uterus through the abdominal parietes, occasionally it
may be necessary to pass the hand within, past the presenting
part. If we place the hand externally we shall find, during
the intervals, what pains remain, or if they are wholly
absent ; the uterus hard and firm, and tightly moulded to the
form of the foetus, which, unlike that which was before
noticed in the former class, cannot be swayed about, but the
whole mass is more or less fixed. It occasionally happens
that the foetus is rolled up into a globular form, having lost
the ovoid, and this is most common where the child is dead.
In either case the want of mobility on the part of the foetus is
a distinguishing sign of this contracted state of the uterus.
Another sign will also readily help us. If it be the con-
tracted uterus, resonance on percussion will exist up to the
margin of the hard body. If the uterus be lax, then dullness
will extend beyond the hard body.
A proper consideration of these two forms of deficiency of
the rhythmical uterine action enables us to decide upon the
14 DR. BRAXTON HICKS ON
proper mode of treatment with great distinctness, and it will
materially help us also to do so at an early period— earlier,
indeed, than generally has been held possible.
If it is true, as already stated, that when the clamping
continuous action of the uterus has once begun, there is very
rarely any hope that the rhythmical expulsive pains will
again preponderate to such an extent as to expel the foetus at
least unaided ; and as we know that the action of the ergot
of rye is to cause this very action, if it fail to cause expulsive
pains, and to increase it when present, it is clear that the
administration of this drug should be avoided in this state of
affairs. I am not prepared to affirm that it may not, in some
few cases, again rouse the expulsive pains sufficiently to
expel the foetus, but its use must under the circumstances be
attended with a degree of risk such as it seems very undesirable
to incur.
But if there be this objection to the use of secale and other
uterine stimuli, there is on the other hand a clear and distinct
indication in favour of operative interference; the mode
in which it is carried out of course depending on the nature
of the case, but that which is accomplished by means of
traction would suggest itself as being the best, inasmuch as it
would enable the foetus to pass through the uterine grasp, and
to distend the contracted portions.
An example of this class of cases is not infrequently found
in a primipara in whom, notwithstanding uterine pains have
continued for a long time, no progress has been made.
On examination it will be found that, although the head of the
child have escaped the os uteri, the shoulders are caught
either by the os uteri itself, or by a contraction a little way
above it. When the detention has continued a certain time,
the rhythmical pains gradually merge into the continuous
form, and then it is very rarely that the foetus is naturally
expelled, particularly so if, secale having been given, it has
failed to extrude it. Then, unless timely assistance be given,
the foetal life is extinguished, symptoms of irritation, then of
exhaustion come on, followed by putrid decomposition of the
foetus, and the patient sooner or later succumbs. Thus a
comparatively small obstruction occurring, delivery by natural
THE UTERUS IN OBSTRUCTED LABOUR. 15
powers is made nearly impossible by the grasping uterine
contraction. It matters not, however, in what part of the
parturient passage the hindrance is situated, its position only
affects the period and rapidity of the occurrence of the serious
symptoms.
There is no doubt but that in some cases where the case is
taken early, the continuous action yields to the influence of
chloroform, but inasmuch as this remedy also, in a certain
degree, diminishes the expulsive pains, it is by no means
certain that its use will be succeeded by progress ; on the
contrary, it may be said that, with the exception of contracted
states of the os uteri, the cases are rare in which expulsion
of the child would occur after its use in the circumstances
just narrated.
From a consideration of the above circumstances we may
deduce the following as our rule both as to the time and the
mode of our rendering assistance,* namely —
If on placing the hand on the uterus externally we find it
firmly contracted around the foetus between the pains (the
observation of this point being made over a sufiicient period) ;
or if there being no pains we watch for some time and
find no relaxation, w^e may be nearly certain that further
waiting will affect no good ; and therefore, in other words,
it is worse than useless to postpone assistance any longer,
and this rule will be still more distinct if we find the pulse
rising, the countenance anxious, and much distress felt in the
uterus.
If on the contrary we find the uterus lax, then we may
safely wait as long as the pulse be quiet ; to this, perhaps, an
exception may be taken, where in certain cases the head may
be firmly impacted in the cavity of pelvis by the pains which
preceded the state of relaxation. In such case we might wait
safely if we could push back the head a slight degree so as to
remove the persistent pressure on the maternal soft parts,
* It is by no means here intended to be implied that the forceps are
not to be appUed in cases where no continuous action has occurred ; it is
only meant that when it has occurred our line of practice is quite clear ;
neither is it affirmed that we are to wait always till the continuous action
has begun.
16 DR. BRAXTON HICKS ON
being of course ready to employ artificial aid if the recurring
pains were not sufficient ; otherwise, if much time elapse, it
will be necessary to interfere to rouse the pains or draw the
head through.
Should the pulse rise, or vary much, or other general
symptoms arise when the uterus is relaxed for some t ine,
it is more than probable that some lesion has occurrec or
some unusual condition has interfered, such as an attar v of
an exanthem, pneumonia, &c., for the cases are rare ir 'sed
in which the "powerless labour" in Dr. Churchill's sense is
present without the condition of continuous contraction
having preceded it, if we except that state which is induced
by violent mental emotions or rupture.
It has been given as a rule by some authors that abstrac-
tion of the child should not be done unless there are pains
present to assist the withdrawal of the child, secure the ex-
pulsion of placenta, and keep the uterus well contracted
after. To a certain extent this is a safe rule, but it is one
which is indefinite, because the " pains " may be absent, and
yet the uterus very active, over-active indeed, as has already
been pointed out, and even if it be not, yet it is found
that when the head is drawn down the uterus does contract
after.
What are the explanations for these facts ?
When there is the continuous action we may safely draw
down the foetus with proper rapidity without fear. The
uterus contracts firmly on the receding contents, and even
sometimes the rhythmical pains are again re-excited, and the
placenta is expelled naturally, the uterus remaining well
contracted afterwards. Sometimes the uterus continues so
firmly contracted after the withdrawal of the foetus, that the
placenta is held as firmly in its grasp as the foetus was, so that
it has to be removed by artificial aid.
But where the uterine walls are relaxed, it doubtless is the
best plan to endeavour to rouse the uterine action by oxy toxics,
such as secale, &c., but it not infrequently happens that
when the head is drawn down to the outlet reflex act on is
excited so much as sometimes to assist materially in the
expulsion of the foetus, and to secure the expulsion of the
THE UTERUS IN OBSTRUCTED LABOUR. 17
placenta and uterine contraction after. Yet the removal of
the child under these circumstances is attended by some risk
of haemorrhage, especially if the child be extracted too
rapidly; and if the uterus does not respond quickly to the'
fresh irritation. It would be best in these cases to give a
trial of secale first of all, and if then no action ensue, the
head may be slowly delivered, and the remainder of the body
allowed to remain for a time in the passages to stir up the
uterine activity, while, in the mean time, we employ the
various other means known to be capable of rousing expulsive
pains ; and this would be the rule in those cases where there
is clearly such an obstacle to the birth of the child as in any
case would demand traction, but where the pains had subsided
and the uterine walls were lax.
Thus we may briefly say that, in both cases of absence of
the pains, we may do well (with due care) to use extraction.
That extraction is peculiarly required in the cases where con-
tinuous action has supervened, while secale is detrimental;
but that secale and uterine stimuli are of great service where
the uterus is relaxed ; while extraction (if adopted) should be
employed with slowness and caution.
It is proper to state that it is not intended to be said above
that a contracted state of the lower segment of the uterus as
revealed to the hand passed internally, necessarily implies a
generally contracted condition, because the fundus might be
coincidently relaxed, and if extraction were made suddenly,
haemorrhage might occur above the constriction from the
relaxed upper portion.
The following is a resume of the principal points desired to
be established in the foregoing paper :
1. That it is very rare to find symptoms of *' Powerless
labour " (Churchill) where the uterus is relaxed.
2. That where serious symptoms have begun, and at the
same time the pains have apparently ceased, it will almost
invariably be found that the uterus is in a state of continuous
action.
3. That the continuous action is the cause of the symptoms
of "powerless labour."
18 DR. BRAXTON HICKS ON
4. That the times at which these symptoms arise vary
considerably according to peculiarity of the patient, the
violence of the action, and the position and presentation of
the child.
5. That if the constant contraction be fully established it is
better to deliver the child artificially, unless we first try the
effect of chloroform.
6. That the eifect of the continuous action is exhausting
to the mother, and liable to be fatal to the child.
7. That the use of secale is contra-indicated in such cases.
8. Where the uterus is lax we can generally wait a con-
siderable time without danger to the patient or to the child.
When the uterus has been allowed time to recover its nerve
force, then it is advisable to give some oxytoxic, as secale, &c.
If this fail, we may then draw down the head to the vulva
slowly and cautiously, which will probably induce uterine
action. The removal of the child must be done cautiously,
and only as we find the uterus to respond.
No case has been added in confirmation of the above
remarks, because, in a large number of examples which it has
happened to me to have seen, I am not aware of any excep-
tion. Doubtless there are cases which, examined in the
intermediate stage, that is, at the commencement of the
continuous pain, where we have the irregular contractions
described by all authors, might for the moment be deemed as
exceptions; but if sufficient time be taken to observe the
uterine state, it will generally be in our power to say whether
it exists or not over the whole organ. It may be asked : For
what period are we to extend our observations before we can
be sure of the real uterine condition ? Perhaps a quarter of
an hour will be enough for all cases, but less will often
suffice. The hand need not be all the time over the uterus,
but should be during the intervals of two or three pains.
This should be repeated two or three times during the quarter
of the hour. If we upon each occasion find the uterus
contracted firmly, we may conclude that continuous action
has supervened.
No attempt has here been made to explain the difference
between the rhythmical action and the continuous. Numerous
THE UTERUS IN OBSTRUCTED LABOUR. 19
explanations might be ventured upon, but in our present
knowledge we are unable to determine how far it is owing to
anatomical arrangements, or to an alteration of the peristaltic
wave.
One other subject remains for consideration. It appears to
me that the most satisfactory basis for classifying dystocia
is that founded not on the duration of labour, nor upon the
fact as to whether instruments are used or not, but upon the
more simple one of Cause. For instance, taking a. The
uterus as a (1) motive power ; then (2) as part of the partu-
rient passages ; b. The vagina ; and c. The pelvic bones.
The troubles which arise from abnormal conditions of the
ovum would necessarily follow next. After which the com-
plications of labour, as convulsions, &c., would be given.
In the introduction to dystocia it would be pointed out that
from whatever cause in whatever part a detention arose,
certain symptoms sooner or later appeared which, continuing
unrelieved by art or nature, ended fatally. The variation of
their occurrence in time, in intensity, and in rapidity, ac-
cording to the position of the fcetus, and its presentation,
would be specially indicated. It would, therefore, only be
necessary when speaking of each cause to allude slightly to
these points, proceeding quickly to the appropriate treatment.
This basis is of great value, clinically, for the mind, on
finding a detention of labour, will at once seek for the cause;
this having been found, the knowledge of the effects of the
persistence will lead it to seek also the remedy, whether by
natural powers or by art. Whereas the practitioner must
wait till labour is over, if he endeavours to distinguish
whether it be a lingering, laborious, or powerless labour ; or
complicated with the use of instruments. It may be asked :
Does this really signify ? I believe it does much. A clear
and immediate perception of the cause leads one instinctively
to the means required for the solution of the difficulty ;
whereas, where we must wait till the end of labour to classify
it, the mind is naturally apt to wait for a longer period
before it seeks the appropriate treatment, and then it must of
necessity fail to find the rules of management, because, before
it can do so, the case must be over. It is true that the elder
2
20 DR. BRAXTON HICKS ON THE UTERUS, ETC.
practitioners would intuitively classify by the cause, and
remedy it accordingly, but the younger practitioners must be
more or less confused by it ; and even the elder one is doubt-
less in some degree influenced, at any rate he is not assisted
by it, as he would be by the other plan.
ON THE
CONTKACTIONS OF THE UTEEUS
THEOUGHOUT PEEGNANCY:
THEIE PHYSIOLOGICAL EFFECTS AND THEIR VALUE IN
THE DIAGNOSIS OF PEEGNANCY.
I AM anxious to direct the attention of the profession to a
point connected with the pregnant uterus, which has been
almost entirely and surprisingly overlooked, as far as my
researches into authors lead me to believe. Perhaps the
following quotation from Dr. Tanner's work * On the Signs
and Diseases of Pregnancy,' p. 118, 1860, will best show the
state of our knowledge and the authors who have alluded to
the subject : —
" More than twenty years since Mr. Ingleby observed that
* in advanced pregnancy the uterus, when moderately grasped
and rubbed, slightly hardens and almost instantly regains its
yielding condition.' Dr. Oldham has since pointed out that
this power of contraction possessed by the uterus may be
taken as a trustworthy characteristic of pregnancy ; for he
states that the large gravid uterus alters in a marked manner,
under the influence of pressure, from a state of flaccidity to
one of tension. Thus, if we expose a pregnant woman, the
outline of the tumour is seen to be less defined before manual
examination than it becomes afterwards ; for, on applying the
hand, the tumour, which at first is felt soft and ill-circum-
scribed, rapidly assumes a tense rounded form, becoming firm
and resisting. According to Dr. Oldham, no other tumour
but the pregnant uterus possesses the power of altering its
form when irritated by palpation ; but I must here beg to
differ in opinion from this gentleman. Only a short time
22 DR. BRAXTON HICKS ON
since I was examining the abdomen of a poor woman suffer-
ing from an attack of flooding, caused by the presence of a
very large polypus in the uterus. The loss of blood had been
very great, so that all the tissues were relaxed and flabby ;
and on placing my hands — which were very cold — over the
tumour, I distinctly felt an increased rigidity of the walls of
the uterus. The truth, indeed, appears to me to be this —
that the uterus, in common with other hollow viscera, has,
when enlarged through the presence of any substance in its
cavity, a regular peristaltic movement consisting in slight
contractions and dilatations. Under the influence of the
former the outline of the organ can be easily appreciated,
other conditions being favourable, and these contractions are
undoubtedly the more evident the greater the size of the
womb, and the more it is irritated by external manipulation.
But as it seems that the peristaltic motions occur whenever
the uterine cavity becomes enlarged from any cause, it
necessarily appears objectionable to instance such movements
as a trustworthy sign of pregnancy."
To these remarks of Dr. Tanner's I may add a remark of
Dr. Montgomery's in his work ' On the Signs of Pregnancy,'
p. 100. He says : — " The uterus within the first four months
has a feel of a soft, though pretty firm, fleshy tumour, not
sensitive when pressed, of a uniform smooth surface, and of
such a size as would be without difficulty grasped in the
hollow of the hand. After this period, that is, from the fifth
month, it loses somewhat of its firmness and distinct feel,
owing to the greater expansion and consequent lengthening
out of its fibres, which continuing to increase as pregnancy
advances towards its termination, the circumscribed organ
becomes less and less distinguishable ; though generally to be
detected by making pressure with one hand while we examine
with the other, in doing which we also ascertain some degree
of obscure fluctuation, but in the same proportion as the
parietes of the organ become indistinct, its solid contents
are more easily felt, and even separate limbs may be recog-
nised and traced ; the firmness of the tumour as well as the
degree of fluctuation which it affords will very much depend
on the size it has acquired or the natural firmness or supple-
CONTRACTIONS OF PREGNANT UTERUS. 23
ness of its structure, and on the quantity of liquor amnii.
Owing to the variation in these causes a corresponding
degree of difference will be recognised in its consistence in
different instances, so that, while in some persons it is so soft
and yielding as hardly to be felt, in others it presents a
degree of solidity amounting to absolute hardness, though
still healthy, and retaining its round or oval form and its
uniform smooth surface."
Dr. Priestley* remarks only thus far, p. 83 : — " There can
be no doubt, I believe, that it possesses contractile properties
(before impregnation), as it expels blood-clots, dysmenorrhceal
membranes, and intra-uterine polypi. During the extrusion
of these we may sometimes distinctly recognise the alternate
hardening and relaxation of the organ by placing the hand
over the hypogastric region. Its muscularity at the full term
of pregnancy scarcely admits of room for controversy." He
then instances the pressure felt on your hand during a pain,
&c. He thus passes over the contractility during pregnancy.
It is evident that Dr. Montgomery did not recognise inter-
mittent contractile power in the uterus, but thought the
difference he had noticed was owing to an inherent difference
in the tonicity of the tissues in different persons. It does not
appear how far Dr. Tanner's opinion as to the peristaltic
movements was based on facts observed by himself in the
different stages of pregnancy, because he gives no further
information on this point, or whether his opinion was formed
by a consideration of the analogy which the uterus distended
bears to other hollow contractile organs.
Dr. Tyler Smith is much more clear regarding the con-
tractions of the uterus, and foreshadowed in a measure the
substance of this paper ; but the contractions he instances are
those which are caused by excitation, as the context shows.
In discussing the position of the foetus in utero he considers
that the peristaltic action of the uterus has as much influence
as the movements of the foetus itself on its position. These
movements he attributes to reflex irritation, derived from
various causes of excitation. He believes very strongly in
these movements as being of even greater frequency than the
'■' ' Lectures on the Development of Gravid Uterus,' 1860.
24 DR. BRAXTON HICKS ON
movements of the foetus within it. Thus : "I have no doubt
of the frequent movements of the foetus in utero, but wish to
insist upon the equal or even still greater frequency of the
movements of the uterus itself."
Again : " With this change of shape the uterus acquires
more power of muscular contraction, and becomes the subject
of reflex and peristaltic movements."*
These passages from Dr. Tyler Smith's thoughtful work on
* Midwifery' show that he had a very clear perception of the
movements of the uterus, but I gather from them that he
looked upon them as being excited by various accidental
causes of a reflex kind, which he enumerates at p. 197. It
may be that the frequent and almost regular movements I
shall describe are really due to reflex action, but they are
best observed in complete passiveness of the woman. It ma}-
be that the semi-stagnant state of the blood in the uterine
sinuses, &c., may provoke contraction, but certainly there is
some other excitor than either the foetal movements or the
irritation of the various nerves in sympathetic communica-
tion with the uterus. These remarks of Dr. Tyler Smith were
made two years before the appearance of Dr. Tanner's, but
probably they had not arrested his attention. In any case
subsequent authors are silent on the subject, so far as I can
find, both at home and abroad.
It was a source of difficulty to the older obstetricians to
explain how that, at a certain time — namely, at the full j)eriod
of pregnancy — the uterus, passive up till then, began all at
once to acquire a new power, that of contracting ; forgetful
that, long before the full period had arrived, the uterus has
the power to expel the foetus, and, under mental excitement or
local stimulation, attempted to do so frequently.
But, after many years' constant observation, I have ascer-
tained it to be a fact that the uterus possesses the power and
habit of spontaneously contracting and relaxing from a very
early period of pregnancy, as early, indeed, as it is possible
to recognise the difference of consistence — that is, from about
the third month.
When the uterus is normally placed, it is, of course, difficult
- ' Manual of Midwifery,' p. 217, 1858.
CONTRACTIONS OF PREGNANT UTERUS. 25
to make it out till a little after that time, but in the case of
retroversion accompanying pregnancy, then the fundus being
readily felt per vaginam, the contractions can without any
difficulty be perceived.
Up to the end of the second month the walls are still dense,
but after this time the fundus, as can be noticed if the uterus
be retroverted, will begin to be elastic, and variation in its
consistence is recognisable as the end of the third month is
approached.
If, then, the uterus be examined without friction or any
pressure beyond that necessary for full contact of the hand
continuously over a period of from five to twenty minutes, it
will be noticed to become firm if relaxed at first, and more
or less flaccid if it be firm at first. It is seldom that so long
an interval occurs as that of twenty minutes ; most frequently
it occurs every five or ten minutes, sometimes even twice in
five minutes. However, in some cases I have found only one
contraction in thirty minutes. The duration of each contrac-
tion is generally not long, ordinarily it lasts from two to five
minutes. When the uterus is irritable or has been irritated
it lasts longer than this ; under particular circumstances, to
be alluded to again, it may assume an almost continuous
action analogous to that which is noticed after long obstructed
labour.
Supposing, then, we commence our examination when
the uterus is contracted, we find the organ firm and solid,
somewhat like the uterus affected by a fibrous tumour.
Gradually this state alters, the walls becoming softer and
ultimately so flaccid that their outline can be hardly made
out, unless the other hand be placed on the os uteri
per vaginam, and even then sometimes with difficulty.
So also, if we commence our examination when the uterus
is in its flaccid state, it will at first be very ill-defined, so
that, if we are careless or too rapid, we might readily say
that there was no pregnancy ; but shortly the shape of the
organ gradually becomes more and more distinct, till we have
no doubt but that we have an enlargement of the uterus to
deal with ; after a time the firmness abates, and gradually
the original condition of relaxation is complete.
26 DR. BRAXTON HICKS ON
If we more carefully investigate the uterus after the fourth
month of pregnancy we shall further notice the phenomenon,
which has been well described by authors, that during the
period of relaxation the foetus (if one be there) is generally
to be detected by external palpation or by external ballot-
ment. By internal ballotment also, in consequence of the
increased impressibility of the uterine wall, we can make out
the foetal presence, its contour, often its movements, and its
capability of being moved. But it is interesting also to
notice, during the gradual increase of solidity, how the pres-
ence of the foetus, quite distinct before, slowly becomes more
indistinct, whilst the outline of the uterus becomes more
clearly marked, till instead of the foetus we find a hard
globular swelling, which we could at the time we recog-
nised the foetus scarcely, if at all, feel. That this pheno-
menon extends from the early period I have already men-
tioned to the time of labour, is a fact to which I have never
seen but one exception during a course of observations
extending over about eight years ; and this apparent single
exception might have been none at all had a more prolonged
examination been carried out at the time. It occurred in a
case of paraplegia. Although she was under my care some
time, and was subjected to frequent examination, yet the
uterus was never found to contract. She went out of the
hospital before labour arrived, but the labour was natural.
The constancy with which these contractions of the uterus
have always occurred to me leaves no doubt on my mind but
that it is a natural condition of pregnancy irrespective of
external irritation.
In a general way the pregnant woman is not conscious of
these contractions of the uterus, but sometimes she will remark
that she has a tumour in her lower abdomen, thinking it a
constant thing; but another will observe that she has a
swelling sometimes, but which vanishes at other times. But
occasionally it happens that the uterus is more than usually
sensitive, and that the contractions are accompanied by pain ;
and then on examination it is found that each pain she com-
plains of is coincident with a contraction.
Again, when the uterus has been excited by any cause,
CONTRACTIONS OF PREGNANT UTERUS. 27
and these contractions are more than usually powerful, the
woman is conscious of their presence, and by watching these
we shall convince ourselves that the contractions, which were
before unnoticed by her, are really the same as the so-called
** pains" of premature expulsion of the foetus, and also of true
labour.
Sometimes I have found the contractions last a consider-
able time, longer often than the intervals ; and this is more
frequently the case if the uterus contain a diseased ovum,
and particularly a solid or carneous mole ; but in general the
contraction from its commencement to final recession lasts
about five minutes. The duration both of contraction and
interval varies very considerably.
But it is not only in healthy pregnancy that this pheno-
menon exists ; it is well marked, as just mentioned, where
the foetus is dead ; it is also to be found where the foetus is
absent, as in the case of hydatiniform degeneration of the
chorion (vesicular mole).
How far this action is the same as the peristaltic or vermi-
cular movement observed in the lower animals one can hardly
say, but one can hardly doubt a close analogy to it, if not
identity with it. But when excited into a more vigorous
state there can be no doubt but they are of the same cha-
racter and identical with "labour pains." And this serves to
explain how it is that at a short notice we can bring on labour,
and how it is that the uterus shall respond in a few hours (I
have seen labour artificially induced accomplished without
any traction in two hours) so as to expel the foetus at the
sixth month as well as it does at the ninth month.
By our manipulation we simply exaggerate the action
already going on to such an extent that the natural process
exhibited by the uterus at labour at full term continues till
the foetus is expelled. In other words, we supply that
stimulus which nature herself supplies at the beginning of
labour at full terra. The rest of the process is precisely
similar. We need not, with the cognizance of this inter-
mittent action, any longer wonder how it is that suddenly a
new function is given to the uterus at the end of the ninth
month ; it is already in active exercise, not perceptible to
28 DR. BRAXTON HICKS ON
the pregnant woman, though it is to the examining hand.
We also find in this frequent contraction an explanation of
the change of note in the uterine souffle. Everyone con-
versant with the sounds of pregnancy has noticed how that,
while listening to the sounds formerly called placental, but
now acknowledged to be uterine, the loud sonorous sound
has become gradually higher till it is almost a shrill piping
musical one. It has puzzled many authors to explain
this, but one sees no difficulty in it ; the diameters of the
uterine sinuses are slowly reduced by the contraction of the
walls, the rapidity of the rush of the blood increased, and the
pitch of the sound consequently heightened. It also explains
the phenomenon of " after pains," in which we see a continu-
ation of the same intermittent movements after the removal
of the exciting cause. It is probable that the enlarged state of
the cavity after labour allows the exhibition of the action, and
the uterus, being more sensitive than before labour sets in,
the contractions are more productive of pain than during preg-
nancy. As the cavity becomes smaller, and the walls relatively
thicker, and as the uterus resumes its natural state of insensi-
tiveness, the contractions are not any longer recognised unless
exaggerated during suckling.
It is not impossible that a something akin to this is going
on in the unimpregnated uterus ; at least, we find not unfre-
quently that mental emotions and other exciting causes do
bring on a forcing sensation in the empty womb.
In the case mentioned by Dr. Tanner, already described,
and in cases where I have removed intra-uterine polypi,
there is clear evidence of the contractility of the uterus
in the intermittent manner, but these cases occurred upon
handling and irritating the organ. That of pregnancy is
spontaneous.
The only other conditions at all resembling pregnancy are
those which occur from retention of the menses in utero,
collections of pus, or of serum. I am sorry I have not been
able to observe whether in these states the uterus spontane-
ously or upon irritation has the power of contracting. It
would be highly desirable to obtain information upon this
point. To these we shall again allude.
CONTRACTIONS OF PREGNANT UTERUS. 29
Let me next consider the effects or uses of these contrac-
tions. It is possible that there are others, but two appear to
be tolerably clear.
In the Jii^st place, it will provide for the frequent movement of
the blood in the uterine sinus and decidual processes, for as the
sinuses of the uterus are so much larger than the supplying
arteries, the current is more slow in them than in the
ordinary systemic veins. The contraction of the walls through
which the sinuses meander tends to send the current onward,
and to act somewhat as a supplementary heart.
Besides this, it facilitates the movement of the fluid in the
intervillal space of the placenta, or in that which is called
the placental sinuses. Whatever view we may hold of the
structure of the placenta — whether, on the one hand, there be
blood amongst the villi in maternal sinuses, or, on the other,
merely a serous fluid — in any case it is through one or the
other medium the villi absorb the material for the aeration,
&c., of the foetal blood ; and there can be no doubt that from
its position it must be more or less in a stagnant state, for
even if it be blood, this entering in by small openings into a
much larger area, and making its exit also by small openings,
must necessarily proceed at a very much slower rate, as has
been pointed out by Dr. A. Fare, article "Uterus," * Cyclo-
paedia of Anatomy and Physiology.' It is not difficult, there-
fore, to recognise the effect which the change in the solidity
and shape must produce on the fluids in the placenta as well
as on that of the uterine walls ; in other words, the con-
tractions act as a kind of supplementary heart to the fluids in
the uterine walls and the placenta.
In the second place, the uterine action adapts the position
of the foetus to the form of the uterus. There has been, as
is well known, much dispute as to the cause of the head
presenting so frequently in labour as it does. There can
be little doubt but the more recent opinion is the correct
one, namely, that the motions of the foetus combined with
the preparatory pains of labour to secure the head to present.
For it has been also well shown that the head of the foetus
when folded up in utero is not really the larger end, but that
the body with the limbs forms the greater portion ; and as
80 DR. BRAXTON HICKS ON
the uterus is larger at its fundal end than below, the foetus
folded up corresponds to the shape of the uterus only when
the head presents at the os.
But this explanation has been weak in one point, namely,
that the head presents in all the later months of pregnancy
(although not quite so regularly) long before the pains of
labour have set in.
The feebleness of the explanation seems to be corrected in
part, if not altogether, by the recognition of these contractions
to which I am endeavouring to draw attention. During the
whole of pregnancy this silent power is being exerted, so that,
be there little or much liquor amnii, in other words, be the
child freely floating or closely pressed by the uterus on the
approach of full term labour, yet there is a time, even so
early as the fifth or sixth month, when the uterine contrac-
tions must act on the foetus in a manner similar to that in
which it is supposed to act on it during the last stage of
pregnancy. The remarks and quotation above given show
how clearly Dr. Tyler Smith had pointed out this effect of the
uterine contractions.
Let us now discuss of what value in the diagnosis of preg-
nancy is the intermittent action of the uterus.
In the before quoted passage Dr. Tanner says :— " But it
seems that as the peristaltic motions occur whenever the
uterine cavity becomes enlarged from any cause, it necessarily
appears objectionable to instance such movements as a trust-
worthy sign of pregnancy."
To these remarks I would make this rejoinder. For the
last six years and upwards I have made use of the inter-
mittent action of the uterus as the principal symptom upon
which I have depended in the diagnosis of pregnancy. I
am not aware that I have been less successful than others
in determining the existence of pregnancy ; on the contrary,
I have felt myself at an advantage in the possession of an
additional sign to make up the deficiency or temporary in-
applicability of the others ; as, for instance, when external
noise prevents the heart sounds from being heard.
But, leaving egotistical expressions, let us consider what are
CONTRACTIONS OF PREGNANT UTERUS. 31
the other causes of enlargement of the uterme cavity, in order
that we may see how far they are practically liable to impede
our diagnosis.
They are five in number : — 1, retained menses ; 2, hydro-
metra ; 3, collections of pus ; 4, polypus ; 5, large fibroids,
nearly polypoid.
We will dispose of these seriatim; and, first, retained,
menses.
In the first place, it would be very rare to find a case of
retained menses without severe periodical monthly pains.
If such a case presents itself we always examine pervaginam,
and then the obstruction is detected. But it is possible that
a case may present itself to us — indeed, I have met with one
such — where an obstruction exists in the vagina almost in-
superable to the escape of the menses from the very small
opening, and yet a pregnancy occurs. Now, in this case,
of course much obstacle to diagnosis must arise, because of
the difficulty of exploring the lower portion of the uterus.
In such an event we should, independently of the stethoscope,
be enabled in almost every case to make out the presence of
the foetus within the tumour, which we should recognise as
being the uterus by its power of contractility. The foetal
presence, detected by the hand and stethoscope, would
point out the true state of the case. But also in almost
every case of occlusion occurring in those who have already
borne children, there is a history of severe labour, or some
sign which would lead us at once to institute a vaginal ex-
ploration.
But supposing that a girl fell pregnant before the appear-
ance of menstruation, of which I have known one case, then
under these circumstances we should, of course, always insti-
tute an internal examination, because in any case it is neces-
sary to make out the actual condition.
Almost always retention of menses in early life results
from vaginal obstruction, and the majority of those after also;
in these cases the uterus itself does not become distended
by the secretion till the vagina above the obstruction is
dilated to the utmost, and then gradually the uterus enlarges.
32 DR. BRAXTON HICKS ON
But this distension is not gradual as in pregnancy, but at
each monthly "period" it becomes rapidly larger, subsiding
to a certain degree after the "period" has subsided. The
decrease in all cases is very well marked. Thus we can feel
through the parietes two swellings, the upper one the smaller ;
and as this is so unlike the pregnant uterus, we can scarcely,
with any ordinary amount of attention, mistake one for the
other ; even supposing, which has not yet been proved, that
the uterus distended by menses contracts intermittently, as
does the pregnant uterus.
2nd, hydrometray and 3rd, retention of pus in the uterus. —
Both of these conditions are very rare ; both require an
occlusion of the os or cervix uteri. The causes of this occlu-
sion would be sufficiently well marked to place the probability
of pregnancy aside ; but, if any doubt existed, vaginal exami-
nation would show occlusion, or the state of a developed
uterus as in pregnancy. And supposing that vaginal exami-
nation were unattainable, then the absence of any solid
within (assuming that the uterus in these diseases presented
the same phenomena as in pregnancy, which, as I said before,
is still unproved), would be sufficient to distinguish these con-
ditions. When hydrometra attains a great size, it possibly
might be confused with hydrops amnii ; but collections of pus
in the cavity of the uterus seldom, if ever, become larger than
the uterus in the fourth month of pregnancy.
Practically their infrequency during the menstrual epoch
might permit us to ignore them as a source of difficulty in the
diagnosis of pregnancy.
The fourth cause of uterine distension is polypus. In the
first place, it is very rare to find a polypus in utero so large
as to be confounded with pregnancy, without metrorrhagia.
This latter was a very prominent symptom in Dr. Tanner's
case above quoted. It would not interfere therefore with the
diagnosis of normal, but of abnormal pregnancy ; and princi-
pally with that form where carneous mole was present.
For if there were a pregnancy coupled for some time with
haemorrhages, if the ovum were not convertied into a solid
CONTRACTIONS OF PREGNANT UTERUS. 33
form, the foetus would be felt during the interval of relaxa-
tion ; and it is in these cases where very frequently, the foetus
being already dead, we are deprived of the employment of
the stethoscope, that the advantage of the alternate relaxation
and contraction in diagnosis is well shown. Because not
only does it show that the tumour is wholly uterine, but by
the flaccidity we can tell that the contents are not of a solid
nature, for although when the organ is fully contracted over
an ordinary ovum the density is as great as if there were a
fibroid or polypus within it, yet when it relaxes it is seldom
that the laxity is not sufficiently complete but that we can
at once satisfy ourselves that a solid of the size of the uterus
is not contained within.
Again, it would be a very rare case of polypus where the
uterus had by its distension grown as rapidly as it would
have done in pregnancy ; certainly a polypus so large as to
be like a seven months' pregnancy must have taken a long
time to grow, and it would be very rare that it should have
been unnoticed till within that period.
In the case of a carneous mole, however, there may be
some difficulty in distinguishing it from a polypus, especially
in a patient seen only lately ; because by physical signs they
are scarcely distinguishable. By the history, however, we
may generally glean information that the menses had
absented themselves for a greater or less time. However,
the difficulty always has been great, but it is not increased
by the knowledge of the intermittent contractility of the
uterus.
Taking, however, only the tactile symptom in distinguishing
polypus from pregnancy, we may say that the uterus in
pregnancy, when relaxed becomes quite flaccid, and that
a movable solid is felt floating readily about in it, whereas
with polypus, although possibly we may feel the difference
between the contracted and relaxed conditions, yet it is so
very slight that there is no likelihood of their being confused.
But of course we do not always tie ourselves to only one
symptom; and the other symptoms of pregnancy, amenorrhoea,
the size of uterus compared with the date of the absence of
84 DR. BRAXTON HICKS ON
menses, the state of os uteri, &c., will assist us in our
diagnosis, even if the auscultatory signs be absent.
The above remarks apply to the fifth cause of distension of
the uterine cavity, namely, to fibroid tumours of the uterus,
when these project polypus-like into the cavity, except that
it is highly improbable that we should find any sensible
amount of contraction. In any way it would only be in the
case of carneous mole that any difficulty could possibly arise ;
from this the long standing haemorrhages, frequently the want
of symmetry and persistent solidity, with absence of changes
about the os uteri, would enable us to distinguish the fibroid
tumour.
Thus it appears to me that the difficulties which would
seem at first sight to be caused by the assumption that the
uterus distended by diseases contracts intermittently as when
distended by pregnancy, readily vanish on closer acquaintance,
so far as is required in practice. The knowledge of the fact
does not add to our difficulty, whilst it gives us another sign
which adds materially to our ease in the diagnosis of preg-
nancy.
But not only are we assisted in our diagnosis of pregnancy
from other uterine tumours, but still further we are helped to
distinguish uterine from non-uterine enlargements.
Because if we find a tumour varying in consistence at
intervals, it is clear that it must be the uterus, as far as our
present information guides us.
There is only one doubt on my mind, derived from the
absence of information as to whether the bladder in retention
of urine possesses a perceptible intermittent action. That it
contracts periodically under accumulation of urine there can
be no doubt, but how far this is palpable remains yet open to
observation. Of course there is no difficulty in clearing up
the question between bladder and uterus, either by vaginal
examination or passing the catheter ; still, the absence of
any solid within will clearly distinguish the vesical from the
uterine tumour.
There is one form of abnormal pregnancy which, possessing
a consistence between carneous mole and ordinary pregnancy,
CONTRACTIONS OF PREGNANT UTERUS. 85
and being without the presence of the foetus, may be liable to
give rise to difficulty — I mean the vesicular mole or hydatini-
form degeneration of the chorion. In this form I have
distinctly found the intermittent contractions of the uterus,
yet in the state of relaxation no foetus can be found. Of
course, if we examine per vaginam we shall find a more or
less patulous os uteri, history of rapid growth, with, most
probably, some short suspension of the menses, succeeded by
sero-sanguineous discharges. The absence of all foetal signs,
the want of complete fluidity, coupled with the intermittent
contraction, will point out that a pregnancy without a foetus
exists, and will, sufficiently with the other signs, show the
absence of other diseases distending the uterus.
There is also great advantage to be found in the facility
with which in many cases we can obtain an approximative
diagnosis. Whilst engaging the patient in conversation the
abdominal examination can be carried on without arresting
attention such as auscultation would do. If we found a
swelling which relaxed at one time and became firm at another,
this would be quite sufficient to guide us as to the advisability
of insisting on a more complete examination. And then, sup-
posing also there was amenorrhoea, the patient having been
"regular " before, the general health being at the same time
good, with or without sickness, we may be quite assured that
we may extend the examination to a more complete degree
without committing ourselves unnecessarily.
In conclusion I may add that, whilst endeavouring to point
out the proper position, as a diagnostic sign, of this inter-
mittent action of the uterus, I do not wish to underrate the
value of the auscultatory signs of the foetal presence, but
rather when these, from circumstances, are unattainable or
impeded, then this sign proves itself of much more value than
authors have, as yet, attributed to it.
I have not added any cases to illustrate the above remarks,
because, as the phenomenon is so constant and so easily
recognised, and its applicability to diagnosis self-apparent, it
would be unnecessarily occupying the attention of the Society
to relate instances.
d2
ON
INTEEMITTENT CONTRACTIONS
OF
UTERINE FIBROMATA AND UTERUS IN
PREGNANCY
IN EELATION TO DIAGNOSIS.
It may be in the recollection of some members of this
Society that in 1871 I read a paper, published in our
* Transactions,' vol. xiii., describing 'a fact before overlooked,
namely, that the uterus contracted and relaxed alternately at
pretty constant intervals during the whole of pregnancy ; in
other words, that at intervals of about five to ten minutes the
hand could distinctly recognise an increase of its firmness
and then recurrence to its ordinary state — that this could be
observed without difficulty when the uterus was above pubes,
but also that if low down or retroverted or retroflexed it
could be observed per vaginam. In this paper, as also in
subsequent papers read before the Obstetric Section of the
International Medical Congress, 1881, and following, I gave
cases in illustration of the value as regards the diagnosis of
pregnancy and other tumours complicating it, or independent
of it. I also pointed out the physiological use of these con-
tractions ; the principal points of the knowledge thus afforded
us I described in a paper read before the Eoyal Society and
published in its ' Proceedings,' 1878, entitled *' On the
Auxiliary Forces concerned in the Circulation of the Pregnant
Uterus in Woman." Before this Society I also read a paper
showing that the effect of these contractions was such on the
38 DR. BRAXTON HICKS ON
abdominal respiratory wave (described by me in a paper read
before the Medical Society, December, 1882, "On Tension of
the Abdomen and its Varieties ") as to nearly obliterate the
curves of the tracings as shown by the gastrograph there
described.
When my paper was read before the International Medical
Congress in 1881, Dr. Matthews Duncan, in the discussion
following, remarked that " considerable subtraction must be
made from the value of this diagnostic sign, because a soft
iibroma without pregnancy, itself or its capsule, or both,
contracted quite as distinctly and with as much change of
shape as the gravid uterus." It does not appear whether
Dr. M. Duncan himself observed this change.
In a letter to the * Lancet ' shortly after, I said that this
might be the case, but that I had not, up to then, met with
such a one, and that I thought it must be rare, and I remarked
that I thought no one else had noticed it. In rejoinder. Dr.
Herman pointed out that he had, in the * Obstetrical Journal,'
1880, published a case of fibroid tumour in which he had
noticed this varying density ; and Dr. John Williams in same
number of 'Lancet' (Sept. 3rd, 1881) also called attention to
a case he had passingly mentioned in a lecture " On the
Periodical Changes which occur in Fibroid Tumours," 1880.
To this I answered that, although I had not hitherto observed
the change, yet I had great confidence in these gentlemen's
powers of observation, that I was prepared to assent that, so
far as these two cases went, this change did occur, but that
further observations were required before we could accept the
phenomenon to be of common occurrence. I then proceeded
to show how far the power of contraction in fibroids interfered
with the value of the contractions of a pregnant uterus as a
means of diagnosis of pregnancy. This I will not now
repeat, as I shall discuss this point later on.
It was not till about a year and a half ago that I had an
opportunity of seeing a case which was parallel to the cases
of Drs. Herman and Williams. It was in a lady about forty-
three, of a highly nervous temperament, becoming almost
maniacal at menstrual periods. She had lately increased
much in the size of the abdomen, and the menses had been
INTERMITTENT CONTRACTIONS. 39
for four or five months irregular, absent for two months, but
too frequent the latter portion, once or twice profuse.
I found a tumour rather to right side as high as umbilicus,
firm and prominent in centre. During my examination I
became conscious that it had become less dense and promi-
nent. This variation was clearly marked during a prolonged
examination, .and I recognised that if she were not pregnant,
then it was a fibroid simply, or fibroid with pregnancy, for
the feel of the mass was not that of an ordinary pregnant
uterus during its relaxed condition, and, besides, there was an
irregularity in its outline. I consequently made examinations
from time to time, but detected no increase of size cor-
responding to normal pregnancy, and the menses returned
nearly regularly after some time had passed. It was evident
that there was no complication of pregnancy, but a fibroma
of the softer kind, which still remains.
It is due to the above-named observers to corroborate their
experience, and it is also due in the interest of our scientific
advance that we should recognise that occasionally soft
fibromata of uterus do undergo alterations in density. The
bearing of this fact on our diagnosis is the next point that
has to be considered.
As in pregnancy we have amenorrhcea as a most common
condition, so in fibroma and its varieties there is very rarely
absence of menses, but the most common condition is
menorrhagia and metrorrhagia. There is, however, a differ-
ence in the relative frequency of these opposite conditions.
Amenorrhcea is less frequent in fibroma than menses, menor-
rhagia, and metrorrhagia are in pregnancy of all kinds. If
we exclude, however, the abnormal conditions of pregnancy,
the infrequency of the continuation of the menses during the
first half of gestation will more nearly compare, though
slightly in excess, with the infrequency of the amenorrhcea in
cases of fibroma.
When, therefore, we are desirous of diagnosis of tumours
reaching from the size of a three and a half months' preg-
nancy to that of full term and even over, it is in the unusual
cases of fibroma with amenorrhcea, and in the more frequent
(though relatively to ordinary pregnancies much less common)
40 DR- BRAXTON HICKB ON
cases of pregnancy with periodical appearance of blood that
we have to call in other diagnostic aids.
But in forming diagnoses by the doctrine of probabilities,
in a case of enlargement of the uterus after the absence
of the third menstruation, the size of the uterus being in
accord with that of the uterus in normal pregnancy, the
health of the woman continuing good, if we decided that she
was pregnant we should be right in ninety-five per cent.
For by the end of three months the temporary checks are
most commonly rectified, and the accompanying swelling of
the uterus has subsided ; while almost all the enlargements
of the uterus other than from pregnancy are not only not
coupled with amenorrhcea, but most commonly with menor-
rhagia and excess.
But careful consideration of the character of the uterine
contractions in pregnancy and with fibromata will show how
far these will assist us in forming a diagnosis.
One might say at the outset that the rate of frequency in
these contractions will not help us, because in pregnancy the
period of their occurrence is unequal. But in the case of
fibroid I believe it is yet to be determined whether they occur
spontaneously, or whether they are set in motion by the
handling. In pregnancy they certainly occur irrespective of
the handling ; one often finds the uterus already to be firm
and tense, and then to relax during the examination.
Now when the uterus relaxes in normal pregnancy, although
it was impossible to feel the foetus by palpation before, yet
when the relaxation occurs the foetus is generally to be made
out not only by its movements but by "dipping" or
" bobbing," as some have called it ; in the same way as one
feels for solid through fluid in the abdomen, or a solid in an
ovarian cyst. The tips of the fingers press the parietes
firmly on to the uterus and impress its walls steadily, then by
a slight quick movement the fingers dip still deeper, and if a
foetus be there a momentary resistance is felt, varying accord-
ing to the size of the foetus and its mobility. If much fluid
be present there the feeling is but very momentary, for the
foetus recedes as in ballotment. Now it is but rarely in
normal pregnancy that the foetus cannot be thus detected
INTERMITTENT CONTRACTIONS. 41
either externally — the woman placed dorsally or laterally — or
per vaginam.
This recognition of the foetus can be obtained in many of
those few cases I have before alluded to where some kind of
blood discharge is met with in pregnancy, limiting thereby to
that extent their relative number.
But there is generally a different feeling given to the hand
in the case of a large relaxed soft tumour, and although I
would not press this point too far, yet I may say that the
yielding of a hollow body is different from that of the solid
though elastic ; in the one resistance is only just beneath the
fingers, while in the other it continues to the centre.
But if we now take these large soft uterine tumours which
exhibit the intermittent contractions, how very few of them
will really make diagnosis difficult ? In nearly all there will
be a longer history of monorrhagia, of longer growth and
noticeable bulk than in pregnancy, and particularly than in
the abnormal kinds, e.g. vesicular mole and hydrops amnii ;
and again, in the normal pregnancy of equivalent size the
presence of the foetus will almost always be made out by
palpation, if not by other signs, particularly by the develop-
ment of the OS uteri, which would be very different in
pregnancy. Still, if the foetus could not be felt during the
relaxed state, I admit our diagnosis must be difficult judging
solely by the intermittent action. But such cases are very
uncommon.
In cases of vesicular mole the physical condition imitates
very closely that of a soft fibroid, and as no foetus is present
the existence of contractions will not help to solve the
difficulty, though of course there are other circumstances
which enable us to make out the case, such as the short,
history, the state of os, and the extrusion of the vesicular
bodies.
In the hydramnios, however, besides the also rapid history,
we have sensible fluctation and, with care, the presence of
the foetus to guide us, so that the case becomes one rather of
differential diagnosis in respect of ovarian tumour and other
cysts, the contractions proving at once its uterine nature.
However, the cases in which the greatest difficulty of
42 DR. BRAXTON HICKS ON
•
diagnosis between fibroids and pregnancy occurs is in those
abnormal conditions of pregnancy called carneous mole and
early death of foetus, with hemorrhage, because in these there
is great similarity both in physical characters and also in
symptoms ; not that we have the intermittent contractions to
help us, for often the uterus remains firm as a hard fibroid for
some weeks together. Though here again the recent character
of the history is unlike that of a fibroid tumour, and the case
has generally commenced with an absence of one or two
periods. These cases form but a small percentage of the
total cases of pregnancy. The following case illustrates the
difficulty which may arise very occasionally.
A lady had been suffering very severe paroxysms of pain
just above pubes, many times in the day for a few weeks.
She was hardly able to move at the time. She had not men-
struated for four months. On examination I found the uterus
enlarged to a size corresponding to the natural size of preg-
nancy of that duration. It was very hard and solid, the os
not particularly enlarged, and the mass resembled a dense
fibroid. There was no history of previous menorrhagia.
There was nothing about the os to indicate closure, and I
concluded she was pregnant, and the pain was owing to the
normal contractions exaggerated, probably by something
abnormal in the ovum. I saw her at intervals of a week four
times, finding the same conditions of pain and hardness. My
examinations of the abdomen were prolonged each time in
hopes of getting the relaxed state, but without success, till at
the end of the fourth time, just as I was giving up, the whole
uterus relaxed, in other words, that which was so hard and
solid so long had almost disappeared. I therefore pronounced
in favour of pregnancy ; and so it turned out, in due course a
healthy foetus was born. However, when the uterus keeps
continually rigid, it is generally in consequence of irritation
produced by some disease of ovum generally accompanied by
effusion of blood into placenta.
In cases of the complication of uterine fibroma and preg-
nancy, it has been remarked that the difficulty of diagnosis
would be increased. But this opinion has been given without
reflection. The difficulty of making out this state will
INTERMITTENT CONTRACTIONS. 43
always be great in the early months, but unless the uterus be
more than halfway round involved in the tumours, about the
fourth month one will be quite able to distinguish a difference
in substantiality at least, if not to detect the foetus, and then
as the uterus contracts, so we shall notice that the more solid
and relaxed portions are all included in the same mass ; and
this and the converse being repeated at intervals, we gain the
information of the existence of fibroids and also of pregnancy;
and also we are able to note the point I have already alluded
to, namely, the distinction between the feel of a relaxed
fibroid and that of a pregnant uterus.
In cases of differential diagnosis between two tumours, say
uterine and ovarian, we can utilise the contractions (whether
they occur in a uterus enlarged by tumour or pregnancy or
both), recognising the one altering in firmness as uterine, the
other as ovarian ; the same in a uterine tumour and hydro-
nephrosis, or in cases of extra-uterine pregnancy to distinguish
the uterus from the sac.
It must be remembered that we do not apply the test of
this alternate action of the uterus till we have learnt the
history of the case ; and before we approach the idea of
pregnancy we should have excluded a good number of the
cases to which I have alluded above.
And so, whilst we admit that a certain deduction has to be
made when employing these contractions as absolute evidence
of pregnancy, we find that they may be used in a large
majority of cases, either as a distinct proof, or in corrobora-
tion of other signs, or in differential diagnosis of abdominal
tumours, and I am sure it will be agreed that it is a point of
much importance that we should have additions to the direct
signs of pregnancy, for I have for many years taught that the
secondary signs and symptoms are scarcely worth considering,
in the presence of the opportunity of direct evidence derived
from the examination of the uterus and its contents.
AN
INQUIRY INTO THE BEST MODE OP
DELIVERY OF THE F(ETAL HEAD
AFTER PERFORATION.
Notwithstanding that the adoption of the induction of
premature labour and the employment of podalic presentation
in cases of diminution of the diameter of parturient passages
have much diminished the necessity for perforation, still, from
one cause or another, cases will from time to time arise in
the practice of every one, in which it will be imperative to
open the foetal head ; and also some will occur in which,
though not absolutely so, yet, from the fact of the child
being dead, lessening the head will be the simplest mode of
delivery. To those who are engaged largely in the practice
of midwifery these cases are not infrequent ; and, indeed, it
will by no means rarely happen that, after perforation has
been adopted, considerable, if not insuperable, difficulty
will be found in extracting the head with the crotchet or
craniotomy forceps.
I need, therefore, scarcely apologise for bringing before
the Society the results of an inquiry into the best mode of
delivering the head under these circumstances ; and although,
to a certain extent, I must admit I am treading on not
unbroken ground, still, as the subject has not been so fully
gone into as it deserves, I hope I shall be able to develop
some new points which will serve to improve our practice,
and which will place the operation upon a more satisfactory
basis.
46 DK. BRAXTON HICKS ON
The question itself may be put more practically before us
thus — In a given case of severe distortion of the pelvis, is it
necessary to perform Caesarean section ?
This can only be answered by first disposing of the ques-
tion — What is the smallest antero-posterior diameter of the
pelvis through which the head can be brought by any means
in our power ?
Upon this a third then arises— What is the mode of
reducing the measurements of the foetal head, and of altering
the relations of the now altered diameters so as to produce
the least obstruction ? This latter inquiry seems of late to
have been much overlooked. As a scientific question, I believe
there are only two authors who have reduced it to experi-
ment, namely. Dr. Burns and Dr. Hull, the latter of whom,
in his * Defence of the Caesarean Section,' gives an account of
some experiments made by himself in order to disprove the
assertion of Dr. W. Osborn (upon the celebrated case of
Elizabeth Sherwood), that a foetus could be drawn down
through a pelvic brim whose conjugate diameter is an inch
and a half.
The violent controversy that sprung from this assertion,
headed by Drs. Hamilton and Hull, it must be acknowledged
by all, was a disgrace to our profession, and it tended, no
doubt, as all such violent personalities generally do, to mask
the essence of the point under discussion. Thus, some
valuable facts were lost sight of, and fair argument on them
was prevented.
Doubtless Dr. Osborn was too hasty in his assertion that
in any case he could deliver with the crotchet where the
conjugate diameter was of the size above mentioned, and
possibly he might not have been accurately correct in his
estimate of the measurements of the pelvis of E. Sherwood,
a point always open to some error in the living ; but it is a
curious circumstance that Dr. Hull, in his very attempts to
prove Dr. Osborn false, made some very practical experiments
which went very far to substantiate Dr. Osborn's assertion,
and they showed that it was possible to get the mutilated
head through a very small space when tilted sideways.
The state of mind in which these experiments were
DELIVEEY OF FCETAL HEAD AFTER PERFORATION. 47
undertaken, and the object for which they were designed,
prevented any material advantage being gained by midwifery ;
the roads they opened up were not fully followed to their
goal, and thus the question as to the best mode of delivery
was not answered at that time, so as to be embodied in the
general knowledge of the obstetric art.
The only author, besides Hull, who has gone experimentally
iuto the subject is Burns. The rest of obstetric authors, in
alluding to the use of the crotchet and craniotomy forceps,
have not clearly discussed the best mode of delivering the
head after perforation.
I do not mean to affirm that the use of the crotchet is not
generally alluded to, and directions given to change its posi-
tion on the head in case of its failing to pull it down in one
way or in another ; yet there has been no instruction as to
the principles by which we should be guided in that traction,
with reference to the altered relations of the mutilated head,
except in very general terms.
Dr. Burns, however, seems to have reflected upon and put
to the test of experiments the hints thrown out by Drs.
Osborn and Hull. His remarks upon the point so entirely
coincide with the results of my experiments that, in respect
of the altering the position of the head after perforating, and
after the removal of part of the calvarium in extreme cases,
I cannot do better than quote them : — " But it sometimes
happens that the pelvis is sometimes so small as to require
the head to be broken down, and nothing be left but the base
of the skull. If the child be recently dead the bones adhere
pretty firmly, and in a contracted space it will require some
management to bring them away. But if the parts have
become somewhat putrid, or long dead, the parietal and
squamous bones come easily away, and the frontal bones
separate from the face and bring their obitar processes with
them. We have then only the face and basis of skull left. I
have carefully measured these parts, placed in different ways,
and I entirely agree with Dr. Hull, a practitioner of great
judgment and ability, that the smallest diameter offered is
that which extends from the root of the nose to the chin.
48 DR. BRAXTON HI0K8 ON
For in my experiments, after the frontal bones were com-
pletely removed, this did not in general exceed an inch and a
half. It is therefore of great advantage to convert the case
into a face presentation, with the root of the nose directed to
the pubis .... but I would conclude that whenever the
pelvis, with the soft parts, measures fully an inch and three
quarters — or if the head be unusually small, the child not
being at the full time, an inch and a half — the crotchet may
be employed, provided the lateral diameter of the aperture in
the pelvis be three inches, or within a fraction of that,
perhaps two and three quarter inches, if the head be very
soft." " In this manner of operating, the face is drawn down
first, and the back part of the occipital bone is thrown flat
upon the neck, like a tippet. If we reverse this procedure,
and bring the occiput first and face last, fixing the instrument
in the foramen magnum, then, as we have the chin thrown
down on the throat, we must have both the neck and face
passing at once, or a body equal to two and three quarter
inches. If, on the other hand, we fix the instrument on the
petrous bone, which is certainly preferable to the foramen
magnum, and bring the head sideways, we must have both
that bone and the vertebrae passing at once, or a substance
equal to two and a half inches in diameter ; and if the head
pass more obliquely, then it is evident that the size must be a
little more. Although, therefore, Dr. Osborn be correct in
saying that the base of the cranium turned sideways does not
measure more than an inch and a half, yet we must not forget
that, when the opposite side comes to pass, the neck passes
with it, which increases the size."
It is a curious fact that Burns was the only author who
clearly saw the true bearing of the whole subject of the dispute
between Osborn and others.
Dr. Davis, who paid much attention to the improvement
of the crotchet, appears to make no mention of the matter ;
and even in his description of the " osteotomist " he does not
give any directions how to draw down, but rather directs to
the total removal of, the head, by bringing it away piece-
meal.
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 49
Dr. Denman, writing after Osborn, even with knowledge of
his works, and being present at the case which was the text
to Osborn's remarks, after advising in cases of moderate
difficulty to pull down the perforated head in the original
position, says (p. 172, vol. ii. 4th edit.) : '' In a case of very
great difficulty it is, however, possible that all the bones of
the cranium might be brought away successively, and nothing
remain of the head but the basis of the skull with integu-
ments. In such a case it has happened, quite unexpectedly,
that I have succeeded in bringing down the remainder of the
head merely by grasping the integuments firmly in a mass, or
even in distinct parts, and pulling down in a proper direction.
But if these should be found insufficient, the crotchet is to be
introduced again, and fixed upon the basis of the skull on any
part where we can get a firm hold, and this, assuming a more
convenient direction, will be more readily brought down. I
have not found, in cases of this kind, that I have acted from a
preference for fixing the instrument in this or that part or in
this or that maimer; but giving myself time to reflect, the
exigence of the case has dictated what I ought to do, so that
I am not solicitous about any particular method. Some have
thought that it was of great importance to fix the crotchet on
the outside of the head, and others have insisted on the
propriety and superior advantages of affixing it on the inside;
hut I am persuaded that such things are of little consequence,
and that in the course of a difficult operation it may be found
necessary and useful to fix it in either way."
This is very explicit, and Denman evidently repudiates
any advantage from any particular manner or direction in
employing traction.
Smellie (see edition of 1784, chap. 3, sect. vii. p. 219), after
describing the introduction of the crotchet into the opening,
as is generally advised, says : *' If it does not soon answer the
purpose, I introduce my finger, as above, further, and slide
the point up along the outside above the under jaw, and have
succeeded several times with this instrument, except when the
pelvis was so narrow as to require a greater force, when we
must use others." But shortly after he particularly says, in
50 DR. imAXTON HICKS ON
approving the passing the tractor outside, "that the head
never comes down in a flattened form, but the vertex is
protuded in a narrow point, and the whole squeezed into a
longish form." After this he says, if it does not then descend,
he places a crotchet on each side of the head, and then pulls
to the utmost of his strength, so that sometimes he has been
scarcely able to move his fingers or arms for many hours
after. Hence it appears he pulled directly down on the axis,
the direction of the head relatively to the brim being
unchanged.
Mbrriman (* Synopsis of Gases of Difficult Parturition ')
says nothing beyond alluding to the fact that Dr. Osborn
has investigated into the best method of procedure in cases of
distorted pelvis.
Dr. Churchill (' Midwifery,' 1860, p. 369) alludes to Dr.
Osborn's investigations, and, after quoting the opinion of
various authors as to diameter of the pelvis through which it
is possible to draw a child, says, "I would not venture to
have recourse to craniotomy unless the antero-posterior
diameter was fully two inches." He, however, does not men-
tion the mode Osborn adopted and recommended, which is an
essential point of his argument, and dwelt on by him particu-
larly. He says: *'In some cases the distortion of the pelvis
is too considerable to admit the passage of the head even
when emptied of its contents, or the obstruction may result
from the ossification of the bones of the skull ; in either
case an extension of the operation is necessary to complete
the delivery. This may be effected by breaking up the
cranium with a small pair of forceps, resembling Dr. Davis's,
or by the cephalotribe."
Dr. Eamsbotham ('Obst. Med. and Surgery') gives no
special direction as to the part of the foetal skull to which the
crotchet is applied, either externally or internally, nor makes
any mention as to the altering the position of the mutilated
skull during the traction. In one part he says, "the small
blunt hook may be fixed in the foramen magnum or behind
an orbit" (op. cit., 306).
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 51
Dr. Bland (* Observations on Human and Comparative
Anatomy,' pp. 213-223), in reviewing Dr. Osborn's work on
the case of E. Sherwood, after alluding to the incompressibility
of the base of the skull, says, "This the author (Dr. Osborn)
seems to be aware of, and therefore says that by removing
the parietal bones we shall be enabled the easier to reach
the basis of the skull and turn it edgeways, and thus with
greater facility to bring it through the contracted strait of the
pelvis." But he denies that Osborn did this intentionally,
but that it was the result of employing only one instrument
in drawing the head down. After discussing the best mode
of applying the crotchet, whether inside or out, he recom-
mends it to be applied externally, against the advice of
Osborn, and continues, "Besides, he seems to think that it is
only by fixing the crotchet withinside the head that we shall
be enabled with it to turn the basis of the skull and bring it
down edgeways." Again: "I have generally thought it
proper to leave it to the discretion of the operator to apply
the hook or crotchet within or on the outside of the skull,
wherever he could get the firmest hold ; but in this it seems
I have been mistaken, and Dr. Denman has incurred the
censure of our author for maintaining a similar doctrine."
Hence it is evident he was fully aware of the bringing the
skull aslant, but has no particular preference on the matter,
and rather stiffly criticises Osborn's having one.
Dr. Murphy ('Lectures on Parturition') quotes Dr. Osborn's
case rather fully, "because it accurately describes an opera-
tion with the crotchet different from what we have described
— one by which the vault of the cranium is quite broken up
and removed, and the base of the skull is drawn obliquely
through the contracted brim of the pelvis, the crotchet being
fixed in the foramen magnum." Beyond this I find no
allusion to the position where it is best to place the crotchet,
nor to the subject of the present paper.
Dr. Hamilton ('Letters to Dr. Osborn') thinks it a very
difficult thing to deliver the head as Osborn stated he had
done. In detailing an experiment with the drawing of a
dead foetus and an artificial pelvis, he makes the following
E 2
52 DR. BRAXTON HIOKS ON
remarks : — "Let the cranium be broken down as much as can
be done in real practice, and then, by means of a crotchet
fixed in the foramen magnum^ let it be tried whether it be
possible to extract it." Again, in another place, he remarks,
when the base of the skull is turned sideways, "the neck
must add somewhat to the volume of the head." Thus, he
was only considering the mode recommended by Osborn,
namely, fixing the head in the foramen magnum and tilting it
sideways.
In the commencement of this paper I alluded to Dr. Hull ;
I shall now notice the experiments he made in the mode
of delivering by embryotomy. In defending Csesarean section
from the conclusions of Dr. Osborn, \vho considered that his
case of Elizabeth Sherwood had shown that the crotchet was
equal to delivery under any circumstances, he made a series
of experiments to prove Dr. Osborn's statements incorrect.
He made in several boards, an inch thick, a series of aper-
tures of the form and size of the brim of several very
deformed pelves, whose measurements are given by him.
Three of these were produced by malacosteum, three by
rickets. Among the latter the pelvis of Elizabeth Sherwood,
after the size of Dr. Osborn himself.
He then produced a foetus of moderate size, from which he
removed the parietal and frontal bones down to the base of
the cranium, and bent the occipital bone a little behind the
foramen mangum, so that it would either lie back on the neck
or forwards upon the base of the cranium. Thus reduced, it
measured from chin to the top of nose, at its smallest,
an inch and a half, and nearly a quarter inch more from
chin to top of orbits ; from the external canthus of one orbit
to that of the other two and a quarter inches ; the same from
one zygomatic arch to the other ; from the top of the nose to
the posterior part of the condyles of the occipital bone three
and a quarter inches. He then remarks: "When these
different dimensions are attentively considered it will appear
to every one that the most favourable position in which the
head so reduced can be applied to a small aperture, with a
view of dragging it through with a crotchet, is endivise, with
the chin to the sacrum or to the os pubis ; not occiput
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 53
foremost, because in this case the volume of the face must be
added to that of the neck ; nor sideways, as Osborn states he
placed it in the case of Elizabeth Sherwood."
These remarks are very important, and I believe, with the
exception of Dr. Burns, no other English author has so
clearly pointed out this fact, although, doubtless, it must have
struck many minds before and since, the point being palpable
on the slightest consideration.
He then with the crotchet endeavoured to draw this muti-
lated head through these apertures, trying sideways and then
endways ; the crotchet sometimes fixed in the foramen mag-
num or in the sella turcica ; sometimes with the chin to
pubis, sometimes to sacrum. But in all these trials he found
it impossible to draw it through sideways, and with only great
force endways in some instances, and in one or two without
much difficulty ; and concludes that it would not be possible
to draw a child through a pelvis having the diameter of
Elizabeth Sherwood's, as stated by Dr. Osborn, without
inevitably destroying the woman ; that it is not always prac-
ticable to extract a child by crotchet through a pelvis having
that space from pubis to sacrum, or from the fore to the hind
part of the superior aperture. He then proceeds to discuss
the mode of applying the crotchet, disputing the policy of
the plan recommended by Dr. Osborn, namely, on the inside
of the head. He says, *' But if we apply the crotchet on the
outside, especially under the lower jaw, we shall find it more
easy to obtain a firm purchase, and to turn the head edge-
ways or more or less endways."
He afterwards gives some rules, or rather indications, of
treatment in difficult cases. Those which belong to our
subject are the following : — " Supposing the pelvis affected
with rickets measures less than two and a half inches and
more than one and eleven-twelfths from pubis to sacrum, a
foetus of average size may be brought through by the perforator
and crotchet ; and it may be extracted by them even when the
same diameter is less than the above, provided there be a space
on one side equal to two inches from before to behind, and a
little more than three and a half inches long. Supposing the
pelvis distorted by malacosteum measures one and three
64 DR. BRAXTON HICKS ON
quarter inch from before to behind on each side opposite the
acetabulum, a moderate-size foetus may generally be extracted
by embryulcia, as the diameter taken from the symphysis
pubis to the os sacrum is always considerably greater in these
cases, and the pelvis sometimes yields a little to the head as
it passes. The practicability of delivery will, however, depend
in a great measure upon the depth of the tube of pelvis,
especially anteriorly." After directing in the larger pelves to
wait after perforating, he continues : " But if the directions
given above should not be sufficient, we should break the
bones composing the upper part of the cranium, by repeated
application of the crotchet ; and we should loosen them from
the scalp, and extract them carefully with the fingers or a pair
of forceps, to avoid injuring the vagina and other soft parts.
When the deformity is very great it will be necessary to
apply the crotchet on the outside of the cranium, in order to
give the base of it a more favourable direction by turning it
edgewise or more or less endwise."
These important observations and experiments have not, it
appears to me, had their fall weight upon practice. Possibly
they have not been so completely gone into as they deserve.
Dr. Simpson, in entering upon the same subject, says
(* Obstetric Memoirs,' 1855, vol. i. p. 622), after alluding
to the error of changing position by the use of the crotchet,
and increased difficulty thereby in cases of common embry-
otomy, says: "We are perfectly aware that when the pelvis
is much contracted we are obliged, as has been well pointed
out by Dr. Hull, to alter in various ways the presentation of
the head, always, however, bringing it into such positions
that its diameters are in each case those requiring the least
possible space."
Foot-note to same. — " When the crotchet is fixed upon
the posterior part of the parietal or upon the occipital region,
the infant's head can be brought down through an inch or so
less in diameter than when the crotchet is fixed upon the
frontal region. In fact, when the crotchet is fixed upon the
forehead it brings the head down in an increased diameter,
required by an ordinary forehead presentation."
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 55
This, of course, applies to ordinary perforations. But is
this really the case ? And if it is so, to what extent is it so ?
Where is the division between an ordinary case of perforation
and one in a much contracted pelvis ? What is the rule for
those cases which are between these extremes ? It is highly
important that we should know something of these points, in
order that we may have some sort of principle by which to
employ our traction, and some knowledge of the extent to
which cephalotomy is required.
It is these questions whose answer is attempted in this
paper.
And, first, it must be understood that, unless expressly
stated to the contrary, the head is in the position termed " at
the brim," with the base at least still above the brim. It
will, it appears to me, be the clearer plan to consider first the
best mode of delivering the head after perforation in severe
distortions, and then to pass to the notice of the less im-
portant obstructions.
If the whole calvarium of a full- term foetus be, removed,
so that only the base of the skull be left, it will be readily
perceived that the relation of the diameters is altogether
altered, as I have before shown was illustrated by Drs. Hull
and Burns. This is so self-evident that it were almost a
needless task to enter further into the subject had it received
that full attention it deserves.
The diameters of the head, in opposition to the conjugate,
are nearly the same as before the biparietal was destroyed,
the bizygomatic taking its place if the head be still pulled
down in somewhat the same direction as that in which it
presented originally ; it will therefore be seen that but a
slight advantage will be gained by this removal. The differ-
ence of half an inch is the very outside of the gain. This, of
course, in slight obstructions, is sufficient for delivery, but of
these I am not now speaking, because simple perforation will
also give the same amount of reduction.
If, then, traction were continued by the crotchet attached
to the neighbourhood of the centre of the base inside, nearly
the same difficulty continues as before perforation. But by
removing the calvarium we completely destroy the vertical
56 DR. BRAXTON HICKS ON
diameters of the foetal head, and thus annihilate the dis-
advantage of face presentation. What remains of the vertical
diameter never exceeds an inch an a half in the largest child,
hut on the average is about one inch only. That is to say,
the distance from the alveolar ridge of the upper jaw to the
root of the nose or the supra-orbital ridge is of never more
than these measurements. In this I do not reckon the
lower jaw, because it never need be considered as a serious,
or even any, obstacle ; it either opens, thereby passing out
of consideration, or it can be readily broken by moderate
traction.
Let, then, a skull so reduced be made to present at the
brim, with the face downwards, as in face presentation. It
will be seen that the longitudinal diameter of the head,
normally opposed to the transverse or oblique of the pelvis,
now is coincident with the axis of the pelvis. The transverse
of the head is now opposed to the transverse or oblique of the
pelvis ; and the vertical diameters of the head, now reduced
to between one and one and a half inch, is opposed to the
antero-posterior or conjugate of the pelvis.
Now, as it is very seldom that the transverse diameter or
its representative is so much reduced in distortions of the
pelvis as to fall below the diameter of the bizygomatic,
namely, from three to three and a half inches — say, in the
largest clothed skull, four inches — it is evident that with this
space laterally, and the conjugate of over one and a half
clear diameter in the clothed pelvis, could we succeed in fairly
adapting them, we should be able to draw an average-sized
head through.
Of course, in the irregular distortions of the pelvis the
difficulty of adaptation is great, and it will now and then
happen that, although the antero-posterior diameter may be
over two inches, its working diameter may be much less, or
the lateral portions of the brim may pass backwards so
sharply as to exceed the curve of the base of the skull. These
conditions may cause an insuperable obstacle to the passage
of the head in any way, and particularly if the outlet and
cavity be also deformed. These are the extreme cases, and
they must be carefully examined before delivery is attempted
DELIVERY OF FCETAL HEAD AFTER PERFORaTIOx^. 57
under the guidance of the principle for reducing the head as
here laid down. Dr. Hull has carefully examined this point
in the work above quoted, to which the reader will do well to
refer. Tt is in the more common form, namely, reniform or
ovate pelvis, that we find less difficulty in adapting the
remains of the head to the distorted brim.
This adaptability will be still more complete when, with a
face presentation, we cause the inside of the base to present
backwards, so that the promontory of the sacrum can project
into the hollow of the base, while the curve of the lateral
portions of the base will naturally correspond to the curve of
the distorted brim, which, it will be remembered, is always
directed backwards in those whose antero-posterior diameter
is shortened either by rachitis or mollities ossium. In this
case the chin will be forwards in the normal position, as in
ordinary face presentations.
In the accompanying drawing is shown, of the natural size,
the outline of the brim of the pelvis given by Dr. Swayne in
last year's volume of the 'Transactions,' in which he per-
formed Csesarean section. In it is placed the head, face
forwards, of an oversized foetus, which weighed ten pounds,
whose calvarium has been removed, also drawn of the natural
size. This head was made to descend without much difficulty
through it. Of course it will be understood that, the soft
parts being absent, this result cannot be taken as a guide as
to the possibility of delivering the child by craniotomy in
this case. A rather small full-term foetal head treated in the
same way readily passed through this dry brim. This pelvis
measured one and six-tenths inch in its longest antero-
posterior diameter. The other measurements are given in
the drawing.
But if, instead of inducing face presentation, we cause the
head to present to the brim by the side, drawing it down
sideways, as recommended by Osborn and others, it is not
difficult to perceive that the neck would to a certain extent
be added to the depth of the base in causing an obstacle to the
passage ; besides which the transverse or oblique of pelvis is
still opposed to the longitudinal diameter of the head, instead
of the bizygomatic, as in the face presentation instanced above.
68 DR. BRAXTON HICKS ON
Supposing, again, the occiput be drawn down first instead
of the face, the diameters of the head as opposed to the
pelvis are the same as in the face presentation above
described ; but it will be readily perceived that the neck adds
considerably to the vertical diameter as soon as the posterior
half of the base is drawn through the brim. Therefore
we have the difference between neck and occipital bone as
when face presents, and neck and facial bones with the lower
jaw as when the occiput is drawn down, equal, at least, to an
inch.
Thus it will be perceived that after the calvarium has been
removed the easiest position for the head to descend is by the
face presenting downwards, the chin pointing forwards. This
I wish particularly to dwell upon, because it has almost
entirely been overlooked by obstetric authors in England,
and, as far as I am aware, abroad also. I believe Dr. Burns
is the only one who has clearly seen and described this point
as I have above quoted.
Assuming that these points will be received as sufficiently
proved, let us now turn our attention to those cases where
perforation is required under the slightest amount of obstruc-
tion which may necessitate its employment. In the lesser
obstructions requiring it, it is plain to all that the mere les-
sening the contents of the head will permit such a diminution
of the diameters as will allow the head to pass by the assist-
ance of the natural efforts or by very slight traction. In this
case, of course, we do not require to do more than pull the
head down in the original direction. This point also, I con-
sider, will be admitted by all.
It seems, therefore, to follow that, if in considerable con-
tractions of the pelvis the induction of face presentation,
after the removal of the calvarium, is the best plan of
delivering the head ; and yet in the minor diminutions the
original position, that is, the continuation of the vertex
X^resentation, is the best ; there will, of necessity, be states of
pelves where the advantages of the two plans would be equal.
In other words, we may put it as an inquiry — In what amount
of pelvic contraction can we best induce face presentation,
and in what continue traction by pulling at the occiput ?
DELIVEBY OF FOETAL HEAD AFTER PERFORATION.
59
/
60 DR. BRAXTON HICKS ON
This will be answered by ascertaining the reduction ot the
various diameters of the foetal head produced by varying the
degree of the evacuation of the brain, and afterwards removal
of different quantities of the bones of the calvarium.
It will be well to remember that after lingering labour with
vertex presentation, the head having entered half way into
the brim, there has been a not inconsiderable diminution of
the fronto-occipital diameter as well as of the lateral, so that,
could the presentation be converted into a face, a great portion
of the obstacle to this latter presentation would be removed.
The appearances of the foetal head after both these presenta-
tions readily show this point, the chief difference being that
after face presentation the vertical depression is the more
complete, the elongation taking place more towards the occi-
put than in the lingering vertex labours. However, the
elongation, and that in a backward direction, of the mento-
bregmatic diameter, by these means would interfere somewhat
with the facility of the conversion, presenting, by its projec-
tion against the right or left side of the promontory of the
sacrum or other portions of the brim, an obstacle requiring
some force to overcome. Again, supposing we perforate and
evacuate some of the brain, we shall still further reduce the
fronto-occipital diameter, in addition to that produced by the
compressive action of the pains, and, therefore, to a certain
extent, neutralize the comparative advantage of changing the
direction of the presentation.
Another point has also to be considered, namely, this, that
with face presentation at the brim, even with a certain amount
of reduction of the size of the cranium, the bizygomatic
diameter of the foetal head is still opposed to the conjugate of
the brim, much the same as in ordinary vertex presentation ;
while the fronto-mental corresponds with the oblique of brim,
in obedience to the mechanical law that the smallest diameters
of the head will be -opposed to the smallest of the brim, and
the longest to the longest ; as long, therefore, as the bizy-
gomatic is smallest it will oppose the antero-posterior of brim,
so that it follows that till the reduction of the size of the
cranium is carried to a point below the bizygomatic diameter
there will be no material advantage gained by altering the
DELIVERY OF FffiTAL HEAD AFTER PERFORATION. 61
vertex presentation into that of face. If we calculate the
average of the clothed bizygomatic of a full-term fcetus at the
lowest to be three and two-eighths of an inch, then down to
that point there will be no particular advantage in changing
the vertex presentation into face, excepting this, that if the
bones easily separate we have a better hold on the outside of
the skull, with less liability to bring away the bones. It is
when the antero-posterior diameter of the pelvis falls below
that of the bizygomatic that the advantage of induction of
face presentation begins to be apparent, but, of course, only
by the removal or fracture of more or less of the bones of the
calvarium, proportionately to the decrease in the conjugate.
In order to ascertain the amount of reduction of the
diameter of the foetal head under varying degrees of perfora-
tion, evacuation, and breaking up of the calvarium, I have
made experiments, comparing these diameters which oppose
under the different presentations.
The details of these examinations I have placed in a
somewhat tabular form, but the results all lead to the same
conclusion, which I may briefly sum up in these words : —
After perforation, and up to the evacuation of about one
quarter of the brain, the occipito-frontal diameter is smaller
than the mento-bregmatic ; but after this point the mento-
bregmatic diminishes in direct proportion as we evacuate
the brain, reduce the rigidity of the calvarium, or remove it
altogether.
In other words, when a quarter of the brain has been
evacuated, and the bones of the vertex somewhat softened
by the aperture made by the perforator, the mento-bregmatic
and the occipito-frontal cause equal resistance, but that the
continuation of the evacuation and removal of the bones
renders proportionately the mento-bregmatic the less. Thus,
the induction of face presentation, after this point has been
reached, will be the most easy way of delivering the head,
provided the obstacle cannot be overcome by traction on the
occipital bone, and provided the conjugate be less than the
bizygomatic, as I before mentioned.
These experiments have been made upon fourteen full-term
children, many of whose heads were larger than the average.
02 DR. BRAXTON HICKS ON
From the analysis of the results of these experiments the
case may, perhaps, be stated even stronger, for it will be seen
that although, as all are well aware, the vertex presentation
is better than the facial when the head is in the natural state
(although not so much always from its less diameter as from
its greater facility for compression), yet that directly after the
opening of the skull, and evacuation of as much of its
contents as takes place in the simple forms of perforation,
the vertical diameter, or mento-bregmatic, receives a reduc-
tion in a greater ratio than that one which engages the brim
in ordinary vertex presentations, namely, the fronto-occipital.
Indeed, even in this stage in many instances the former was
actually rendered materially less than the latter, so that at
any rate the conclusion above arrived at may be accepted as
rather within the truth than beyond it.
To militate against this advantage there is the less com-
pressibility of the head in face presentations, also the obstacle
above alluded to from the elongation of the head into the
cavity of the pelvis.
It will, however, readily be seen, from the nature of the
case as well as from the experiments, that upon removing a
part of the calvarium these two objections cease entirely,
while at the same time all the advantages which I have pointed
out to be gained by face presentation after total removal of
the bones rapidly come into play.
I have in these remarks treated the head at the brim as if
the plane of the fronto-occipital diameter were parallel to
that of the brim (a point which has many supporters),
because in this case it makes no difference ; any obliquity
which does or may occur does not influence the principles
here laid down, acting equally in all.
I have not alluded to the obliquity the above-named
diameters of the head may assume during its progress through
the brim, because, as this takes place by mechanical force,
the movement is sure to occur in those directions which give
the least opposition to the passage, and any obliquity which
occurs acts equally to the advantage of both.
Of course, in the more complete mutilations of the head,
and in the severe and irregular distortions of the pelvis, such
DELIVERY OF FtETAL HEAD AFTER PERFORATION. 63
as those produced by malacosteum, the head will have to be
brought through in a less regular manner than obtains in
ordinary simple perforation, but then this also has equal
effect on both sides of the question ; all our traction must,
however irregular, be guided by some principle or another,
and it seems to me a great advantage to know for certain the
position of the head, which of necessity offers the least
obstacle to a deformed brim ; the advantages to be gained by
altering slightly, by swaying or other procedure, the head in
its newly induced position will be readily recognised by those
at all conversant with the operation, and which will be
developed in the progress of the case almost as a matter of
course. This may be well observed if we watch the descent
of the head reduced as above indicated whilst drawn through
an unclothed pelvis. It will, unguided, in the majority of
cases, follow in the direction most free from opposition.
Should any check take place it will be then overcome by
varying slightly the direction of the traction.
These remarks are, indeed, but truisms ; yet in ail their
bearings they are not so fully considered as they ought to be,
neither by authors nor by most of us. Perhaps a good
illustration of this may be frequently found in the records
of severe craniotomy cases, where it is stated that, after long-
continued efforts to draw down the head by the crotchet in
every direction, it was at last accomplished by hooking the
instrument into the orbit, superior maxilla, or zygoma.
In urging, however, the advantage of face presentation
after a certain degree of collapse of the skull, I may be per-
mitted again to mention that it is clearly to be observed that
there is much difference in the opposing diameters, whether
the chin descend anteriorly or posteriorly, and this holds
peculiarly strong in considerable contractions of the pelvis.
A glance at any pelvis whose sacrum has fallen forwards will
show that there is a general tendency to a quarter-moon form,
the concave aspect being forward ; and this may be said to be
more or less present in the working spaces of even the
most distorted brim of this class. A slight consideration
also in reference to the form of the base of the foetal skull
without the calvarium points out a similarity, at least in its
64 DR. BRAXTON HICKS ON
internal aspect, and consequent adaptability to the projecting
sacrum.
Hence, it makes some difference in these cases of severe
distortion whether we make these curves coincident or oppos-
ing, and particularly in the Y-shaped or beaked pelvis. It is
not difficult to see that if we do not attend to this point we
may lose the advantage in some cases of three-quarters of an
inch to one inch.
I directed my attention during the experiments with a view
to ascertain how best to secure this result, and I was pleased
to find that there was a great tendency in the mutilated head
during traction to assume, by the mechanical forces, a posi-
tion which gradually brought about this desired coincidence ;
besides which it was found always quite possible and easy at
the commencement of drawing down to change intentionally
the position of the child from the posterior-oblique aspect to
that of the anterior-oblique ; when so much has been accom-
plished, if we draw down the face, the chin readily glides
forward and assumes the position as in ordinary face pre-
sentations. It is only the first quarter turn which is required,
and the rest follows naturally, and this quarter turn is best
made at the very commencement of traction. Of course, I
assume that by this time the exact position of the head has
been ascertained, which is easily done by an examination of
the base, even if not discovered previously. And the ob-
servations from these experiments have been corroborated by
actual practice, for I have not hitherto found any difficulty in
inducing the chin to take a forward direction.
To place the. whole of these observations in a concise form,
it may be said as follows : — That although, as has been
always acknowledged, the vertex presentation in natural
labour is the best, and that after perforation and the evacua-
tion of the brain up to the extent of one fourth this rule holds
good ; yet if the evacuation of the brain and collapse of the
calvarium by this means, or by more or less fracturing the
bones, be carried to a greater degree, that is, in cases where
the conjugate diameter is less than the bizygomatic, we find
that the facial presentation affords the easiest mode of de-
livery ; and, further, that if we remove the whole calvarium.
DELIVERY OF POSTAL HEAD AFTER PERFORATION. b5
leaving merely the base, and then induce face presentation,
taking care that the chin as it descends point anteriorly, we
diminish to the smallest possible amount the opposition of
the head, leaving only from one to one and a half inch in
depth to oppose the conjugate diameter of the pelvis, and
three to three and a half, at the most four, inches to the
transverse or its representative. When I say "to the smallest
possible amount," I mean except we remove the whole of the
base piecemeal.
It now remains to consider what practical inferences we can
draw from these facts, and in what manner we can best
apply them; afterwards to give some illustrations of their
application to practice.
The first inference which I would mention is that, when the
pelvis was only moderately contracted in its antero-posterior
diameter, and it was found that after the simple operation
of perforation due traction made by the ordinary means
failed, it would be better to remove a portion of the calvarium
purposely, if this had not been already done by the efforts of
pulling ; or to fracture the bones of the calvarium ; or both
combined, and then to induce face presentation. The extent
of fracture and removal of the bones must depend upon the
deformity of the pelvis ; but I am sure it would be better to
make it too complete than the contrary, for whereas this
portion of the operation is but simple, and with ordinary
care against laceration attended with but little risk, the same
cannot be said of the tearing away portions of bone during
the continued endeavours to pull down the head in the man-
ner generally done. The former is done methodically, with
only moderate force, whilst the latter is produced by an
uncertain quantity. The best plan to effect this object is to
pass the outer blade of the craniotomy forceps between the
scalp and the bone, instead of outside the scalp. By this
means the bone is more readily torn away, being also pro-
tected by the scalp completely till the hand can guard it from
lacerating. Let portion after portion be thus removed, and
then, before the face presentation is induced, the loose por-
tion of scalp is to be carefully folded over all the edges and
passed inside the opening of the bones. It is generally the
66 DR. BRAXTON HICKS ON
best plan to fracture the bones first by a sudden twist of the
hand, as suggested by Dr. Simpson.
The second inference we may make is the extension of this
action to those cases where the distortion is severe. Where
the conjugate diameter is reduced below two and three quarter
inches, the foetus being at full term, then the best plan is to
carefully and intentionally remove the whole, or nearly so, of
the calvarium, as just above described, carefully preserving
the scalp as a covering for the edges of the bones, after which
the face is to be made to present. The chin should be drawn
anteriorly if it be not already in this position. As in the
partial removal of the calvarium, so also in the complete, it
is best to do it in the manner above mentioned.
It may be here incidentally remarked that in all cases of
perforation, where it can be easily done, it is of great advan-
tage to pass the hand altogether within the vagina, both w'hen
perforating and also when removing the portions of bone.
As a rule, it will be found very practicable, as those cases are
comparatively rare where, except in mollities ossium, the
outlet and cavity will not permit the hand to pass ; and it
gives great comfort to the operator's mind, inasmuch as he
can regulate his movements with precision ; and much security
to the patient, as the soft parts can be guarded with a
certainty, impossible with the fingers as usually employed.
If the bones be difficult to fracture or remove, then Dr.
Simpson's cutting craniotomy forceps ma^^ be employed
with benefit ; but it is very necessary to be particularly
careful that the sharp edges of the cut bone be not without
protection.
It is advisable to leave the orbital ridge, in order to give
facilities for producing face presentation and to give a firm
part upon which to pull; and the occipital bone should be
well looked to, in .order to remove any spicula projecting from
it, even although guarded by the scalp. If it be difficult to
remove all, or if the pelvis be not much deformed, then it
might be permitted to double the upper parts over into the
interior of the base, so as to be out of the way.
The mode by which face presentation is induced is by no
means difficult, and the readiest plan, I believe, will be found
DELIVERY OF F(ETAL HEAD AFTER PERFORATION. 67
to be by means of the crotchet or, which I much prefer, at
least at the commencement of the operation, by a small blunt
hook. The one I use is of the following size: — The diameter
of the iron rod from which it is made is about a quarter of an
inch, of the length of the ordinary blunt hook, with handle
also alike. The hook is a half circle about one inch in
diameter, and is made hard to prevent its opening during
traction ; the shaft is made of soft iron, and can be bent by
the hand into any form, being thus adaptable to any situa-
tion. I may mention here that this hook is useful in other
cases in a variety of ways, where it is impossible to emplo}^
the unwieldly blunt hook in general use.
The advantage of this hook over the wide awkward crotchet
for the passage outside the head is immediately apparent
when we consider that by passing it flatwise it cannot
possibly do harm in even unaccustomed hands, which cannot
be said of the crotchet in such a position ; and when it is
understood that we have not to fix the hook into the skull, but
into the natural ledges against which we pull, namely, the
orbit, zygoma, upper and inferior maxillae ; and, further ,^
when we see that it can be so readily dislodged from these
attachments, a movement by no means easy in the crotchet,
even should it not have penetrated the bones.
If this small hook be passed flatwise along the exterior of
the head anteriorl}^ and when it has reached the probable
position of the orbit, then the point can be turned towards
the head, and afterwards, by gently feeling, it can be easily
ascertained if it has lost hold of the supra-orbital ridge. If
it has a firm hold, we may at once conclude that it has
reached this point ; if the hold be not firm, we have probably
found the zygoma. We may draw upon this latter point
because I have found that traction on this point will also cause
the face to come downwards ultimately, at least so as to
shortly reach also the orbit. However, it will always be best
to ascertain the actual position of the face, and then to pass
the hook in that direction, and the orbit will be certainly and
readily found. If we do not at once hit off the orbit we must
feel gently with the hook in the neighbourhood ; but, as far
as my own experience is a guide, there is very little difficulty
F 2
68 DR. BRAXTON HIOKS ON
in the matter. One thing prevents much mistake, which is
that we cannot with the hook bring down the occiput, it will
glide off it, while the anterior part of the head, which we
wish to bring down, has numerous points of attachment.
And here, again, the advantage of the small blunt hook will
be seen, that, whereas the crotchet would seize any inequality
and thus deceive us, the other would only retain hold upon
the desirable parts. I generally, in the less complete reduc-
tion of the foetal head, bend the shank of the hook so as to
facilitate its adaptation to the curve of the head's surface, in
the same form as the shank of the crotchet.
When, then, the hook has taken hold of the orbit, we must
gently draw it down, securing as before mentioned the gliding
the chin anteriorly should it not have already done so.
After the face has been caused to present nearly downwards,
the hook, from the position of the orbit, ceases to hold, and
may glide off; it is then to be passed into the mouth or
under the under jaw. I prefer the former, but should it
slip from this then it can be readily carried under the under
jaw. Should there still be difficulty of retaining firm hold
now, the crotchet should be employed, for the objection to its
use before noticed has by this stage ceased ; the point can be
pressed into the hard palate, and thus a secure attachment
made, and even the blunt hook can be made to assist at the
same time, and thus a steady traction can be employed with
the face thoroughly presenting.
By these means, and by such modifications of it to varying
conditions as any practitioner used to perforation will readily
judge judicious, the induction of face presentation will be
found not at all difficult, and, once accomplished, it will be
seen to be productive of the best results. The descent of the
head, before impossible, now takes place with much celerity ;
nothing is more surprising than the rapid advantage gained,
as has been witnessed by me in several cases.
In these cases, as above shown, there is no necessity for
taking the impediment the lower jaw will give into account,
for when traction is made on the upper the lower jaw is
depressed, and thus the mouth is so opened that it ceases to
impede.
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 69
Should this, from unusual circumstances, be not the result,
the jaw can without much difficulty be broken, and thus also
it will give no resistance. This should be avoided, if possible,
inasmuch as in all these operations any unnecessary chances
of laceration should, of course, be carefully guarded against.
The depth from upper alveolar ridge to root of nose or
frontal sinus is seldom more than one and a half inch, gener-
ally about one inch ; the same measurements will also repre-
sent the depth of the rest of the base till the anterior half
has passed. The resisting portions are then composed of the
neck and posterior half of the base ; this is about the same
as the former in effective resistance, perhaps rather less, for
the neck is not quite a compensation for the facial bones.
It should be here remarked that when the conjugate
diameter is decidedly small, and we have begun to remove
the bones, we must not be tempted, in order to gain time,
to induce face presentation till we have accomplished what
we had at first intended, otherwise it may prove not so
complete as the case requires, and it will be difficult to reach
the occipital bone again, or at least it will cause unnecessary
trouble and distress. The removal of every portion of the
calvarium is not absolutely required in the cases where the
conjugate diameter is about two and four-eighths inches ;
below that measurement it will be proper to remove all.
The rules for guarding the maternal soft parts during every
stage of the operation are the same, and as requisite as in
ordinary craniotomy, of which, indeed, the plan above indi-
cated can scarcely be called a modification, being rather the
substitution of a definite plan of management for an indefi-
nite one. But to one point here it will be well to call
attention, namely, that in the employment of traction on the
outside of head the point of the instrument is always directed
away from the maternal soft parts, and the danger of lacera-
tion from the instruments much reduced.
How far the use of the cephalotribe in vertex presentations
may be superseded by this manner of delivering the head
after perforation, I am not in a position to say. From the
results of my own experience, my impression is that, as far
as brim obstructions are concerned (and it is with these only
70 DR. BRAXTON HICKS ON
I have here dealt) we shall be able thereby to accomplish as
much as, and a great deal more than, can be done by this
instrument. Comparing the relative risks of lacerating the
maternal soft parts by either, one would think that there was
not much difference. Carefully done, the removal of the
fragments of bones need seldom cause injury; about the
same may be said of the extrusion of angles of bone during
the crushing of the cephalotribe, because they would in most
€ases be covered by scalp ; without this protection the latter
instrument would be more likely to injure, because it would
occur without our knowledge.
Comparing the ease of application, it is clear that the
small blunt hook can be passed in spaces impassable to the
cephalotribe.
In the severe contractions of the conjugate diameter delivery
of the head by the plan above recommended is more practic-
able than by crushing. No amount of compression can so
effectually reduce its diameter as the removal of the cal-
varium. Indeed, there is little doubt but that it brings us to
the boundaries which divide embryotomy from Caesarean
section.
By it we can reduce the head to such small dimensions
that it will pass more readily than the remainder of the body.
In one of the cases hereafter given I found even the foetal
pelvis cause much more trouble to draw through the brim
than the foetal head.
And thus Dr. Osborn, although he asserted strongly upon
only one case, was not so very wide of the truth as his
contemporaries would have us believe when he asserted that,
given a conjugate diameter of one and a half inch, he could
bring a child through. That there were other elements to be
considered before he could with safety assert that thereby
Caesarean section could be done away with was well pointed
out by his critics ; but doubtless he saw so clearly the advan-
tages that the tilting of the base of skull purposely (although
he did not tilt it in the best manner) gave the practitioner,
that the gist of the question whether the foetus could be
brought through the natural passages in extreme cases, did
not then apply to the head.
DELIVERY OP FCETAL HEAD AFTER PERFORATION. 71
Be this as it may, I feel that with craniotomy, conducted
on the principles herein indicated, the consideration as to the
performance of Caesarean section is to be influenced rather by
the size of the body, and particularly of the pelvis, than by
the size of the head.
This brings us, as above observed, to the plan recommended
by the late Dr. Davis in extreme cases, namely, of removing
the child piecemeal by the instrument he invented — the
osteotomist. However, it is not intended here to enter on
this part of the discussion ; but this much, I think, may be
said in reference to delivery by natural passages or by
Caesarean section, that in extreme cases, with the foetus alive,
we should carefully weigh the respective dangers ; but if the
foetus be ah-eady dead, and particularly if decomposition be
commencing or already established, whereby the peritoneum
will be exposed to most irritating matters, then, the risk of
Caesarean section being extreme, we should proceed to reduce
the bulk of the foetus by these other measures, if they be by
any means practicable.
In the above remarks I have purposely avoided discussing
the plan of turning after perforation, which is valuable in
certain cases, confining myself to cases of vertex presenta-
tion, where we have no option but to deliver the head as it
originally presented at the brim. However, here we must be
guided by the foregoing principles ; and should the head
remain fast after version, the occiput should be drawn down
first, in preference to the face.
It might be said that in using the crotchet inside, or the
craniotomy forceps, in every case of craniotomy, we do
virtually tilt the skull when these are employed in front or on
side of head. To a certain extent this is true, but hitherto
the directions have generally been to apply them to the
posterior rather than to the anterior, or to any part indefi-
nitely. In some works the crotchet is directed to be applied
to the sella turcica or foramen magnum, than which nothing
can more show the want of appreciation of the whole ques-
tion. The difference between the application of the tractor
to the inside of the skull and when applied to the orbit or
upper jaw is, that the latter is definite and complete, and in
72 DR. BRAXTON HIOKS ON
severe contractions of the conjugate diameter this makes the
difference between the possibihty and impossibility of deHvery.
This imperfection of alteration rather tends to increase the
opposing diameters produced by the head than to decrease
them in the extreme cases ; it is, however, of less importance
in the minor contractions.
There is one more practical hint which may be derived
from the above considerations, namely, that the plan of
waiting for collapse of the bones need not be employed.
When once we have determined to perforate, it will be best to
proceed at once to its final result. The putridity of the child
adds much to the risks of the mother, especially if abrasions
or lacerations should occur. These remarks, perhaps, are
scarcely needed in the present day, but I think they cannot
be too well remembered.
It must not be understood that in the above remarks it
is intended to be stated that the passing of a hook outside
has never been employed as a means of delivering the fcetal
skull, because the records of difficult cases show that it has
been frequently done ; but generally, as a last resource, after
long trials with the other instruments, most of them generally
show that no distinct ideas have possessed the minds of the
operators as to any advantage of one position of the mutilated
head over another.
To place this upon a more accurate and scientific bearing
has been the endeavour of this paper, as well as to point out
its advantage in practice, as shown in the following cases.
Illustrative Cases.
The results of these cases must not be quoted in respect of
the statistics of mortality after perforation, because they are
the more severe instances, and because the deaths which
occurred were owing to its postponement, not to the operation
itself.
Case 1.— January 11, 1863 ; in Guy's Hospital Maternity.
Mrs. , about forty years old ; has had six children ; all
her labours were difficult, but all her children born alive.
The last is four years old.
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 78
She had been some thirty-six hours in labour, without
progress, when it was found that the pelvic brim was much
reduced in the conjugate diameter. An attempt was made to
turn, but the leg would not pass the head. The operator
desisting, I made a careful digital examination of the brim,
and found the antero-posterior diameter measured not more
than two and a quarter inches. This I ascertained by the
joints of middle finger, and by the fact that my wrist would
not readily turn round at this part. Not only did the sacral
promontory fall forwards, but the symphysis projected back-
wards about half an inch ; both bones were thickened and
irregularly nodulated. Besides this the transverse diameter
was contracted to a small extent on the right side, apparently
from the shape of the horizontal ramus of pubis ; I therefore
at once perforated. I found the bones of the cranium easily
separable upon slight traction ; so much so that it was
impossible to employ much force by the craniotomy forceps.
As soon, therefore, as a considerable portion of the calvarium
was removed, I passed up the small blunt hook in front of the
head, on the outside, and seized the most anterior projection,
in order to produce face presentation ; the part seized proved
to be the supra-orbital ridge. The head immediately rotated,
the face coming down with face to pubis. The head was
brought down after gentle traction, the chin passing to the
left side of pubis in its descent. Just before the head was
delivered the hook was changed into the upper jaw, and so
continued till the end of delivery.
The shoulders gave much more difficulty, and the passage
of the pelvis through the brim was much more troublesome
than that of the head after the induction of the face presenta-
tion. I may mention that chloroform was given, and acted
very benignly. The patient did very well.
Case 2.— March 10, 186B. Mrs. G , third pregnancy,
at full term ; the first child born dead after a most lingering
labour ; the second delivered alive by forceps after severe
traction, with some laceration to os uteri.
I was called into her in the third, after having been in
labour thirty hours. The head was above the brim, but as
74 i>ri. niiAXTox hicks on
she had not been in very full labour long, I waited twelve
hours, during which period no great improvement took place.
The brim was probably a little over three inches antero-
posterior diameter, and, as she was beginning to lose strength,
the forceps were applied — the long pair — with some difficulty,
on account of the cicatrices of os and the elongation of its
posterior lip. However, I found it impossible to bring the
head through the brim by legitimate pulling, upon which I
endeavoured to turn. I, however, found the uterus contracted
as tightly as possible round the neck of foetus. There were no
signs of pulsation in neck, &c. I therefore gave up the plan
of version for perforation ; this w^as accomplished while left
hand was in vagina. The bones were very firmly ossified. I
had at first great difficulty in drawing down the head by the
craniotomy forceps and crotchet, owing partly to the reten-
tion of the child by the uterine contraction. But when I had
produced face presentation by the small blunt hook, passed
on the exterior of skull into orbit, the head came without
any great difficulty, and the rest followed without much
further trouble.
Case 3.— July 22, 1863. A single girl, i^t. 19 ; much
undersized in every respect. The pelvis was puerile, with an
antero-posterior diameter of two and a half inches, as far as
I could ascertain. The whole diameters w^ere, of course,
deficient. The sacrum had fallen forward, causing a very
hollow back, and rendering the cavity of pelvis very shallow.
She had been in labour twenty-four hours, and the funis
prolapsed for twelve hours, before I saw her.
The head was wholly above brim, the os uteri not fully
dilated. The medical attendant had already perforated, and
had removed some bones from the calvarium ; but the open-
ing had been closed up by the pressure of uterine action, and
yet the head had not descended, nor could he bring it down
by the crotchet or craniotomy forceps. I found that the head
would have to be opened afresh, so tight was the closure of
the original aperture, in order to employ the crotchet or other
instrument inside. However, as there seemed to have been a
considerable reduction of the total size of the head, I
DELIVERY OF FUriAL HEAD AFTER PERFORATION. 75
determined to induce face presentation, which was accom-
plished by passing the small blunt hook into the orbit. Trac-
tion was made in a backward direction so as to bring down
the face, and at same time draw it behind the pubis, on which
it rested. Advance was gained, but the orbit gave way ; the
craniotomy forceps were then employed to the front of the
head, and after some variation in the direction of the traction
the head was delivered, after which no difficulty arose.
She did well afterwards, but when I heard that she was
again pregnant I recommended induction of premature labour;
but this she avoided, and placed herself under another
medical man, who knew nothing of the precedents, but who
was obliged to employ craniotomy, with much difficulty.
Case 4. — Sept. 27, 1863. Mrs. , a stout primipara,
had been in labour thirty-six hours when I saw her ; two
attempts to deliver by forceps had failed. The pains had
gone off, but the uterus was rather tightly contracted round
the child. Patient was rather exhausted, but nothing of
moment. The head was above the brim. Thinking it useless
to apply the forceps again, I attempted turning, as the child
was still alive. Chloroform was given, but I could not bring
the foot past the head, which would not recede. During this
effort the child died from funic pressure, and thus there was
no use in persevering to turn. Upon this perforation was
employed. The head was very firmly ossified, so that little
collapse of diameters occurred. Traction not producing any
benefit, I proceeded to remove the greater part of calvarium,
a matter of no slight difficulty, from the excessive rigidity of
the bones and general diminution of the cavity of the pelvis.
However, by care and time this was accomplished, assisted
much by Simpson's craniotomy cutting forceps. After this
was accomplished, I passed the small blunt hook into the
orbit and made face presentation ; in this manner the head
came through the brim without trouble, but the passage was
rendered difficult by the small pelvic cavity and unyielding
nature of the cranial bones. However, after carefully guard-
ing the soft parts, which required much time, the head was
delivered, but it required an hour more, and no very gentle
70 DR. BRAXTON HICKS ON
efforts, to deliver the shoulders. This at last was accom-
plished, and she recovered without any anxious symptoms,
rather slower than after normal labour. Keliable measure-
ments of the diameters were not taken ; probably antero-
posterior of brim was about three and one quarter inches.
Case 5. — A small, single primipara, ast. 19, had been in
labour two days when I saw her ; foetal head remaining still
above brim, the os having been dilated twenty-four hours.
She was in powerless labour, and for the last few hours the
death of the child was very apparent from the putridity of
the discharge, which filled the room. Pulse 120 p.m. Uterus
remaining firmly contracted around foetus, without the slightest
rhythmical action.
I found the antero-posterior diameter of brim not much
more than two and a quarter inches, the promontory of the
sacrum low^ down and readily reached by the finger ; the
cavity ran backwards, at first nearly horizontally, then
curving round to the coccyx. The whole brim smaller than
normal. The remainder of pelvis imperfectly developed,
although the outlet was not so bad as the brim.
I perforated at once, and at once proceeded to remove
calvarium ; this was readily accomplished, owing to the ease
with which the bones separated. By seizing a portion of the
frontal bone the craniotomy forceps produced face presenta-
tion, and the head was soon delivered, but great difficulty
was experienced in delivering the shoulders ; the thorax had
to be reduced by the crotchet. However, after a short time
the body was delivered, and the placenta was obliged to be
removed. She continued to evolve the putrid odour till she
died, five days after delivery. The secretion of urine was
nearly suspended, and she died in a typhoid state. This
patient refused chloroform.
Case 6. — This patient I had delivered once before by forceps,
and again, about a year before, by perforation, after the trial
of long forceps, with much difficulty, she having a brim of
not much over three inches in its conjugate diameter, the
head of the foetus also being of large size and highly ossified.
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 77
When she became again pregnant she refused the induction
of premature labour ; I therefore, in conducting the case, told
her I would not accept the responsibility ; however, as she
was very anxious for a live child, I endeavoured to deliver by the
forceps first of all. In consequence of spontaneous laceration
of a rigid os in the first labour, there was contraction of os,
which in the last labour required three days for its expansion.
To overcome this I dilated it with elastic water bags, with
such effect that in three hours I was able to pass the long
forceps, the head being still above the brim ; it was a very
firm one, and evidently large. As I had anticipated, I found
the forceps useless, even using them to the limits of safety.
I had therefore to perforate, evacuating brain and fracturing
the bones, but I could not deliver by the craniotomy forceps
and crotchet, nor until I had passed the small hook into orbit
and brought down the face first. She was about again on the
sixth day. Chloroform in this case could not be employed,
owing to the excessive bronchitic dyspncBa of the patient.
This was a great disadvantage, as her intolerance of pain
made it very difficult to pull downwards properly. Had I not
been able to deliver as mentioned, I should have had a much
greater amount of trouble.
Case 7. — Guy's Hospital Maternity, January 23, 1863.
Mrs. B , primipara, about twenty-five years old. There was
a tumour in posterior part of pelvic cavity, extending from
tip of coccyx to half way towards the promontory of sacrum,
diminishing the antero-posterior of cavity to about half, and
extending laterally about half way forwards ; it was semi-
elastic, with harder parts in places, but contained no fluid, as
proved by the use of the trocar and canula. Some hours of
full pains had elapsed without any progress past the tumour,
upon which I employed the forceps, without any result. The
more traction was employed the more the tumour bulged in
front of the head. After many useless efforts I determined
upon perforating the head. This I did between the blades of
the forceps, but no descent took place upon pulling firmly.
They were removed, and the craniotomy forceps and crotchet
were used without benefit ; the calvarium was then broken up
78 DR. BRAXTON HICKS ON
and in part removed, whereupon I passed the crotchet outside
the skull, bringing down the face foremost, when the head
slowly descended and was delivered. The remaining bones
of the calvarium were pressed into the base of the skull, so
that the vertical diameter was reduced to nearly its minimum.
The head was large. The patient recovered well.
Case 8. — This was a case in which the arm had descended
with the head. The medical practitioners in attendance had
used forceps, and many times endeavoured to return the arm
above the head ; but neither could they draw down the head,
nor return the arm into the uterus. After efforts of some
hours' duration they perforated and removed the calvarium,
with no better result. The patient was passing into the
powerless condition fast ; the pulse intermittent, with sordes
on the teeth, brown furred tongue, haggard expression, and
tympanitic abdomen. The head was partly in the cavity of
pelvis. To her in this state I was called in. I tried to draw
it down with the crotchet and craniotomy forceps, which was
partially successful, but on placing the small blunt hook on
the outside of skull and fixing it on orbit, the skull, now
deprived of a great part of its calvarium, was thereby quickly
tilted, and delivered without any further trouble, the chin
gliding underneath the pubis rapidly, the arm coming down
along with it. However, this patient never rallied, but died
within six hours after.
Details of Exjperwicnts.
Experiment 1. — Fidl-sized foetus.
As in Tertex, As in face pre- t>-
occipito- sentation, iiiento- Biparietal. izygo-
frontal. breginatic. matic.
Natural size . . 4| 5 3f 3|
After perforation . , 4^ 3f — —
Calvarium nearly | ^^ (now mento-
removed j frontal)
Ditto, quite removed — 1^ («iento- _ __
■^ " orbital)
When " after perforation " is mentioned, here or elsewhere,
it means the simplest form in w'hich the operation is employed.
DELIVERY OF FCETAL HEAD AFTER PERFORATION. 79
Experiments 2 to 4 inclusive.
Experiments Avere made with three full-grown foetuses.
The calvaria were removed, and in all the mento-orbital
diameter did not exceed 1| inch.
Experiment 5 (see Case 1).
In this case, where, wdth careful digital measurement, the
pelvis of the mother possessed a conjugate diameter of only
2f inches, — the foetus, moreover, weighed about 10 lbs. (9| lbs.
without brain or blood) — the head w^as perforated, and the
principal part of calvarium was removed ; the craniotomy
forceps were useless as tractors, on account of the ease with
which the bones separated from one another. The small
blunt hook was then passed on the outside of head and fixed
into the orbit, upon which the face was easily drawn down ;
with moderate pulling the head was delivered, certainly with
much more ease than the pelvis of the foetus. The chin was
anterior to left of symphysis pubis.
On measuring the head after, I found the mento-orbital
depth 1| to If.
But when the occiput was placed in the position in which it
would be if it were hooked down first, I found the smallest
diameter by which it could pass the brim 3-| inches. That is,
from about the supra-orbital ridge to the nape of neck.
With the face presenting, the greatest opposing diameter
Avas, without any compression at all, 2| inches, but a gentle
compression easily reduced it to 1^ inch.
Experiment 6. — Full-term foetus ; head firmly ossified and
unyielding.
This was a case of perforation for obstruction by a tumour
in cavity of sacrum (see Case 7), in which, after evacuation
of brain, fracturing the bones, and removing some portions
of them, face presentation was induced by the blunt hook,
and the head drawn away without any great difficulty, but
with the frontal and other bones completely pressed down into
the base so as to pass the tumour.
80 DR. BRAXTON HICKS ON
When the bones were replaced the diameters were measured ;
they were as follows : —
Occipito-frontal . . . . 3|
Mento-frontal 3t
This shows a gain, without compression, of f inch. But
in the state in which it was delivered the latter was reduced
to much less, and when the calvarium was removed the
mento-frontal was reduced to the same as in former examples.
The bizygomatic diameter was 3f inches.
Experiment 7. — Full-term foetus.
Natural size I Occipito-frontal . H inches
I Bi- parietal . . 3f to 3| „
The calvarium was removed, except the occipital bone,
which was bent in, and the scalp drawn down over all the
edges.
Occipito-frontal was 3 inches (occiput downwards).
Orbito-mental ,, If ,, (face downwards).
I could not make any opposing diameter with occiput down-
wards less than three inches.
I then tested the reduced head through a pelvis whose
antero-posterior diameter was not more than two inches ;
face downwards, chin anterior ; it passed through without
any difficulty ; with the chin posterior it passed with some
trouble, but this was got over by bringing the chin well down.
But the tendency was for the chin to pass anteriorly as it
came down. But with the occiput drawn downwards it was
impossible to cause it to pass the brim, or, indeed, in any
other direction than face presenting.
Experiment 8. — Full terriii weighed nearly 11 lbs.
Natural size . .
As in vertex
presentation,
bccipito-frontal.
4f
As in face pre-
sentation, mento-
bregmatic.
41
Biparietal.
4
Bizygomatic,
3|
After perforation .
Calvarium in part
4f
H
—
removed . . .
4f
3|
—
Calvarium quite
removed . . .
14
—
DELIVERY OF FGBTAL HEAD AFTER PERFORATION. 81
Experiment 9. — Full-term foetus.
Occipito-frontal. Mento-bregmatic. Biparietal.
Natural size ... 4f 4| 3|
After perforation . . 3| 3J —
Calvarium removed . — If —
In this case the first two diameters are the same, but after
perforation, although both have gained by it, the mento-
bregmatic has gained the most in reduction.
ExPERia
lENT 10.-
—Full-term
foetus.
Occipito-
frontal.
Mento-
bregmatic.
Biparietal.
Bizygomatio
Natural ....
4f
4|
3|
3
After perforation .
4
9f
—
Calvarium in part
removed . . .
H
2f
—
Calvarium quite re-
moved ....
—
H
—
Here, also, it will be seen that the first two diameters are
the same, but after perforation the mento-bregmatic begins to
be the least, after which it becomes the least of ail.
Experiment 11. — Full foetus ^ weighing 10 lb.
After perforation, and rather \ ( occipito-frontal was 3| to f
more collapsed than in [j mento-bregmatic 3
above cases . . . . J ( or without lower jaw 2f
Calvarium removed If
or rather less.
Experiment 12. — Full-term foetus, with head rather
flattened above.
Biparietal. Bizygomatio.
31 31
Natural size . . .
Occipito-
frontal.
4
Mento-
bregmatic.
31 to 3|
After perforation
Cranial bones all
fractured . . .
3f
3i
3i
2|
Cranial bones quite
removed . . .
3
If
82 DR. BRAXTON HIOKS ON DELIVERY OF FCETAL HEAD, ETC.
In this case long labour had reduced the mento-bregmatic
diameter below the occipito-frontalis, so that the former all
through possessed less length than the latter.
Experiment 13. — Rather small full-term foetus.
Sat ^f^:^.. Biparietal. Biwm^tic.
Natural size ... 4 3| 3| 3|
After perforation . 3f 3| — —
After removing nearly
all calvarium . . 2f If — —
In this instance it will be observed that from the first the
mento-bregmatic diameter was the best, so that face presenta-
tion would have been as easy as vertex, especially when it is
observed the biparietal and bizygomatic are the same.
Experiment 14.
In this case it was found, after removing the greater part
of the calvarium, that the —
Occipito-frontal, or its representative, the
fronto-cervical, was 2f inches.
Mento-bregmatic, or its representative, mento-
orbital, was 2
Eizygomatic 2^
a
Experiment 15.
^?;S- wS^c. Biparietal. Bl..go.atic.
Natural size . . . 3| 4 3f 3|
After perforation . 3f 3| 3| —
In this case it will be noticed that the fronto-occipital was
not sensibly altered by perforation, while the mento-bregmatic
was considerably reduced, as also the biparietal.
INTEODUCTION TO DISCUSSION* ON
PLACENTA PKiEVIA.
The collective wisdom of the authorities of this Section
having pronounced solemnly the fearful word " Blood," pro-
ceeded further to do me the honour of asking me to open a
discussion that should, as the result of our combined talents
and experience, draw out the plan best calculated to arrest
its terrors and to staunch its stream ; and then the same
authoritative wisdom also thought that it would be helpful to
the profession generally if that formidable cause of blood
loss — namely, placenta praevia — were the immediate subject
of your consideration.
Thus it is that I find myself in this responsible position ;
and would ask you kindly to take off some of its weight, the
more so as the time allotted me is only fifteen minutes — a
very short time to treat of only one case of placenta praevia —
and you only ten minutes. As, therefore, all of us must
necessarily be brief, I shall confine my remarks to the treat-
ment of this condition, passing over the theories which have
been advanced — and will be advanced later on in this Section
— to explain the cause and nature of the position, and only
very briefly touching on the after-treatment.
And, because I am anxious to present so important a subject
free from personal considerations, lest these may be a hindrance
to our conclusions, I shall avoid all reference to the authors
of the various plans which have one way or other within the
* Introduction to a discussion on Placenta Praevia, in the Section of
Obstetric Medicine and Gynaecology, at the Annual Meeting of the
British Medical Association, held in Leeds, August, 1889.
G 2
84 DR. BRAXTON HICKS ON
last thirty years reduced the death-rate from thirty per cent,
to somewhere near five per cent. But I may say this much,
that the early handling of these cases and the general anti-
septic management of midwifery cases, both during and after
delivery, can rightly claim to have had much to do with these
excellent results. I think we shall all agree : —
1. That when the placenta is inserted somewhere within
the lower third of the uterus, there is very generally a
liability to haemorrhage. It would be difficult to say that it is
absolutely "unavoidable," because I have seen the placental
edge a little over the os without the slightest bleeding ; and
doubtless there are cases of what is called " accidental
hsemorrhage," which have occurred with a low insertion of
the placenta. But I take it that for practical purposes, when
the placenta is inserted about or over the os uteri, haemor-
rhage is to be expected before or upon the supervention of
labour, whether premature or at full time.
2. I think also most of us will agree that, when once
haemorrhage has declared itself, there is no security for the
patient, but that her life is in imminent danger from liability
to recurrent bleedings.
3. My experience teaches me, and I think I shall gain your
assent to this also, that the relative position of the placenta
to the OS has no influence on the frequency or quantity of the
blood loss. In other words, whether it be marginal insertion
or central, the risk is the same.
If you join assent with me so far, I would submit this pro-
position as a deduction from the foregoing, as a rule of
practice, namely : —
That as soon as we ascertain the case to be one of placenta
praevia, we should make arrangements for terminating the
pregnancy at the earliest possible time. I believe also I shall
have your assent to this, the importance of this rule having
been constantly shown in my practice : as far as possible we
should not leave our patient ; certainly not to an indefinite
future.
Having accepted this rule, our next consideration is : In
what way and by what means we shall accomplish this.
Perhaps it will clear the ground if, before we proceed in this
PLACENTA PK^VIA. 85
direction, we take note of the main points we have to combat.
And, first, we desire to prevent further bleeding; secondly,
we wish to overcome the resistance the substance of the
placenta presents to the passage of the foetus. But also we
cannot in the majority of these cases leave out of considera-
tion the state of anaemia which the patient presents from the
haemorrhage which has already occurred. Sometimes so
profound that the smallest movement, even ordinary ex-
amination, extinguishes the pulse. Of course, in all cases, it
behoves us to carry out our manipulations with as much
gentleness as possible — choosing, especially in the severer
cases of anaemia, that plan the least disturbing.
Let me consider these points more completely : —
1. The bleeding can be stopped by pressure : either by
tampon ; by the head being pressed down by the uterine
efforts, or drawn down by the forceps ; or by the leg and
breech drawn down if presenting, or made to present by
turning.
With regard to the pressure by the tampon, I believe the
general consensus in British midwifery is against its use, and
with this I am in accord — partly because, unless perfectly
done, and this is difficult, it is of no use ; and if perfectly
done, it is very distressing to the patient, especially if it be
necessary, which it often is, to renew it to avoid septic
generation. Still, it has some advantages, because, by dis-
tending the roof of the vagina, we also dilate the os, and
provoke uterine action. But its action is tedious, and lacks
the precision afforded us by the more recent methods.
2. But the uterine action alone will occasionally suffice to
produce sufficient pressure on the inner surface of the placenta
to stay bleeding ; though it requires the head to be entering
the OS before it can efficiently do this ; so that, if we found
the OS uteri fully dilated, the placenta marginal, and the
membranes tense, we might rupture the membranes, and if
the head descended we should not expect further bleeding,
and the case may be allowed to end naturally. But, practic-
ally speaking, these cases are not the most frequent. If the
placenta were mainly over the expanded os when the mem-
branes were ruptured, the head, retarded by the bulk of
86 DR. BRAXTON HICKS ON
placenta, would not effectively enter, and then it would be
our best plan to press the flap of placenta aside and apply
forceps, drawing down the head into the os, retaining it there
by gently hanging on to the forceps till the pains were
sufficient to expel the head, assisting them by gentle traction.
3. But it is very possible that we may have no forceps, and
for one reason or another the head is unable to enter the os,
then we are under the necessity, in order to place our patient
in safety, to bring the breech to the os by turning. This can
be accomplished by either slowly pushing the hand through
the OS, seizing the leg, and bringing the breech into the os ;
or by the combined external and internal version, effecting
the same result but in a gentler way. Of course, if the breech
present originally, all that will be needful will be to bring
down the leg, fixing the breech in the os. The hand should
retain hold of the leg, so that the weight of the arm gives
pressure sufficient to prevent further bleeding. The great
object of these manoeuvres is to produce pressure enough to
check bleeding, and this pressure need not be much.
In both the employment of the forceps and in turning the
action is not for instant delivery ; as soon as the os is plugged
by head or breech the object is accomplished, a little addi-
tional traction as the pains come on sufficing for the
delivery, which may be left mainly to Nature. Thus we gain
time, valuable to our patient, wherein we can sustain her
energies while the circulation is recovering its balance. When
the OS is fully expanded, the engaging firmly of head or breech
is followed in an hour or two by uterine action. Supposing
the OS is not sufficiently expanded to introduce forceps, or to
readily turn, then the os uteri can be expanded by the dilating
bags, or in the event of our not having them, the os could be
gently dilated by the fingers introduced one by one. But if
the OS be so small as that, then I think the best plan would be
to proceed by the combined method of version, as, the leg and
breech being of conical form, it assists dilatation, and, as the
OS expands, it keeps up a corresponding pressure on the
bleeding surface, for it has been constantly found in a large
number of cases that if very slight traction is kept up just at
first, no further bleeding has recurred.
PLACENTA PREVIA. 87
If with all these states of os uteri, particularly if small,
the placenta be attached more or less across, it is of much
advantage to separate gently the placenta for a forefinger's
length ; this very distinctly releases the lower portion of the
uterus from the restraint caused by the attachment of the
placenta, and this is very noticeable if the margin of the
placenta be across the os, because the margin is the part most
firmly adherent to the uterus. By this separation the flap of
the placenta also somewhat retracts, and is pushed aside as
the head or breech descends. If the membranes are perfect,
then they need not be ruptured till the act of version ; and
when this rupture occurs, a still further easement is felt
in respect of the rigidity.
Now, with respect to the detachment of the placenta from
around the os, it is necessary to make a few remarks.
The act of doing it may be attended with severe and
continuing haemorrhage, particularly in central insertion of
the placenta. In two cases which occurred to myself with
central insertion, I was alarmed at the large flow, and this
was only restrained by penetrating the centre of the placenta,
performing bipolar version, and bringing the leg through the
OS, which was so small that scarcely two fingers could enter.
To discuss the source of this bleeding would, I am afraid,
take up too much of the time allotted me, and therefore I
would call attention to the practical fact that sometimes in
detaching the placenta we have severe bleeding, whilst at
other times we may not ; indeed, these cases are the more
frequent, and it has practically been found that a free, bold
detachment of the placenta as far as the fingers can reach
has the effect in a large number of cases of checking bleeding
for a time, and thus we come to another means of restraining
bleeding in placenta prsevia. But inasmuch as by this action
we have the placenta partially detached, and as our experi-
ence tells us that both in " accidental " and in post-partum
haemorrhage there is, with partial detachment, liability to
floodings, so when we employ this method as one which will
give us time by temporarily restraining bleeding whilst the os
uteri is dilating and the patient recovering her powers, yet we
must treat it as a measure itself requiring supervision. This
88 DR. BRAXTON HICKS ON
my experience bears out. In other words, it is imperative
that we should be in close attendance on the patient, ready to
act should any bleeding of importance occur, the action
indicated being, of course, either to bring the head down by
forceps or breech by turning. We must also remember, when
we detach the placenta, we cut off the foetus from its aeration
to the same amount ; and although it may be said that when
it comes through the os about the same amount of the
placenta will be made useless by pressure, yet it may be
rejoined that the effect of the detachment will generally
extend many hours longer than that of the pressure. If the
placenta be inserted more or less centrally, these considera-
tions do not enter, for the placenta sooner or later must be
detached to an extent probably fatal to the child.
I would venture a suggestion here, in order to lessen the
bleeding on detaching the placenta, that the finger should
keep close to the uterine surface, rather pressing it from the
surface of the placenta than the placenta from the uterus. If
this plan does not lessen the loss from the maternal side, it
may prevent loss from the foetal villi, which must occur when
we lacerate the placenta.
Now there is a certain class of cases, practically the more
numerous, in which there has been severe loss, and it is
necessary to secure the safety of the patient ; but where the
OS is so small that we cannot put in operation the foregoing
plans, so also where, although the os uteri be somewhat
expanded, we have at hand neither forceps nor dilating bags,
or where, in peeling off the placenta, we are confronted with
alarming blood-loss — in these cases the only plan we have
at command is version by combined internal and external
method, and in these cases we see its great advantages.
But when this method of version is used it must always be
understood that it is not the version itself which is the
haemostatic remedy, but that by it we are enabled to bring
the foetal leg or breech down on the placenta from within, and
so are able at an earlier date than otherwise possible to stay
the flow. It is possible in some case to dilate the os with
fingers, and after some time, and with more or less force, to
pass the hand through the os and reach the leg ; but I feel
PLACENTA PB^VIA. 89
quite sure that anyone who has tried the two plans will,
without hesitation, pronounce in favour of version by the
newer method ; and it is interesting to note that, although
very little or no uterine action was observed before turning,
yet shortly after the leg has been brought in through the os
the pains commence and continue, so that labour is accom-
plished without requiring much assistance from the attendant,
often within a couple of hours.
But in selecting our plans for the safety of the mother, we
cannot leave out of consideration the preservation of the
child so far as possible ; and here I think we shall all agree
in choosing, where the state of the os, the position of the
placenta, and the condition of the mother permit it, delivery
by the head as the most likely to secure its safety — that is to
say, with a fully expanded os and placenta marginal. But
when the os is only large enough for two fingers to pass, and
the placenta much across the os or central, the time which
elapses before labour is over, and the great reduction of its
aeration adds so much to its jeopardy, that the extra risk
produced by pressure on its funis as the result of turning is
scarcely to be taken into calculation. In either case the
death-rate is very high. But if for any reason there has
been laceration of the placenta, there will also be laceration
of the villi, and in consequence an oozing of blood will be
going on, serious to the vitality of the child, if it be free or
continuing during long hours, whilst we are waiting for the
expansion of the os and pressure of the head, so that risk by
pressure on funis after turning is, I think, pretty evenly
balanced in the other mode by the loss of its blood. If, after
gently detaching the placenta just enough to set free the
lower portion of expansion, we quickly bring the leg or breech
into the os, all loss from the placenta is checked, as it is at
the same time from the maternal vessels. In all cases of
labour before the end of the seventh month, and where we
know the foetus to be dead, of course the question of preserving
the life of the foetus does not arise.
In those cases where the anaemia is so profound that
almost the least movement eclipses the pulse, our difficulties
are very great, but whatever we do we must do it with extreme
90 DR. BRAXTON HICKS ON
gentleness. Our first object is of course to prevent further
loss, while we sustain the powers by restoratives till the circu-
lation recovers its balance. If there be no bleeding, we had
better wait, but keeping watch at the bedside in case it
return. Should it do so, or when the patient has rallied, we
may elect to use forceps or combined version according to
circumstances. But as detachment of the placenta may be
attended by more or less blood loss, I should not advise this
method. But these cases are so formidable, that often before
we see them their fate is sealed, and while we are waiting for
the rallying, already coagula in the heart have formed, and
slowly but surely block the current.
EULES.
I would propose, therefore, the following rules, deduced
from the above considerations, for your acceptance : —
1. After diagnosis of placenta prgevia is made, we proceed
as early as possible to terminate pregnancy.
2. When once we have commenced to act, we are to remain
by our patient.
3. If the OS be fully expanded and placenta marginal, we
rupture the membranes and wait to see if the head is soon
pushed by the pains into the os.
4. If there be any slowness or hesitation in this respect,
then we employ forceps or version.
5. If the OS be small and placenta more or less over it, the
placenta is to be carefully detached from round the os ; if no
further bleeding occur, we may elect to wait an hour or two.
Should the os not expand, and if dilating bags are at hand,
the OS may be dilated. If it appear the forceps can be
admitted easily, they may be used ; but, if not, version by
combined external and internal method should be employed,
and the os plugged by the leg or breech of foetus ; after this
is done the case may be left to Nature, with gentle assistance,
as in footling and breech cases.
6. If the OS be small, and if we have neither forceps nor
dilating bags, then combined version should be resorted to,
leaving the rest to Nature, gently assisted.
PLACENTA PE^VIA. 91
7. If during any of the above manoeuvres sharp bleeding
should come, it is best to turn by combined method in order
to plug by breech.
8. Where the foetus is dead, or labour occurs before the
end of the seventh month, combined external and internal
version is the best method, no force following.
To these I may add the following : If, however, we employ
a routine method in all cases, it will be found that the version
by combined method, no force following, gives a result as good
as, if not better than, any.
After-Treatment. — The after-treatment must be conducted
on the modern principles : should oozing occur after the
expulsion of the placenta, the swabbing of the lower uterus
by styptics will be easy ; and, inasmuch as the outlet of the
uterus is liable more especially to be blocked by adherent
clots, it will be wise to irrigate the uterus daily with some
antiseptic solution, or insert iodoform pessaries in the vagina,
particularly if the irrigation cannot be done.
A SHOET NOTICE OF THE LIFE AND WOEK
OF THE LATE
J. BRAXTON HICKS,
M.D., F.R.S., F.E.C.P.,
FROM THE
ANNUAL PKESIDENTIAL ADDRESS DELIVERED BEFORE THE OBSTETRICAL
SOCIETY OF LONDON, FEBRUARY 2nd, 1898.
BY
C. J. CULLINGWOETH, M.D., Hon.D.C.L., F.E.C.P.
In endeavouring to give an adequate account of the life
and work of Dr. Braxton Hicks in the short time at my
disposal, I feel I have before me a difficult task. He was one
of the founders, and for many years one of the most active
supporters of our Society, a past President, a recently elected
Honorary Fellow, and a contributor of no fewer than forty
papers to its * Transactions ; ' on these grounds alone it
would be fitting that the annual Address should contain as
full an account as possible of his personality and his career.
But when it is also remembered that the science and art of
obstetric medicine owe to him several of the most important
advances of recent years, and that his name has taken a
permanent place amongst those of the most distinguished
British obstetricians, there is still more abundant reason
why our records should contain a more than usually full
appreciation of the man himself as well as of the work of
his life.
John Braxton Hicks was born at Eye, in Sussex, in the
year 1823. He was the second son of Mr. Edward Hicks, of
94 DR. BRAXTON HICKS :
Lymington, who was at one time a banker, and for many
years held the position of chairman of the bench of county
magistrates. From the age of twelve to fifteen Braxton
Hicks was educated as a private pupil of the Eev. J. 0.
Zillwood, of Compton Eectory, near Winchester. He became
apprenticed to a medical practitioner in the town where he
lived in 1842, and at the age of eighteen he entered as a
medical student at Guy's Hospital. He was a favourite both
amongst his teachers and his fellow- students. " I shall never
forget," writes an old fellow- student, Dr. Daniel Hooper,
*' his amiable, cheerful expression, bright, piercing eyes and
noble forehead ; his alacrity was remarkable ; he was always
busy — I never saw him idle for one moment — he would hurry
with a very quick step to the lecture theatre, literally run
down the steps (a huge volume of Pereira, perhaps, under his
arm) to the bottom bench, and there sit motionless and
attentive till the lecture was over." He took first prizes in
anatomy, materia medica, practical chemistry and botany,
and he also won a medal for double sculling given by the
hospital boat club. He was very fond of botany, and in the
summer vacation collected specimens from the New Forest.
In 1844 he passed the first examination for the degree of
Bachelor of Medicine at the London University, taking
honours in every subject, and carying off the exhibition and
gold medal in materia medica. In 1847 he passed the final
M.B. examination, obtaining honours in physiology and com-
parative anatomy, medicine, and surgery. He soon afterwards
received the diplomas of the Eoyal College of Surgeons and
the Apothecaries' Society, and in 1851 took the degree of
M.D. at his university. Wishing to marry and to settle in
practice, he entered into partnership with the late Mr. W.
Moon, of Tottenham, and became a highly respected general
practitioner. But in 1859 he was invited by his old hospital
to accept the post of assistant obstetric physician, whereupon
he relinquished general practice and came to reside in the
Borough.
In the same year he passed the examination for the
membership of the Eoyal College of Physicians, of which he
was elected a Fellow in 1866.
HIS LIFE AND WORK. 95
In 1870 he was appointed senior obstetric physician to
Guy's Hospital, and lecturer on obstetrics at the school.
These appointments he continued to hold until 1883, when he
was elected consulting obstetric physician. Feeling that the
age limit at his own hospital had cut short his career as a
teacher somewhat prematurely, he acceded in 1888 to a
request to become obstetric physician to St. Mary's Hospital
in succession to the late Dr. Meadows, the then assistant
obstetric physician being considered at the time a little too
young for the full responsibility of the senior post. This
appointment Dr. Hicks held for several years, doing his
hospital work conscientiously, and taking a share of the
systematic teaching in the school. But he never forgot that
he was a Guy's man, and that his early successes and interests
were connected with that hospital. He was for several years
Examiner in Obstetric Medicine at the University of London,
and held a similar position at the Koyal College of Physicians
from 1872 to 1878, and again from 1889 to 1893. For
many years Dr. Braxton Hicks was physician to the Koyal
Maternity Charity, and he was also for a time physician
to the Koyal Hospital for Women and Children in Waterloo
Koad.
Dr. Braxton Hicks was all his life a devoted student of
natural science, and many contributions from his pen appear
in the ' Proceedings of the Koyal Society,' in the ' Transac-
tions of the Linnean Society,' and in the ' Journal of Micro-
scopical Science.' On the 5th of June, 1862, he was elected
a Fellow of the Koyal Society. I have been favoured by the
clerk of that Society with a copy of his nomination paper,
which I here reproduce not only on account of the interest
attaching to the names of his proposers, but as showing the
precise grounds on which that great distinction was conferred
upon him. He is described as residing at No. 6, Wellington
Street, London Bridge, and as being the author of the
following scientific papers : —
' ' On Certain Sensory Organs in Insects hitherto undescribed, ' '
read before the Koyal Society, and published in abstract in
the ' Proceedings,' May 26th, 1859.
*' On New Organs of the Antennae of Insects," and "On
96
DE. BRAXTON HICKS
Organs on Nervures of Wings," two papers in the 'Trans-
actions of the Linnean Society.'
"On New Organs on the Halteres of Diptera," in the
* Proceedings of the Linnean Society.'
" On a New Species of Draparnaldia," and *' On Amoeboid
Conditions of Volvox globator,'' * Microscop. Journ.,' April
1860.
"On the Development of the Gonidia of Lichens in rela.
tion to Unicellular AlgsB," * Microscop. Journ.,' Oct., 1860.
" New Sensory Organs in Insects," in the 'Linnean Society's
Transactions,' 1860.
" On the Homologies of the Eye and its Parts in Inverte-
brata," read before the Eoyal Society, January, 1861.
He is lastly spoken of as part author of a little work
published by Van Voorst, and entitled, * Humble Creatures
[the Earthworm and House-fly] .'
The following names of Fellows of the Society are attached
to the document : — W. B. Carpenter, J. Lubbock, G. Busk,
E. Lankester, F. Currey, J. J. Bennett, J. Hilton, A. S.
Taylor, T. Bell, C. Ansell, and E. W. Brayley.
It will thus be seen that it was mainly his contributions to
entomology and botany that obtained for him the coveted
blue ribbon of science. His interest in these studies continued
to the end of his life, and many other papers relating to them
appeared from time to time in the Journals and Transactions
to which they were specially appropriate. To us, however,
his work in connection with our own Society and the science
of obstetrics must necessarily have the chief interest, and of
this I must now speak. He was one of the founders of the
Obstetrical Society of London, and took an active interest in
it from the first. He twice served on the Council, namely, in
1861 and 1862,. and again in 1869. He held the office of
Hon. Secretary from 1863 to 1865, was Vice-President from
1866 to 1868, became Treasurer in 1870, occupied the
presidential chair during the years 1871 and 1872, and was
elected an Honorary Fellow in 1896. To the ' Transactions '
of the Society he contributed, as I have already said, no
fewer than forty papers. He was a close and accurate clinical
observer, and many of his papers which record single cases
HIS LIFE AND WORK. 97
or groups of cases are models of what such contributions
should be. To these I shall not have time further to refer ;
their titles will be found in the bibliography appended to this
Address. But of some of his more important papers I must
speak a little more at length.
In the month of July, 1860, there appeared a paper in the
'Lancet' on "A New Method of Version in Abnormal
Labour," in which were described *' five cases of placenta
prsevia in illustration of its peculiar applicability to that
formidable complication of labour." In the same journal for
February 9th, 1861, cases were given of other forms of labour
to which the new method had been successfully applied. It
was by these papers that Dr. Braxton Hicks first brought
before the profession his now celebrated method of version by
coinbined external and internal manipulation. He chose
that mode of communicating the method to the profession,
in preference to laying it at once before a society, because he
considered that the subject was too new for its merits to be
then discussed with satisfactory results. When, however, he
had had more experience of the method, and had tested and
proved its value, he made it the subject of a paper which
was read before this Society in November, 1863. In the
following year the paper reappeared in a revised form as a
thin octavo volume of seventy-two pages, published by Long-
mans and Co., with the title " On Combined External and
Internal Version." Up to within a very few years of this
period the operation of turning, whether the object was to
bring down the head, breech, knee, or foot, had involved the
introduction of the whole hand into the uterus. Cephalic
version was very seldom adopted on account of the difficulty
of grasping the head and retaining it at the os uteri : whilst
in regard to the other forms of version, foot-turning had
almost entirely taken the place of the older method of breech-
turning. All these methods, however, required the introduc-
tion of the whole hand, and generally part of the arm, within
the uterus, a process which added materially to the painfulness
and difficulty of the case, not to mention the valuable time
often lost whilst waiting until the os and cervix had become
sufficiently dilated for the operation to be performed. In a
98 DR. BRAXTON HICKS :
few cases men like Collins, of Dublin, and Dr. Robert Lee, of
St. George's, had occasionally shortened this period of delay-
by pushing the child round with the finger, but the practice
was only now and then successful. Dr. Robert Lee had also
pointed out that in some cases of transverse presentation it
was unnecessary to pass more than two fingers into the os
uteri in order to seize the knee, a plan which he named "two-
finger turning." Meanwhile several German observers had
demonstrated the possibility of turning the child in utero
from the outside. Braxton Hicks showed how, by the com-
bination of these two methods, each acting upon opposite
ends of the foetus, there was obtainable a certainty and a
celerity of which neither plan was capable when employed
alone.
In the discussion which followed Dr. Hicks's paper at this
Society, Dr. Robert Barnes stated that an admirable memoir,
in which the principle of turning by external and internal
manipulations was fully described, had been published by
Wigand in 1807. Not having any knowledge of Wigand's
paper. Dr. Hicks was unable at the time to call this state-
ment in question, but before the paper and discussion were
printed he acquainted himself with the precise purport of
Wigand's essay, and embodied the result in an appendix. He
bore generous testimony to the value of Wigand's suggestions,
but he showed that they were by no means identical with his
own. Wigand had discovered that pressure upon the exterior
would make the foetus move to a considerable extent, and
that by pressing on both poles of the child in opposite
directions, he could bring that end which was nearest into the
OS uteri, but he only employed the inner hand to guide and
receive the head or breech into the os. The difference is
important, for while, by his method, Wigand was merely
able to rectify abnormal presentations, the adoption of Hicks's
plan enabled the operator to accomplish version in any man-
ner, whether partial or complete, podalic or cephalic. Wigand
never contemplated complete version, and he expressly men-
tioned that his method was not applicable to cases of haemor-
rhage, or of prolapse of the funis, or of convulsions ; in other
words, the most important cases requiring version could not
HIS LIFE AND WORK. 99
be treated by the method he suggested. The plan described
by Hicks, on the contrary, combined the power of rectifying
abnormal presentations with that of performing complete
version. It differed from all previous methods in enabling
the operator to produce cephalic or podalic version at will,
and in being capable of application as soon as the os uteri
was sufficiently dilated to admit one or two fingers. The
advantages thus gained are obvious. It permits early inter-
vention in such cases as neck, shoulder, and transverse
presentations ; it furnishes a new and safe resource in cases
of convulsions in which the introduction of the hand is
attended with much risk, and in which speedy delivery is
desirable ; it diminishes the danger of turning in those cases
of contracted pelvis in which turning is the most appropriate
treatment ; and it removes from the operation the risk of
producing fatal shock when it is necessary to turn the child
under circumstances of extreme depression on the part of the
mother. But it is especially in the treatment of placenta
prsevia that it has proved of the greatest service, both in
saving life and in diminishing professional anxiety. When,
summoned to a case of severe hsemorrhage from this cause,
the medical attendant found the cervix only sufficiently ex-
panded to admit one or two fingers, he had hitherto been
compelled to wait for hours whilst endeavouring to dilate the
OS, or to content himself with plugging the vagina and en-
deavouring to press the head on to the placenta by exerting
pressure on the fundus uteri. "Anything," to use Dr. Hicks's
own forcible words, "which gave the practitioner some power
of action was to be earnestly welcomed ; anything better than
to stand with folded arms, incapable of rendering assistance
for hours and even days, every moment of which might be
carrying the sinking and suffering patient nearer to the grave."
By the new method, not only would bleeding be arrested, but
time could be saved to an extent of which the value can
scarcely be over-estimated. As soon as the os uteri would
admit two fingers, version could be performed and the os
effectually plugged by drawing through it the foot and leg,
and exerting such gentle traction as the mere weight of the
operator's arm, in retaining hold of the limb, is sufficient to
H 2
100 DR. BRAXTON HICKS :
supply. Henceforth the case could be watched with as little
anxiety as an ordinary case of breech presentation. Rapid
extraction is not only unnecessary, but, as favouring post-
partum hoGmorrhage, extremely dangerous. Dr. Hicks was
very emphatic on this point. *'What is the use," he says,
" of hastily delivering before the os is well dilated and before
the system has time to rally from the effects of flooding and
of the version ? Many of the deaths following placenta
prsevia may, I believe, be fairly attributed to too rapid delivery.
How much must the collapse be increased and the uterus
injured by endeavouring to drag the head through the yet
rigid OS ! Turn, and if you employ the child as a plug, the
danger is over. Then wait for the pains, rally the powers
in the interval, and let nature, gently assisted, complete the
delivery."
Dr. Hicks had to wait many years before he had the satis-
faction of finding his suggestions adopted. In spite of his
fecundity as a writer, the advertising instinct was wanting in
him. Had it been otherwise, he would have been long ago
recognised by all the obstetricians of the civilised world as
one of the greatest benefactors of lying-in women that this
age has produced. When, after the lapse of time, obste-
tricians did awake to the value of his work, the mortality from
placenta prsevia at once fell from thirty per cent, to some-
thing near five per cent.
In the year 1867 Dr. Braxton Hicks made a still more
valuable contribution to the literature of obstetrics ; I refer
to his paper " On the Condition of the Uterus in Obstructed
Labour," probably one of the most admirable communications
that has ever appeared in our ' Transactions.' The greatest
confusion and ambiguity had hitherto existed as to the precise
meaning of the terms " cessation of the pains," " powerless
labour," and " exhaustion," and the interpretation and signi-
ficance of the train of symptoms which these terms were
used to denote.
There were but two British writers on obstetrics who, up to
that time, appear to have observed the real condition of the
patient in obstructed labour, viz. Dr. Murphy and Dr. Eigby.
These authors had noticed that, when any obstacle prevents
HIS LIFE AND WORK. 101
the exit of the foetus, the pains, after being suspended for a
time, returned with a totally different character ; they became
short and extremely severe, and never entirely passed off in
the intervals. These writers had further noticed that if the
hand was placed on the abdomen the uterus was felt to be as
hard and contracted during an interval as during a pain, and
so sensitive that the patient could scarcely bear to be touched.
In other words, they had observed that a state of continuous
action was substituted for the rhythmical pains. This condi-
tion they attributed to inflammation consequent upon the
injury done to the soft parts. Dr. Hicks was the first to
appreciate the importance of this observation, but he did not
accept Murphy and Kigby's explanation. He pointed out
that even in a normal labour the demand made on the
nervous force by the action of the uterus, the largest in-
voluntary muscle in the body, is so enormous that, if it were
not for the replenishing that takes place during the intervals,
the constitutional effects would be disastrous. He showed
that, if from any cause the length of the ordinary intermis-
sions was curtailed, the powers of the system would soon
undergo a serious drain ; and that, if matters went further
and uterine action became continuous, symptoms of dangerous
exhaustion would inevitably supervene. In short, he showed
the state of tonic contraction of the uterus and the constitu-
tiona phenomena that accompany it to be the result of
nervous exhaustion, the true source of danger in all cases of
obstructed labour.
He went on to show that there are two distinct classes of
cases in which the pains, having once been vigorous, cease to
be rhythmical or apparently subside, and that it is of the
utmost importance to distinguish between these classes in
order to be guided to the proper treatment. " The first and
simplest form," he says, " is well known, and is that in which
the uterus is simply quiescent, resting passively for a time
while the nervous power is being, so to speak, collected ; after
a time the uterus begins to act, and the labour is accom-
plished. In this case there is no rise in the pulse ; gener-
ally, on the contrary, it is weak and feeble ; nor are there any
untoward symptoms but languor and some faintness. The
102 DR. BRAXTON HICKS:
reflex function is deficient, and its action sluggish, and there-
fore the demand on the constitution to supply nerve force is
proportionately small." Here we have the first clear descrip-
tion of what Scanzoni called, and is now known as, secondary
inertia of the uterus. ** The second form of subsidence of
the pains is .... of the opposite character. The uterus
becomes gradually irritated, so that, although some of the
pains still occur at irregular intervals, the uterus is really in
more action than before, tightly compressing the child, falling
into the inequalities of its form, whereby the foetus is pre-
vented from escaping, every indentation of the uterus forming
as it were a ledge past which it is difficult to draw the child,
or to pass the hand if we desire to turn. When this condition
.... has once been fairly established, it is rare that the
rhythmical pains ever recur with such force as to expel the
foetus ; as a rule, the continuous action remains, and sooner
or later symptoms set in telling one of the necessity for
interference." What a graphic picture of tonic contraction
of the uterus from obstructed labour ! It is to Braxton Hicks
that we are indebted for a simple and yet certain means
whereby to distinguish between these two classes of cases.
In the one we find on placing the hand upon the uterus that
the uterine walls are lax and flabby, the foetus being readily
felt "within it floating about with ease." So long as this
condition lasts we need feel no anxiety, and there is no occa-
sion for manipulative interference. In the other class we find
the uterus continuously hard and firm, and tightly moulded to
the form of the foetus, which, contrary to what is found in
the former class, cannot be moved about, the whole mass,
consisting of the uterus and its contents, being more or less
fixed. Under such circumstances we may feel sure that it is
worse than useless to postpone assistance. It is impossible to
over-estimate the importance of this teaching. There was
another matter of equal importance to which Hicks in this
paper was the first to call attention, viz. the risk of haemor-
rhage from want of response on the part of the uterus if the
labour be unduly hastened and the child extracted while the
uterine walls are relaxed ; that is, when the case is simply
one of secondary inertia. On the other hand, when there
HIS LIFE AND WOKK. 103
is continuous action, extraction is the proper and only safe
treatment.
I am glad to know that this invaluable paper is likely soon
to be reprinted, along with some other of Braxton Hicks's
contributions to obstetrics, by the New Sydenham Society.
The lessons it enforces have long since become part of our
common stock of knowledge, but it is well to be reminded
that we owe them to the exceptional powers of observation of
a Fellow of our own Society. I had intended, had time per-
mitted, to give a resume of some other of Braxton Hicks's
papers, especially those on the rhythmical contractions of the
uterus during pregnancy, to which he was the first to call
attention.
In looking through the list of his obstetrical and gynae-
cological contributions, one feels that there must be few
subjects on which he has not written something. There are
papers on the anatomy of the human placenta, on the be-
haviour of the pregnant uterus in chorea, on pregnancy
associated with ovarian disease, on the induction of premature
labour, on face presentation, on hydatidiform degeneration of
the chorion, on transfusion, on rapture of the vagina in
labour, on rupture of the uterus, on inversion of the uterus,
on concealed accidental haemorrhage, on the cephalotribe (his
modification of which instrument became the one almost
exclusively employed in this country), on Caesarean section, on
extra-uterine and intramural gestation, on the temperature
during parturition and in the puerperal state, on puerperal
diseases, on eclampsia, on labour obstructed by abnormal
conditions of the foetus, on prolapsed funis, on labour with
twins, on the best mode of delivering the foetal head after
perforation, on acephalous monsters, and on an outbreak of
diphtheria in the obstetric wards. Turning to gynaecological
subjects, we find him writing on retention of menses, on
uterine poIyjDi, on proliferous cysts of the ovary, on sloughing
fibroid of the uterus, on the treatment of malignant disease,
on tension of the abdomen, and many other subjects. His
series of lectures on some of the diseases of the female
urethra and bladder, published in the ' Lancet ' in 1867, still
remains the best systematic account of these diseases in our
104 DR. BRAXTON HICKS :
language. He was not a finished writer or an effective
speaker. His papers have no charm of style. His sentences
are often ill-arranged, and his meaning is occasionally ob-
scure. But his papers are always worth reading, for he was
a clinical observer of the first rank, and he never wrote
merely for the sake of writing. Sure of his ground, and
therefore free from hesitation in his statements oi fact^ he
was studiously guarded in his expressions of opinioyi, sug-
gestive rather than dogmatic. In some of his essays, and
notably in that on obstructed labour, he showed great
originality, and that wide grasp of his subject that enables a
man to harmonise apparently discordant phenomena, and to
construct out of chaotic materials an orderly presentation of
facts and a workable hypothesis in explanation of them. If
I were asked which of his contributions I consider to deserve
the highest place, I should select the two of which I have
endeavoured to give a synopsis this evening, namely, those on
obstructed labour and on combined version, and I should add
for a third the series of papers on the rhythmical contractions
of the uterus during pregnancy. These were all characterised
by a rare originality, and are contributions to obstetric know-
ledge of which the value is likely to be permanent.
It was difficult for those who only knew Braxton Hicks in
his later years to realise that this mild-mannered, chatty,
beaming little old gentleman was the man whose name was
associated with so many advances in the science and art of
obstetrics. He was in no sense one of those who either look
or talk like a leader of men. But his wide interests, his keen
love of nature, and his gentle unassuming manner made him
a most interesting companion. He continually displayed a
quite unexpected acquaintance with the most out-of-the-way
subjects, and his mind was a storehouse of general informa-
tion. He had read much, observed much, and thought much.
He was a good draughtsman, and drew accurately on stone
from the microscope. He was a large collector of Wedgwood
and oriental china, and had in his house typical examples of
different makers. He was fond of architecture, and indeed of
art generally. He was a deeply religious man, and a sincere
member of the Church of England. He was always ready to
HIS LIFE AND WORK. 105
give help to those who needed it, whether in the form of
advice or money, or, if necessary, of both ; but it was all
done so quietly that few knew him for the charitable man he
really was. His character had the charm of simplicity.
Utterly free himself from all that was base and sordid, he
judged others to be the same ; hence he never expressed him-
self unkindly of his fellow men. He died at his residence,
the Brackens, Lymington, August 28th, 1897, at the age of
seventy-four, from heart failure after a long illness following
an attack of influenza. He had retired from the active
practice of his profession about three years previously, and
had gone back to the home of his childhood, where he settled
down to the quiet enjoyment of his garden and his books and
the peaceful pleasures of a country life, and where his friends
had vainly hoped for him " a long and mellow eventide that
the night should linger to disturb."
LIST OF
DE. BEAXTON HICKS'S PUBLISHED WEITINGS
AERANGED CHRONOLOGICALLY.
I. Medical Papers, &c., with Subject Index.
II. Scientific (Non-Medical) Papers, &c.
I. Medical Papers, &c.
1. Case of ruptured uterus during parturition, Guy's Hosp.
Rep,, vol. v., 1859, pp. 84-8.
2. Eemarks on two cases of extra-uterine foetation, ibid.,
vol. vi., 1860, pp. 272-80.
3. On a new method of version in abnormal labour, Lancet,
July 14th and 21st, 1860, pp. 28-30 and 55.
4. On concealed accidental haemorrhage at the latter end of
pregnancy and during labour, Trans, Ohst, Soc. Lond., vol. ii.,
1860, pp. 53-78.
5. Eemarks on kiestine and its existence in the virgin and
sterile states, Guy's Hosp. Rep., vol. vii., 1861, pp. 102-8.
6. On cauliflower excrescence of the os uteri, ibid.,
pp. 241-56.
7. New instruments for the removal of uterine polypi.
Trans. Obst. Soc. Loud., vol. iii., 1861, pp. 346-9.
8. Cases of retention of menses (from malformation), Med.
Times and Gaz., August 17th, 1861, pp. 163-4.
9. Further illustrations of the new method of version,
Lancet, February 9th, 1861, pp. 134-6.
10. Cases of induction of premature labour, ibid., October
5th, 1861, p. 331; and Med. Times and Gaz., December 14th,
1861, p. 609.
108 LIST OF DR. BRAXTON HICKS'S
11. Five cases of vaginal closure, Trans. Ohst. Soc. Lond.,
vol. iv., 1802, pp. 228-42.
12. Two cases of extra-uterine foetation treated by abdomi-
nal section, Guy's Hosp. Rep., vol. viii., 1862, pp. 127-41.
13. Notes on two cases of uterine polypi, ibid., pp. 142-6.
14. On combined external and internal version. Trans.
Ohst. Soc. Lond., vol. v., 1863, pp. 219-59 ; Appendix, pp. 265-6.
15. Three cases of labour obstructed by abnormal con-
dition of the foetus, with some other points of interest, ibid.,
pp. 285-90.
16. On the glandular nature of proliferous disease of the
ovary, with remarks on proliferous cysts, Guy's Hosp. Rep.,
vol. X., 1864, p. 238.
17. On combined external and internal version. Lond.,
1864, 72 pp.
18. An inquiry into the best mode of delivering the foetal
head after perforation, Trans. Obst. Soc. Lond., vol. vi., 1864,
pp. 263-303.
19. Three cases of obstructed labour ; forceps and cranio-
tomy employed in former labours in each ; delivered readily
by version, Med. Tirnes and Gaz., vol. i., 1864, p. 425.
20. Introductory address at Guy's Hospital (abstract), ibid.,
October 8th, 1864, pp. 378-9; Brit. Med. Journ., October
15th, 1864, pp. 436-7.
21. On two cases of face-presentation in the mento-posterior
position, with remarks. Trans. Obst. Soc. Lond., vol. vii.,
1865, pp. 57-67.
22. On cystic or hydatidiform disease of the chorion, Guy's
Hosp. Rep., vol. xi., 1865, pp. 181-5.
23. On a rare- form of extra-uterine foetation. Trans. Obst.
Soc. Lond., vol. vii., 1866, pp. 95-98.
24. Large fibrous tumour of uterus ; spontaneous slough-
ing; death from peritonitis, ibid., pp. 110-12.
25. Kemarks on the use of fused anhydrous sulphate of zinc
to the canal of the cervix uteri, ibid., vol. viii., 1866, p. 220.
26. Notes on cases connected with obstetric jurisprudence,
Guy's Hosp. Rep., vol. xii., 1866, pp. 471-8.
27. Contribution to the pathology of puerperal eclampsia,
Trans. Obst. Soc. Lond., vol. viii., 1866, pp. 323-34.
PUBLISHED WRITINGS, ARRANGED CHRONOLOGICALLY. 109
28. On amputation of the cervix and other methods of
local treatment in cases of malignant disease of the uterus and
vagina, Guy's Hasp. Rep., vol. xii., 1866, pp. 365-80.
29. On a rare case of intra-mural foetation, Trans. Ohst.
Soc. Lond.y vol. ix., 1867, p. 57.
30. The cephalotribe, Brit. Med. Journ., October 19th,
1867, pp. 337-8.
31. Case of extra-uterine foetation treated by abdominal
section, Trans. Ohst. Soc. Lond., vol. ix., 1867, p. 93.
32. Dissections of acephalous monsters without head, heart,
lungs, or liver (with J. Bankart), Guy's Hosp. Rep., vol. xiii.,
1867, pp. 456-61.
33. On the condition of the uterus in obstructed labour ;
and an inquiry as to what is intended by the terms *' cessation
of labour pains," "powerless labour," and "exhaustion,"
Tra7is. Ohst. Soc. Lond., vol. ix., 1867, pp. 207-27 ; Appendix,
pp. 229-39.
34. Eeport of forty-one cases of uterine polypi, with re-
marks. Gay's Hosp. Rep., vol. xiii., 1867, pp. 128-51.
35. Lectures on some of the diseases of the female urethra
and bladder. Lancet, vol. ii., 1867, pp. 449, 479, and 509
lOctober 12th, 19th, and 26th).
36. Case of Csesarean section. Trans. Ohst. Soc. Lond.,
vol. X., 1868, pp. 45-9.
37. Oration, annual, before the Hunterian Society, Med.
Tillies and Gaz., March 21st and 28th, 1868 ; and (abstract)
Lancet, February 22nd, 1868, p. 260.
38. Case of face presentation in which delivery was effected
by the cephalotribe, Trans. Ohst. Soc. Lond., vol. x., 1868,
p. 144.
39. On transfusion (abstract and discussion), Brit. Med.
Journ., August 8th and 22nd, 1868, pp. 151 and 203-4.
40. Cases of transfusion, with some remarks on a new
method of performing the operation, Guy's Hosp. Rep., vol. xiv.,
1868, pp. 1-14.
41. Further remarks on the structure of the growths within
ovarian cysts, ihid., p. 145.
42. On rupture of the vagina in labour. Lancet, January
23rd, 1869, p. 119.
110 LIST OF DR. BRAXTON HICKS'S
43. Some remarks on the cephalotribe, Trans. Ohst. Soc.
Lond., vol. xi., 1869, pp. 43-52.
44. Vesical absorption (memorandum), Brit. Med. Journ.,
March 16th, 1869, p. 235.
45. Case of Csesarean section, Trans. Ohst. Soc. Lond.,
vol. xi., 1869, pp. 99-102.
46. Cases of pregnancy associated with ovarian cystic dis-
ease. Trans. Ohst. Soc. Lond., vol. xi., 1869, pp. 263-5.
47. Kemarks on the use of the intra-uterine douche after
labour, where offensive lochia exist, as a rule of practice,
Brit. Med. Journ., November 13th, 1869, p. 527.
48. The cephalotribe (Letter), Brit. Med. Journ., October
15th, 1870, p. 425.
49. Cases of successful version after failure of the forceps,
Guy's Hosp. Rep., vol. xv., 1869-70, pp. 501-8.
50. On the formation of a Eoyal Academy of Medicine
(Letters), Med. Times and Gaz., March 12th, 19th, and 26th,
1870, pp. 295, 318, and 347.
51. A contribution to our knowledge of puerperal diseases,
being a short report of eighty-nine cases, with remarks,
Trans. Ohst. Soc. Lond., vol. xii., 1870, pp. 44-113.
52. Some observations on an outbreak of diphtheria in the
obstetric wards, Guy's Hosp. Rep., vol. xvi., 1870-71, pp. 165-70.
53. Inaugural address [on election as President] , Trans.
Ohst. Soc. Lond., vol. xiii., 1871, pp. 27-37.
54. Medical treatment of uterine fibroids (note), Brit. Med.
Journ., April 8th, 1871, pp. 370-72.
55. Abdominal puncture in tympanitis (two memoranda),
ihid., November 4th and 11th, 1871, pp. 526 and 556-7.
56. Kemarks on tables of mortality after obstetric opera-
tions (with J. J. Phillips, M.D.), Trans. Ohst. Soc. Lond.,
vol. xiii., 1871, pp. 55-85.
57. A record of observations of temperature during parturi-
tion and in the puerperal state, Guy's Hosp. Rep., vol. xvii.,
1871-2, pp. 447-64.
58. On the contractions of the uterus throughout preg-
nancy, their physiological effects, and their value in the
diagnosis of pregnancy. Trans. Ohst. Soc. Lond., vol. xiii.,
1871, pp. 216-31.
PUBLISHED WRITINGS, ARRANGED CHRONOLOGICALLY. Ill
59. The education of women in midwifery (Letter), Med.
Times and Gaz., November 25th, 1871, p. 659.
60. Annual (Presidential) address, Trans. Obst. Soc. Lond.,
vol. xiv., 1872, pp. 25-34.
61. A form of concealed accidental haemorrhage, Brit. Med.
Journ., February 24th, 1872, pp. 207-8.
62. Some remarks on the anatomy of the human placenta,
Journ. of Anat., vi., 1872, pp. 405-10.
63. The anatomy of the human placenta. Trans. Obst. Soc.
Lond., vol. xiv., 1872, pp. 149-207.
64. Four cases of inversion of the uterus, Brit. Med. Journ.,
May 4th, 1872, p. 470.
65. Two cases of chronic inversion of the uterus, ibid.,
August 31st, 1872, pp. 237-8.
66. Observations on pathological changes in the red blood-
corpuscles. Quart. Jou7ii. Micr. Sci., vol. xii., 1872, pp. 114-17.
67- Annual (Presidential) address, Trans. Obst. Soc. Lond.,
vol. XV., 1873, pp. 16-27.
68. Address at the opening of the section in obstetric
medicine, British Medical Association, Brit. Med. Journ.,
August 6th, 1873, pp. 184-7.
69. Case of delivery by the forceps in face presentation in
the mento-lateral position. Trans. Obst. Soc. Lond., vol. xv.,
1873, p. 39.
70. Cauliflower excrescence of os uteri (Letter), Brit. Med.
Journ., December 20th, 1873, pp. 738-9.
71. A case of cephalotripsy, with short remarks, Trans.
Obst. Soc. Lond., vol. xv., 1873, p. 41.
72. Note on the muscular susurrus in relation to the foetal
heart-sounds. Trans. Obst. Soc. Lond., vol. xv., 1873, p. 187.
73. Post-partum haemorrhage, Brit. Med. Journ., January
17th, 1874, pp. 74-6.
74. Pyaemia in private practice (speech), ibid., February
21st, 1874, pp. 235 and 237-8.
75. Local treatment of cystitis in women, ibid., July 11th,
1874, pp. 29-30.
76. Application of galvanic cautery in gynaecology, ibid.,
November 28th, 1874, pp. 672-3.
77. Lecture introductory to " Dystocia " delivered at Guy's
112 LIST OF DR. BRAXTON HIOKS's
Hospital, Med. Times and Gaz., 1874, pp. 201-3 ; reprinted as
pamphlet, 12 pp., 8vo., Lond., 1888.
78. (Letter on) the risks of obstetric practice [apropos of a
case, Keg. v. Peacock, in which a medical man was charged
with having cut away a portion of intestine which had become
prolapsed during labour through a rent in the vagina] , Lancet,
March 27th, 1875, p. 454.
79. Eeport of three cases of cephalotripsy (with two casts),
Trans, Obst. Soc. Lond., vol. xvii., 1875, pp. 49-54.
80. Kemarks in discussion on puerperal fever, ibid., pp. 108,
141, 195, 209.
81. Note on a dissection of a uterus pregnant about three
and a half months, the placenta being prsevia and fibroids
extensively developed in the walls of the uterus, ibid., p. 298.
82. Keposition of the prolapsed funis umbilicalis, Obstet.
Journ. Great Britain, vol. iii., 1875-6, p. 84.
83. The uterus of Harriet Lane, referred to at the trial of
Wainwright, with statistics of measurements of nulliparous
and muciparous uteri, Trans. Obst. Soc. Lond., vol. xviii.,
1876, pp. 70-74.
84. On the displacement of the uterus by the distension of
the bladder, as shown by experiments on the dead body (with
J. F. Goodhart, M.D.), ibid., pp. 194-205.
85. Duration of quarantine required after puerperal fever,
Brit. Med. Journ., January 22nd and April 1st, 1876, pp. 101
and 407-8.
86. Haemorrhage from the retroflected uterus, and its treat-
ment, ibid., October 6th, 1877, pp. 469-70.
87. Phantom employed for class purposes in midwifery,
Trans. Obst. Soc. Lond., vol. xix., 1877, p. 231.
88. On the very frequent connection between eczema and
diabetes mellitus, Lancet, March 31st, 1877, p. 456.
89. Sex in disease. Croonian Lectures, Eoyal College of
Physicians, Med. Times and Gaz., March 24tb, 31st, April
21st, 1877, pp. 305-6, 331-4, 411-15.
90. Case of Csesarean section. Trans. Obst. Soc. Lond.,
vol. XX., 1878, pp. 106-9.
91. Puerperal scarlatina (memorandum), Brit. Med. Journ.,
February 2nd, 1878, p. 153.
I.
PUBLISHED WRITINGS, ARRANGED CHRONOLOGICALLY. 113
92. Scarlatina and surgery (memorandum), ibid., November
30th, 1878, p. 796.
93. Scarlatinoid rash of ichorrhaemia and septicaemia
(memorandum), ibid., January 4th, 1879, p. 11.
94. Kemarks in discussion on the use of the forceps. Trans.
Obst. Soc, Lond., vol. xxi., 1879, pp. 218-26.
95. Three cases of very large polypi of the uterus, in which
the usual modes of diagnosis were unattainable, removed suc-
cessfully, Obst. Journ., vol. vi., January, 1879, pp. 609-17.
96. Note on the supplementary forces concerned in the
abdominal circulation in man, Roy. Soc. Proc, vol. xxviii.,
1879, pp. 489-94.
97. Note on the auxiliary forces concerned in the circula-
tion of the pregnant uterus and its contents in woman, ibid.,
pp. 494-7.
98. On nursing systems, Brit. Med. Journ., January 3rd,
1880, p. 11.
99. On recording the foetal movements by means of a gas-
trograph, Trans. Obst. Soc. Land., vol. xxii., 1880, p. 134.
100. Case of extra-uterine foetation about the seventh month
of pregnancy; urgent symptoms; removal of foetus by ab-
dominal section ; death, ibid., pp. 141-50.
101. Case of congenital abnormality of the uterus simulating
retention of menses, ibid., pp. 260-4.
102. Case of pregnancy with double uterus and vagina,
ihid., vol. xxiii., 1881, p. 23.
103. Vertical septum in lower part of vagina impeding
hour, ibid., p. 24.
104. Case of twins, short funis in both, ibid., p. 253.
105. Further remarks on the use of the intermittent con-
tractions of the pregnant uterus as a means of diagnosis.
Trans. Intern. Med. Congress, Lond., 1881, vol. iv., p. 271.
106. Illness of the Duchess of Connaught (Letter), Brit.
Med. Journ., March 25th, 1882, p. 441.
107. Cases in which the whole or part of the placenta was
retained for a longer time than usual, Brit. Med. Journ., July
22nd, 1882, pp. 123-5.
108. The government of Guy's Hoswital (Letter), ibid.,
November 18th, 1882, p. 1021.
I
114 LIST OF DR. BRAXTON HICKS's
109. On the behaviour of the uterus in puerperal eclampsia,
as observed in two cases, Trans. Ohst. Soc. Lond., vol. xxv.,
1883, pp. 118-25.
110. The tension of the abdomen and its variations. Trans,
Med. Soc. Lond., vol. vi., London, 1884, pp. 325-42.
111. Clinical memoranda of two cases of chronic vaginitis,
remarks, Lancet, vol. i., 1885, pp. 610-11.
112. A condition of the inner surface of the uterus, after
the birth of the foetus, of practical importance, Brit. Med.
Journ., October 10th, 1885, p. 696, and January 23rd, 1886,
p. 145.
113. Notes of cases in obstetric jurisprudence. Lancet,
August 1st, 8th, and 15th, 1885, pp. 198, 243, and 285.
114. The treatment of placenta prsevia, Med. Press and
Circular, September 9th, 1885, p. 223.
115. Puerperal diseases : an explanation, Amer. Journ. of
Ohstetrics, May, 1886, pp. 474-81.
116. On a cause of uterine displacement not hitherto men-
tioned contra-indicating the use of pessaries. Lancet, vol. i.,
1886, p. 537.
117. On the spontaneous rupture of the uterus during
pregnancy (Letter), Med. Press and Circular, November 17th,
1886, p. 441.
118. Management of placenta pr?evia (Letter), Brit. Med.
Journ., January 1st, 1887, p. 42.
119. (Two Letters) on the treatment of placenta prsevia.
Lancet, vol. i., 1887, pp. 648 and 749.
120. On the influence of bodily movements over septic
absorption. Intern. Journ. Med. Science, July 1888, pp. 38-43.
121. Case of inversio uteri ; reduction; recovery; remarks.
Trans. Ohst. Soc. Lond., vol. xxxi., 1889, pp. 340-42.
122. (Two Letters) on the best mode of delivering the foetal
head after craniotomy, Lancet, vol. i., 1889, pp. 197 and 400.
123. Why does the uterus contract during pregnancy ?
(Letter), Lancet, vol. i., 1889, p. 765.
124. Puerperal fevers and septicaemia (Letter), Brit. Med.
Journ., March 30th, 1889, p. 742.
125. On the treatment of placenta prsevia (introduction to
discussion), ibid., November 30th, 1889, p. 1205.
PUBLISHED WRITINGS, ARRANGED CHRONOLOGICALLY. 115
126. The best mode of delivering the foetal head after
craniotomy (Letter), ibid., February 9th, 1889, p. 328.
127. On the non-retention of urine in women (Letter),
Brit. Med. Journ., November 16th, 1889, p. 1091.
128. A case showing the behaviour of the pregnant uterus
in chorea. Trans. Obst. Soc. Lond., vol. xxxiii., 1891, p. 486.
129. Puerperal eclampsia (Letter), Brit. Med. Journ.y Octo-
ber 3rd, 1891, p. 766.
130. Further contribution to the clinical knowledge of
puerperal diseases. Trans. Obst. Soc. Lond., vol. xxxv., 1893,
pp. 412-19.
131. Our knowledge of puerperal diseases (Letter), Brit.
Med. Journ., December 9th, 1893, p. 1307.
132. On intermittent contractions of uterine fibromata, and
in pregnancy, in relation to diagnosis, Med. Press and Circular,
May 9th, 1894, p. 481.
133. In memoriam Sir Thomas Spencer Wells, Bart.,
F.E.C.S., Trans. Amer. Gyn. Soc, vol. xxii., 1897, pp. 313-18.
I 2
116
LIST OF DR. BRAXTON HICKS S
SUBJECT-INDEX
TO SOME OF THE PRINCIPAL PAPERS IN THE FOREGOING LIST.
Addresses, 20, 37, 53, 60, 67, 68.
Csesarean section (cases), 36, 45, 90.
Cephalotribe, 30, 43, 48, 71, 79.
Cervix uteri, cauliflower excre-
scence of, 6, 28, 70.
Contractions, uterine, during preg-
nancy, 58, 105, 123, 132.
Diseases of urethra and bladder in
women, 35, 44, 75, 127.
Diseases, puerperal (febrile), 51, 74,
80, 85, 91, 92, 93, 106, 115, 120,
124, 130, 131.
Displacements of uterus, 84, 86,
116.
Eclampsia, puerperal, 27, 109, 129.
Face presentation, 21, 38, 69.
Fibroids, uterine, 24, 54, (in preg-
nancy) 81.
Forces, auxiliary, in abdominal
circulation, 96, 97.
Gestation, ectopic (cases), 2, 12, 23,
31, 100, (intra-mural) 29.
Haemorrhage, concealed accidental,
4, 61.
Head, delivery of foetal, after per-
foration, 18, 122, 126.
Inversion of uterus, 64, 65, 121.
Jurisprudence, cases in obstetric,
26, 78, 83, 113.
Labour, obstructed, 33, (cases) 15,
19.
Malformations of female genital
organs, 8, 11, 101, 102, 103.
Menses, retention of, 8, 11, 101.
Ovary, proliferous cysts of, 16, 41,
(in pregnancy) 46.
Placenta, anatomy of, 62, 63, (pla-
cental site) 112.
Placenta praevia, treatment of, 81,
114, 118, 119, 125 (see also Ver-
sion).
Polypi, uterine, 7, 13, 34, 95, (in-
struments for) 7.
Eupture of uterus, 1, 117.
Rupture of vagina, 42.
Sex in disease, 89.
Tension, abdominal, 110.
Version, 3, 9, 14, 17, 19, 49.
PUBLISHED WRITINGS, ARRANGED CHRONOLOGICALLY. 117
II. Scientific (Non-Medical) Papers.
1. On a new organ in insects (1856), Linn. Soc. Journ.,
vol. i., 1857 (ZooL), pp. 136-40.
2. Description of a new British species of Draparnaldia,
ibid., (Bot.), p. 192.
3. Further remarks on the organs found on the bases of the
halteres and wings of insects, Linn. Soc. Trans., vol. xxii.,
1857 (part 2), pp. 141-6.
4. On a new structure in the antennae of insects, ibid,,
pp. 147-54.
5. Humble creatures : the earthworm and the common
house-fly. In eight letters (jointly with J. Samuelson).
With microscopic illustrations by the authors. 8vo., London,
1858, pp. 78.
6. Further remarks on the organs of the antennae of insects,
Linn. Soc. Trans., 1859, pp. 383-99.
7. On certain sensory organs in insects hitherto undescribed,
Roy. Soc. Proc, vol. x., 1859-60, pp. 25-6; Linn. Soc. Trans.,
vol. xxiii., 1862, pp. 139-53.
8. Contributions to the knowledge of the development of
the gonidia of lichens, in relation to the unicellular algae,
Microsc. Journ., vol. viii., 1860, pp. 239-44; vol. i., 1861,
pp. 15-23; vol. ii., pp. 90-97.
9. On the amoeboid conditions of Volvox globator, Microsc.
Soc. Trans., vol. viii., 1860, pp. 99-102.
10. The honey-bee : its natural history, habits, anatomy,
and microscopical beauties (jointly with J. Samuelson). 8vo.,
Lond., 1860, pp. 166.
11. On the homologies of the eye, and of its parts, in the
Invertebrata, Roy. Soc. Proc, xi., 1860-62, pp. 80-84.
12. On the diamorphosis of Lyngbyn, Schizogonium, and
Prasiola, and their connection with the so-called Palmellaceae,
Microsc. Journ., vol. i., 1861, pp. 157-66.
13. On the motionless spores (statospores) of Volvox globator,
ihid., pp. 281-3.
118 LIST OF DR. BRAXTON HICKS's PUBLISHED WRITINGS, ETC.
14. On the nerve proceeding to the vesicles at the base of
the halteres, and on the subcostal nervure in the wings of
insects (1861), Linn. Soc. Trans., xxiii., 1862, pp. 377-9.
15. Observations on the gonidia and confervoid filaments of
mosses, and on the relation of their gonidia to those of lichens
and of certain fresh-water algae, ibid., pp. 567-88.
16. Observations on vegetable amoeboid bodies, Microsc,
Journ., vol. ii., 1862, pp. 96-103.
17. Eemarks on Mr. Archer's paper on algae, Quart. Journ.
Microsc. Sci., vol. iv., 1864, pp. 253-9.
18. On the difficulties in identifying many of the lower
kinds of algae. Pop. Sci. Rev., vol. iv., 1865, pp. 335-42.
19. On the Volvox glohator, Pop. Sci. Rev., vol. v., 1866,
pp. 137-44.
20. On the mode of growth of some of the algae, ibid.,
vol. vi., 1867, pp. 1-9.
21. On fresh-water algae. Quart. Journ. Microsc. Sci.,
vol. vii., 1867, pp. 4-8.
22. On Draparnaldia cruciata mihi, ibid., vol. ix., 1869,
pp. 383-5.
23. On the similarity between the genus Draparnaldia and
the confervoid filaments of mosses (1869), lAnn. Soc. Trans.,
xxvii., 1871, pp. 153-4.
AN
ESSAY
ON THE
TREATMENT AND CURE
OF
PULMONARY CONSUMPTION,
ON PRINCIPLES NATURAL, RATIONAL, AND SUCCESSFUL :
WITH SUGGBSHONS FOR AN IMPROVED PLAN OF TREATMENT OF THE
DISEASE AMONGST THE LOWER CLASSES OF SOCIETY ; AND A
RELATION OF SEVERAL SUCCESSIVE CASES RESTORED
FROM THE LAST STAGE OF CONSUMPTION TO A
GOOD STATE OF HEALTH.
By GEORGE BODINGTON,
SURGEON.
LONDON :
LONGMAN, OKME, BEOWN, GKEEN, & LONGMANS,
PATERNOSTER ROW.
[A reprint of the original work published for Dr. Bodington by
Messrs. Longman in 1840.]
INTRODUCTION
In venturing to put forth an Essay on the almost hopeless
subject of the treatment and cure of Pulmonary Consumption,
which has been so often written upon, and viewed in so many
and various ways, and yet is generally felt and considered still
to remain in statu quo, whilst the wants of the community at
large, as regards this particular disease, are greatly on the
increase, and the character and power of the medical art, as
a curative and remedial means, continues obscured under a
dark and cheerless cloud. For these reasons the Author
trusts to obtain that forbearance and indulgence from his
medical brethren of which he is conscious he so much stands
in need of ; and that they will deem every effort attended with
any success, in this important branch of medicine, of sufficient
value to warrant publication, even if the only effect obtained
was to draw attention to the subject, excite discussion, pro-
mote further efforts, and direct into fresh channels the ideas
of others in relation to the treatment of this disease. As
regards the causes, origin, and nature of the disease, the work
of Sir James Clark, who reaped advantage from the labours
of Carswell and other pathologists, is complete and satis-
factory. He has, however, failed in directing attention to
anything like a decided plan of treatment, either of his own
or of any other, contenting himself with some remarks on all
the means hitherto known to have been tried, and leaving the
matter upon the whole pretty much in the same state he
found it ; that is, in almost all respects decidedly inefficient
and ineffectual. He professes not to interfere with the present
theories which govern and direct the practice of medicine,
but founds his treatment upon them ; and herein I cannot
but think the evil exists. The faultiness of the theories of
the day is one of the causes of the excessive mortality arising
124 BODINGTON ON CONSUMPTION.
from Consumption ; a scrutinizing search, with a view of
investigating their truth or unsoundness, and the adoption of
correct principles, must precede a better general system of
treatment of this as of many other diseases. In the mean-
time, those who are able or willing (laying aside preconceived
notions, and the prejudices arising from early instruction) to
think and observe for themselves may adapt their practice to
the real necessities of such a disease as Pulmonary Con-
sumption, probably with advantage to the public and to their
own credit ; whilst the formation of more perfect theories
must await the result of the labours and researches of patho-
logical anatomists, and of experimental physiologists. Sir
James Clark rather sarcastically alludes to what he terms the
" beef-steak and porter system," which he decidedly condemns,
apparently guided by the " phlogistic " theory. I could never
recommend porter and beef-steaks to any person suffering
from tubercular consumption — not from any preconceived
notion of "phlogiston," but on account of its very grossness
and unfitness for a consumptive patient. On the other hand,
neither could I recommend to such an one, from a prejudice
in favour of the aforesaid theory of "phlogiston," a meagre
diet of vegetables, rice, and water, aided by tartarized anti-
mony, &c. I should recommend to one thus consuming away,
under the influence of this ivasting disease^ a nutritious diet
of mild fresh animal and farinaceous food, aided by the
stimulus of a proper quantity of wine, having regard to the
general state and condition of the patient. If this is to be
called the " beef-steak and porter system," then I am guilty
of patronizing it ; but, to my mind, it rather has the character
of a preservative system, whilst the wasting plan is as much
entitled to be called the destructive one. Be that as it may,
not having the fear of "phlogiston" before my eyes — that
" raw head and bloody bones" of medical science — I have, as
will be found by a perusal of the following pages, employed a
nutritious and moderately stimulating diet with much success ;
and, without that, I do not think the other means could have
been so effectual, or the treatment complete.
I have been brief and concise in drawing up this small
volume, preferring rather to form a strong outline than to
INTRODUCTION. 125
enter into tedious detail ; besides that, the filling up, in the
treatment of individual cases, must always be left to the
judgment of the medical attendant, who alone can direct the
varieties of practice called for by peculiarities arising from
constitutional or other causes.
It will be observed that the main ground of the treatment
has been to preserve or restore to a normal condition the
functions of the nervous filaments interwoven with the sub-
stance of the lungs, and exercising influence over the capillary
system and other parts of the organization. It has been
assumed that the first link in the chain of morbid actions
arises there, as they first feel the irritation from the presence
of the morbid matter deposited as a foreign body, and that all
the other changes are consecutive to this wasting or destruction
of the nervous energy of the filaments with which the tuber-
culous matter comes in contact. Upon this view the treat-
ment of Pulmonary Consumption in the way herein recom-
mended has been founded.
With the intention of further extending this mode of prac-
tice, and of reducing it to a system of regularity and order, as
well as to be ready to meet the wishes and hopes of some who
may read these few pages, and who might anxiously desire to
reap the advantage which this plan promises them, and which
some have already obtained to an extent beyond their own
or the expectation of their friends, I have taken for the pur-
pose a house in every respect adapted, and near to my own
residence, for the reception of patients of this class who may
be desirous, or who are recommended, to remove from their
homes for the benefit of change of air, &c. It is presumed
that, as the situation is very superior in point of dryness,
mildness, and purity of air, the advantages to be derived from
systematic arrangements with regard to exercise, diet, and
general treatment, with the watchfulness daily — nay, almost
hourly — over the patient of a medical superintendent, great
advantages may be obtained by the consumptive patient
treated in this way, in comparison with those to be obtained
by the removal of such an one to a boarding-house or hotel
merely for change of scene ; and it is hoped that this plan
may meet the approbation of the medical profession, and
126 BODINGTON ON CONSUMPTION.
prove beneficial to many afflicted or threatened with the first
symptoms of this direful disease in this neighbourhood or
elsewhere.
This Essay has no pretension to a complete or perfect work
on the subject of which it is composed ; much of it is the
substance of reminiscences of occurrences which took place
several years since ; but it has this to be said in its favour
with regard to the cases related, that the individuals who were
the subjects of them are alive and in good health at the pre-
sent day, thus showing that the disease will admit not only
of palliation, but of cure. Some of those individuals were
despaired of by professional men of eminence, who were
acquainted with the state of their health previous to their
undergoing the treatment under which they recovered; and I
know, and their friends know, that opinions adverse to any
hope of their recovery were expressed. A larger and more
perfect work on the subject may become necessary, as the
result of more experience and the collection of more facts
may happen to be made. The present Essay has been
written in a somewhat hurried manner, when short intervals
of time could be snatched from occupations varied and almost
incessant. Hence, as a literary composition, its imperfections
are very great ; but, as the aim has been to give the pith and
substance of the matter treated on, it is hoped this fault may
be passed over.
Sutton Coldfield, Waewickshire :
January, 1840.
ON THE
TEEATMENT AND CURE OF PULMONARY
CONSUMPTION.
A uniform and complete success having resulted in the
treatment of several cases of tuberculous Consumption upon
the principles and plan explained in the following pages, the
author deems it his duty to publish them, with his opinions
and principles of treatment. It would not accord with the
brevity and conciseness of the plan of this treatise to enter at
length into the nature and causes of Consumption, the dia-
gnostic symptoms, physical signs, morbid anatomy, &c. ; these
are subjects which have been elaborately handled by several
eminent authors, whilst little has yet been done by way of
improvement in the treatment of the disease. Consumptive
patients are still lost as heretofore; they are considered hope-
less and desperate cases by most practitioners, and the treat-
ment commonly is conducted upon such an inefficient plan as
scarcely to retard the fatal catastrophe. One mode of treat-
ment prevailing consists in shutting the patients up in a close
room, to exclude as far as possible the access of the atmo-
spheric air, and thus forcing them to breathe over and over
again the same foul air contaminated with the diseased
effluvia of their own persons. But what could rationally be
expected to be the result from such practice than that of the
conversion of a slow or moderate consumption into an intense
or galloping one ? This is, indeed, a treatment founded on
the most erroneous principles, and is much more deserving
of reprobation than is even the apathetic indifference and
desperate hopelessness generally entertained with regard to
this disease.
128 BODINGTON ON THE TREATMENT AND CURE
To aid the powers of the close room system, tartarized
antimony is often given in excessive doses, and generally
with the effect of nearly destroying the patient. It materially
assists the disease in destroying the powers of nutrition, the
muscular power, and the functions of the skin, at the same
time increasing the nervous excitement. Patients seldom
survive long the use of this medicine, when administered
freely, if the disease is much advanced, unless an antidote to
the poison be timely given. I have never seen anything but
mischief arise from the use of it ; it is entirely inconsistent
with the method and the principles upon which I have success-
fully treated the disease. It is, however, at the present time,
a fashionable medicine, and, I may add, a most destructive
one. I am quite sure that the employment of this remedy (?)
hastens the fatal event.
Digitalis is another drug that has been vaunted as a remedy
for consumption. It has the power of controlling the action
of the heart, and diminishing the number of its beats ; there-
fore, it has been argued, it must or ought to be serviceable in
this disease. It is perfectly well known that it entirely fails
even in retarding the progress of consumption ; it has no
power to cure that disease ; and I shall be able to show
clearly that the diminution and regularity of action in the
heart and arteries is to be attained by far different means
than by the use of digitalis.
I believe, having mentioned the shutting up plan in close
rooms, the use of antimony and digitalis, if I add the use of
demulcents, of blisters, leeches, plasters, &c., I shall have de-
scribed the helpless and meagre system of medical treatment
of consumption in general use at the present day, the utter
uselessness of which is so well known and so obvious that the
members of the medical profession in the towns are in the
habit of dismissing their patients to some distant seaport or
watering-place, where, falling under precisely the same mode
of treatment, they there commonly die. The gravestones in
the churchyards of many of these places of resort of the con-
sumptive patients bear testimony to the truth of this remark.
There is nothing gained by resorting to the coast ; in truth,
the interior of the island is the best ; the air is just as pure
OF PULMONARY CONSUMPTION. 129
and much milder, and more suitable for the lungs of con-
sumptive people, if they will but breathe it. There is but one
other proposition in the way of treatment to which I have to
allude — I mean to the inhalation of gases of various kinds, by
which means it is proposed to convert the cough of consump-
tion into a catarrhal cough, which catarrh is to continue so
long as the patient lives, or, discontinuing, the consumption
would supervene. We have not heard what success has
attended this method of treatment, but it may be fairly in-
ferred that such an artificial mode of proceeding, so contrary
to the dictates of common sense and sound principles, could
not sustain itself for long, and must have perished nearly at
its birth. The only gas fit for the lungs is the pure atmo-
sphere freely administered, without fear ; its privation is the
most constant and frequent cause of the progress of the
disease. To live in and breathe freely the open air, without
being deterred by the wind or weather, is one important and
essential remedy in arresting its progress — one about which
there appears to have generally prevailed a groundless alarm
lest the consumptive patient should take cold. Thus one of
the essential measures necessary for the cure of this fatal
disease is neglected, from the fear of suffering or incurring
another disease of trifling import. No two diseases can be
more distinct from each other than consumption and catarrh.
It is the latter only which might be caught by exposure to
atmospheric causes ; with the former they have nothing to do.
Farmers, shepherds, ploughmen, &c., are rarely liable to
consumption, living constantly in the open air; whilst the
inhabitants of the towns, and persons living much in close
rooms, or whose occupations confine them many hours within
doors, are its victims. The habits of these latter ought, in
the treatment of the disease, to be made to resemble as much
as possible those of the former class, as respects air and exer-
cise, in order to effect a cure. How little does the plan of
shutting up the patients in close rooms accord with this
simple and obvious principle ! As to the result of such a
practice, it is known to all ; one-fifth of the deaths annually
in England are from consumption, whilst cures are scarcely
ever heard of, and never expected. Despair seems to have
K
130 BODINGTON ON THE TREATMENT AND CURE
taken full possession of the medical profession as regards this
destructive disease, and none but the feeblest efforts are
exerted to oppose its progress. The successful treatment of
several cases successively of severe, decided, and genuine
tubercular consumption on principles, I believe, differing
from the usual routine of practice, and from the doctrines
and theories of the present day, which form the basis of
medical practice, induces me to lay those cases before the
public, and to explain my views and principles of treatment
on which that success was founded.
When I began to practice medicine as an art, after having
imbibed the theories of the schools, I very soon found the
necessity of laying them aside as a guide, having discovered,
as I believed, that the practice founded thereon was useful to
a certain extent only, and, as far as that went, fit to be
employed ; but that it was worse than useless, when employed
like a talismanic wand, to unlock and overcome every difficulty
that might present itself. Thus I found that it was for the
most part useful to preserve as much as possible, in very
many diseases, the muscular power, contractility ; but that
antiphlogistic treatment, as it is called, had a direct tendency
to destroy it. Again : To preserve the powers of nutrition, I
have found needful and beneficial always when they can be
maintained ; for disease makes a slower progress when
opposed by a firm muscular tone and good nutritive powers.
Antiphlogistic treatment directly impairs and destroys the
powers of nutrition. Again : In order to oppose the progress
of disease, I have found it of paramount importance to allay
nervous excitement locally and generally ; that is, to endeavour
to bring to a healthy action the nervous influence from that
morbid, irregular, or inefficient action which it exerts under
the influence of disease. If the nervous system can be pre-
served entire, disease will be overcome, and healthy actions
be maintained. If disordered nervous actions are restored to
a healthy state, the functions of all the lower tissues de-
pendent upon them will resume a healthy condition ; for this
purpose Nature has provided man with a bountiful supply of
remedies, in the whole class of sedative and anodyne plants.
In the proper use and application of these medicines is to be
OF PULMONARY CONSUMPTION. 131
found the means of restoring disordered nervous power to a
healthy standard. I shall have to show by and by their im-
portant use in the treatment of consumption. Antiphlogistic
treatment, carried out exclusively in the usual way, and in
accordance with the doctrines of the schools, has a tendency
to excite and irritate the nervous system, and to weaken its
powers over those tissues which rank below it in the scale of
animal life ; consequently it has a tendency to destroy every
natural bulwark to the progress of morbid actions.
If consumption is considered in this light, we shall find the
first step of its progress consists in nervous irritation, or
altered action, or weakened power, in the substance of the
lungs, from the presence of tuberculous matter deposited
there as a foreign body. In consequence of this condition of
the nervous power the contractility of the lungs becomes im-
paired in its membranes, cellular substance, and blood-vessels.
So soon as the nervous power is entirely destroyed in those
portions of the lungs where the tuberculous deposits exist, then
the destruction of the remaining tissues follows immediately ;
they die, dissolve down into a half-fluid, half-putrid condition,
and are expectorated through the bronchial tubes, leaving
cavities in the substance of the lungs which can be never
healed but under the most favourable combination of circum-
stances. Here is then, first, nervous power altered, weakened,
or exhausted ; then the destruction of the remaining tissues
constituting the main substance of the organ. To preserve
the latter the integrity and strength of the former must be
maintained ; and upon the means necessary for that purpose
the whole question turns. I shall endeavour to explain those
I have employed successfully in a plain, distinct, and in-
telligible way to all classes of readers ; for not only the
medical profession, but every family is interested, and ought
to be made acquainted with the means of guarding off this
fearful malady, and of rescuing its victims, wherever it makes
an attack.
Those persons who are for the most part the freest from the
attacks of consumption, such as agricultural labourers, are
commonly but little troubled with nervous disorder ; they are
rather remarkable for an apparent obtuseness of nervous
K 2
132 BODINGTON ON THE TREATMENT AND CURE
susceptibility, and this is in strict keeping with fully developed
muscular, nutrient, and sanguiferous powers. This nervous
quietude harmonises exactly with this condition of the latter
powers ; it is a plain inference that, to guard against the
attacks of consumption, the condition of the patients should
be assimilated as much as possible to that of the above-named
class of individuals. The nutrient, muscular, and sanguiferous
systems must be maintained in the highest perfection that is
possible ; the nervous system quieted, subdued, and rendered
obtuse. The relation of the cases I have treated successfully
will best show the means of effecting these objects. By a
subdued and healthy condition of nervous power, and by a
full and complete condition of health as regards the nutrient
system, &c., the nervous system of the substance of the lungs,
those nervous fibres immediately acted upon by the tuberculous
deposits, will not yield to their influence. Tuberculous matter
is often found deposited upon sound lungs, where it has been
rendered harmless by a vigorous state of nutrition and the
sanguiferous system ; but let individuals thus affected be
exposed to the causes of innutrition, and there are but too
many, by which the muscular and sanguiferous systems lose
their tone and become weakened, and you have removed the
barriers to the progress of consumption; the nerves of the
lungs are no longer able to resist the morbid impression from
the presence of the tuberculous matter, their energy becomes
exhausted, ulcerations and excavation of the substance of the
lungs follow, constituting consumption.
In order then to restore a consumptive patient, it will be
necessary especially to attend to the following matters. We
shall find first of all a rapid and weak pulse, ranging from
120 to 140 beats in a minute, clearly indicating a deficient
supply of blood, and the heart and arteries irritable in pro-
portion to this deficiency. This condition must be met at
once, not by the means termed "antiphlogistic," but with
frequent supplies, in moderate quantities, of nourishing diet
and wine ; a glass of good sherry or madeira in the forenoon,
with an egg, another glass of wine after dinner, fresh meat
for dinner, some nourishing food for supper, such as sago,
or boiled milk, according to the taste and digestive powers of
OF PULMONARY CONSUMPTION. 133
the patient. This will be supplying means to rectify the
morbid condition of the nutritive functions, and to allay the
irritability of the heart and arteries. I have generally suc-
ceeded in the course of a few days, or perhaps a week, in
reducing the pulse from 130 or 140 down to 90, by means of
this diet, and by a systematic use of sedative medicines, and
other means. The whole nervous system is unduly excited,
or affected in some way we know not how to express or
understand, from our limited knowledge of it, when under
the influence of this disease, and neither can nutrition be
affected, or the muscular system recover strength, or the
vessels be filled with a due supply of the vital fluid, unless
that nervous disorder be allayed and soothed, or rendered more
in accordance with a healthy condition. The plan to obtain
this object is to give alterative doses of sedatives, and also direct
or full ones. The former consist of moderate doses given at
intervals throughout the day, with the view of allaying the
general nervous excitement. The direct or full dose is given
at bed-time, to allay coughing and procure sleep. Aconite,
henbane, or the salts of morphia may be used. I have
preferred generally the hydrochlorate of morphine: a sufficient
dose to procure a whole night's repose should be given every
night, in addition to the alterative doses above mentioned ;
the latter may be administered, in an almond emulsion, in
doses repeated three or four times a day. Should the medicine
produce constitutional effects, paleness, faintness, sickness,
giddiness, it must be laid aside for a period, and an antidote
will be found in small quantities of weak brandy and water,
or wine and water. The sedative medicines should be resumed
so soon as these effects are removed.
I come now to the most important remedial agent in the
cure of consumption, that of the free use of a pure atmosphere ;
not the impure air of a close room, or even that of the house
generally, but the air out of doors, early in the morning,
either by riding or walking ; the latter when the patients are
able, but generally they are unable to continue sufficiently
long in the open air on foot, therefore riding or carriage
exercise should be employed for several hours daily, with
intervals of walking as much as the strength will allow of.
134 BODINGTON ON THE TREATMENT AND CURE
gradually increasing the length of the walk until it can be
maintained easily several hours every day. The abode of the
patient should be in an airy house in the country ; if on an
eminence the better. The neighbourhood chosen should be
dry and high ; the soil, generally of a light loam, a sandy or
gravelly bottom ; the atmosphere is in such situations com-
paratively free from fogs and dampness. The patient ought
never to be deterred by the state of the weather from exercise
in the open air ; if wet and rainy, a covered vehicle should be
employed, with open windows. The cold is never too severe
for the consumptive patient in this climate ; the cooler the
air which passes into the lungs, the greater will be the
benefit the patient will derive. Sharp frosty days in the winter
season are most favourable. The application of cold pure air
to the interior surface of the lungs is the most powerful seda-
tive that can be applied, and does more to promote the healing
and closing of cavities and ulcers of the lungs than any other
means that can be employed ; for it is by the use of the means
which have the power of restoring to a healthy condition the
nervous system, interwoven with and forming a portion of the
substance of the lungs, that healthy actions can be induced in
the remaining tissues. This, then, is to be aimed at, — a healthy
nervous system, which will embrace in its consequences, due
sensibility, motive power, nutritive and reparative power, —
conditions necessary to resist and overcome the morbid in-
fluence arising from the presence of tuberculous matter.
Many persons are alarmed and deterred from taking much
exercise in the open air, from the circumstance of their
coughing much on their first emerging from the warm room
of a house ; but this shows that the air of the room was too
warm, not that the common atmosphere was too cold. To
live in a temperature nearly equal to the latter at all times
should be the aim of the patient, who should avoid warm
close rooms as much as possible, and always keep away from
the fire, taking care to keep the surface of the body warm by
sufficient clothing. Thus the equal temperature so much
considered, and said to be necessary, should be that of the
external air, instead of that so commonly employed, the
warmth of a close room.
OF PULMONARY CONSUMPTION. 135
In order effectually to overcome consumptive disease, all
these several circumstances will be required to be adopted
and followed up with the greatest attention, regularity,
assiduity, and patience. Of those cases which I have treated
upon these principles, having had some of the patients under
my own roof, by which I secured all the advantages of
situation, &c., before spoken of, and some in my immediate
neighbourhood, so that I could closely watch them, I have
met with signal success, and scarcely an instance in which
this mode of treatment has been fully carried out in all
its particulars wherein the consumptive symptoms have not
gradually yielded, and the patients restored to complete
health. I shall now proceed to give an outline of the history
of the treatment of several cases.
One occurred in the person of an awl-blade grinder, living
in the country, in the year 1833. He was of a consumptive
family ; a sister of his had died at about the age of twenty
years, and others of his nearest relatives had died from the
same disease. There could be no stronger exciting cause for
the development of the disease than that which arose from
his daily occupation ; he was about thirty years of age, of
fair complexion, florid, shoulders high, chest narrow, and his
general figure rather spare and slender. His finger nails
were incurvated ; he was troubled with a pain in his side ;
and a cough more or less without intermission. It was upon
the accession of a sudden attack of consumption that I was
•called in to attend. A feeling of suffocation affected him,
which was distressing, arising from the pressure of an abscess
in the bronchial passages, attended with irritative fever ; the
breathing was relieved by the bursting of the abscess, and the
free expectoration of pus and mucus. A cavity was formed
in the upper portion of the substance of the lungs ; the pulse
beat 140 in a minute ; he had profuse night perspirations ;
and his respiration was exceedingly quickened. He was much
exhausted, and fully impressed with a belief that his life was
about to terminate. He had no inclination for food of any
kind ; his muscles were relaxed and powerless, and his whole
frame collapsed. Under these circumstances, had the anti-
136 BODINGTON ON THE TREATMENT AND CURE
phlogistic treatment, or even any part of it, been adopted, I
believe he would have sunk past recovery ; and yet would not
this be called acute inflammation of the substance of the
lungs ? and are not the remedies for this said to be, bleeding,
blisters, calomel, antimony, digitalis, purgatives, &c. ? But
any of these, I firmly believe, would have hazarded his exist-
ence ; the application of the antiphlogistic routine would have
destroyed him. The treatment adopted was this. Seeing
that nutrition was at a stand-still, that the muscular power
was collapsed, and the sanguiferous system running away, at
the rate of 140 beats per minute : to counteract these dangerous
symptoms, he took, first, a wine glass of port wdne, and repeated
it in a few hours ; at bed-time he took a sedative draught,
and slept well; he continued to cough, and expectorated
freely pus and mucus ; he took at intervals small doses of
hydrochlor. morph., about a tenth of a grain ; this, and the
full dose he had taken on the previous night, allayed, in a
great degree, the nervous excitement in the lungs, and the
irritative fever subsided ; but the cough, debility, and expec-
toration continued ; there was a cavity of the lungs to be
healed. I told him that could not be done without a strenuous
effort on his part ; and explained to him my views as to the
beneficial effects to be obtained by early rising, and remaining
out of doors a considerable time in the open air ; that this
would soothe, expand, and invigorate the lungs, so that the
sores would soon heal, and that by no other means could he
be cured ; that if he remained within doors, shut up in the
house, more abscesses would be likely to form, and the irritative
fever again attack him. He saw the force of this advice, and
determined to follow it, being a man of much firmness of
character. All this occurred on the second day after the
acute attack. On the next day following he related to me,,
nearly in these words, the particulars of his morning walk :
*' I got up about four o'clock, and crawled out of the house as
well as I could, and felt, and, I believe, looked, the most
miserable, weak, and pitiable wretch in the world. I crept
along, panting for breath, towards the common ; I thought I
must have died on the road ; at last I reached Welchman's
Hill, and when I began to walk round it I felt my lungs open,.
OF PULMONARY CONSUMPTION. 187
my breathing free, and my strength increase fast. I was now
sure it was doing me good ; I went quite round the hill, and
then home, and was so hungry that I ordered a beefsteak for
breakfast, and ate heartily of it." The distance he walked
would be about three miles. The spot called Welchman's
Hill is said to be equal in elevation to any table-land in the
island. The soil lying on a sandy or gravelly bottom, the air
is very pure and mild. He continued for some time daily to
pursue the same course, and became convalescent in a week,
losing his cough entirely. I wished him to change his em-
ployment, but his circumstances forbade that. He resumed,
after a short interval of rest, his trade of an awl-blade grinder,
and continues it to this time He has had symptoms of a
return of his disorder on several occasions since, and informs
me that, when that is the case, he betakes himself early in the
morning to the common, and that always prevents any serious
attack. The cure in this case was obtained by means applied
to stimulate and invigorate the nutritive, sanguiferous, and
muscular powers ; wine and such nourishing diet as the
stomach could bear, and by means applied to soothe and allay
nervous excitement, locally and generally ; first, by a full dose
at night of the muriate of morphine, followed by small
alterative doses given every five or six hours ; secondly, by
the application of the early morning air to the internal
surface of the lungs, continued for several hours, accompanied
with muscular exertion. The change in the character of the
expectorated matter is very striking. As soon as the full effects
of the morning air are experienced, it becomes light, white,
more transparent, and devoid of puriform matter; it has more
of the nature of mucus, and is no longer heavy, yellow, and
solid. So powerfully does this remedy effect the lungs as a seda-
tive, allaying and subduing nervous disturbance, at the same
time inducing a vigorous tone of the digestive apparatus, and
of the nutrient functions generally, that it will, if boldly and
thoroughly applied, directly and entirely change the character
of the cough, and completely remove the wasting irritative fever.
The next opportunity I had of witnessing the advantages
of the mode of treatment described occurred in the case of a
188 BODINGTON ON THE TREATMENT AND CURE
young lady, about sixteen years of age, whose parents, brothers,
and sisters were all at this time healthy generally ; consump-
tion was not known in the family previous to her case, but at
the present time her brother suffers from the disease. For
several years she had suffered occasionally from pain in the
side, cough, and debility. In 1835 she returned home from a
boarding-school, where she had been placed under medical
treatment for these complaints; she was still ill, and her friends
thought it advisable she should go to the sea-coast. She went
near to Liverpool ; the sea-air had a bad effect, the pain
and cough increased ; she was placed under medical care, and
went through a long course of treatment. She continued to
get worse in every respect, and her friends saw the necessity
of her removal home ; and she came to her native air in
Warwickshire in October, 1835, after an absence of several
months. Her friends were impressed with a notion that the
iodine which she had been taking, if persevered with, would
be ultimately successful. This very interesting patient came
under my care. Her parents, relatives, and numerous friends
were watching her with the deepest solicitude ; for she was,
by all who knew her, most highly and justly esteemed. I
found it necessary, at least for a short time, to acquiesce in
the treatment by iodine, although there was but little hope of
any advantage from it. I met several medical men in consul-
tation, and a treatment was pursued in the usual manner ;
the patient being confined to her room, and consumption
gradually wearing her away. I had explained my views to
her friends respecting air and exercise out of doors, but could
not succeed in gaining their consent to the plan. The two
months of November and December were thus lost to the
patient, or, rather, during that period every symptom of the
disease had become aggravated ; she was now extremely
emaciated, suffered from profuse night perspiration, violent
cough, and difficulty of breathing ; the expectoration was
abundant, consisting of mucus, mixed with opaque solid
portions frequently tinged with blood, most of which sank in
water, some floated. There was a dull sound on percussion of
the upper portion of the lungs, mucous rattle, with a gurgling
OF PULMONARY CONSUMPTION. 139
noise, and a hoarseness, and weakness of voice ; the physical
signs, in combination with the general symptoms, were clearly
indicative of the existence of cavities in the upper portion of
the lungs. In the month of January, 1836, the case was left
entirely to my management ; and, having urged my views
strongly to her friends, I gained their consent to their being
adopted. A donkey was procured, on which the patient began
to take exercise out of doors, notwithstanding the inclemency
of the season, in the depth of winter. The first trial was
unpromising ; the cough appearing to be much increased in
coming into the open air from the warm bedroom. This
arose from the undue closeness and heat of the bedroom, and
not the external air. There cannot be a more fatal error
than that which arises from the supposition of there being
something deleterious in the external atmosphere, because
persons cough when first brought into it out of unwholesome
heated apartments. The latter should be especially avoided,
and the apartments kept cool and airy, corresponding in
temperature nearly to the external atmosphere, whilst the
former should be courted and indulged in to the utmost. The
surface of the body may and should always be kept warm by
sufficient clothing, the lungs cool by the constant access of
cold pure air to them ; thus undue heat is driven from the
interior to the surface. In the present instance it was soon
found that by continuing a long time out of doors the cough
abated materially ; every day some improvement was observed
to take place, very gradual, but constant. A sedative draught
was given every night, which, together with the exercise of
the day, procured sleep and warded off the cough till morning.
In the daytime an emulsion mixture was taken at intervals,
and very small doses of morphine, to subdue by degrees the
irritation arising from the presence of tubercles in the lungs.
The diet was nourishing, consisting of boiled egg, fresh meat,
milk and bread, and two glasses of sherry in water daily.
This treatment was continued very strictly through the winter
and spring months of the year 1836 ; by June the patient had
entirely lost her cough, with all the other symptoms of the
disease, regained her health and strength, and passed through
the succeeding winter in very good health, accustoming herself
140 BODINGTON ON THE TREATMENT AND CURE
to go out of doors, walking or riding almost daily. At this
time, July 1839, she is in perfect health.
Nov. 14, 1886. — A young lady about twenty-three years of
age, residing at Birmingham, of a consumptive family. Two
sisters and a brother died of the disease. She had been
suffering several months from cough, pain in the side, emacia-
tion, difficulty of breathing, and a pulse 140 ; she had all the
usual symptoms of consumption in its last stage. In this
condition she was placed under my roof, for the purpose of
undergoing a treatment similar to that last detailed. As her
brother had recently so died, and other members of her family,
and her symptoms in all respects resembled theirs, her fate
was thought inevitable by her friends ; she was therefore
brought to me as a forlorn hope. She came on the 14th of
November. On the 15th she was called up at eight o'clock,
a.m., after a bad night of incessant coughing. After break-
fasting with what appetite she had, she got into an open
phaeton, and was driven four miles. She coughed at first,
but in ten minutes it ceased ; she alighted at a house and
went into a warm sitting-room, where the cough returned
immediately ; after a short stay she returned home, and on
the road the cough nearly ceased to trouble her. She took a
little wine and water at eleven a.m., and at two p.m. dined
on fresh mutton. In the afternoon, rode out on the donkey
some time ; retired to bed at eight o'clock, taking an anodyne
draught of morphine. She slept well, and on the 16th rose
at half- past seven. After breakfast she rode out on a donkey
and walked alternately till one o'clock. After dinner, drove
out in the phaeton four miles and back. Coughed rather
more this afternoon ; pulse, 120 ; appetite moderate ; an
anodyne draught at bedtime.
11th. — Cough continues ; the strength improves ; out of
doors morning and afternoon, riding and walking ; anodyne
draught at bedtime.
25i/i. — Has been gradually improving since the 17th ; has
been out of doors every day, sometimes walking, at others
riding in the phaeton ; sleeps well, the cough being trouble-
some only at rising in the morning ; coughs but little when
OF PULMONARY CONSUMPTION. 141
exercising out of doors ; takes an almond mixture in the
daytime, anodyne draught every night.
29th. — The weather very stormy, the rain falling in torrents ;
notwithstanding which, at intervals when the rain ceased, the
patient walked in the garden, morning and afternoon. Had
a severe coughing fit last night ; has scarcely coughed at all
to-day. Eats moderately of plain animal and farinaceous
food ; drinks a small glass of sherry wine in water daily
after dinner; the anodyne draught at bedtime, and almond
emulsion occasionally. Her health altogether is greatly
improved.
Dec. Mth. — The same treatment continued steadily up to
this day, when she was considered well, and went home to
Birmingham. She had taken exercise out of doors every day
in some form or other ; now her appetite is very good ;
breathing, free and easy ; pulse, strong, firm, and not too
quick ; sleeps well, the cough seldom troubling her in the
night, and quite absent in the daytime ; she is active and
strong, and regaining flesh fast ; eats pork-pie for breakfast
and supper with advantage, drinks sherry and water after
dinner.
She remained at home comparatively well until she caught
the influenza, which prevailed as an epidemic in the months
of January and February, 1837. The disease ran through
the family, and none suffered so severely as my patient. I
had not the management of her under this attack, until,
whether from the effects of the disease, or from the active
and debilitating treatment employed, or both, she lost all the
advantage she had obtained when under my care, the whole
train of consumptive symptoms returned with greater severity
than before. The debility was so great that she could not
support herself, and, after a consultation with her mother, I
arranged once more to receive her under my roof. She was
conveyed in a car to my house, a few miles from Birmingham.
The same plan of treatment was immediately followed which
had before proved so beneficial, and, in the space of three
weeks or a month, she again recovered, and, with the occa-
sional use of anodyne draughts, has remained tolerably well
up to the present period.
142 BODINGTON ON THE TREATMENT AND CURE
May 16th, 1839. — S. K., a married man, about thirty years
of age, lives in service at — L.'s, Esq., Handsworth, near
Birmingham. A few months since had an attack of haemo-
ptysis ; since then has been subject to cough ; the cough is
become permanent, incessant night and day; expectoration
free ; breathing short, especially on taking exercise ; sharp
pains through the chest, on right side ; great debility, and
wasting of the body ; excessive perspirations in the night ;
pulse 120 ; the tongue clean ; eyes have a glassy expression,
pupils dilated ; complexion florid and fair ; stature tall ;
chest rather narrow. His father died at six and twenty, of
consumption. In addition to these symptoms, percussion
afforded a dull sound on the upper part of the chest ; auscul-
tation discovered mucous rhoncus, with gurgling, on coughing.
There was an excavation in the upper portion of the right
lung, accompanied with all the usual symptoms.
Treatment — The nervous excitement was combated by daily
small doses of mur. morphinae ; by the frequent application
of cool air to the surface of the lungs, by walking or riding
out, beginning at five or six o'clock in the morning. The
wasting, innutrition, and muscular debility, and the accel-
erated pulse, clearly indicated the necessity of two glasses of
wine daily, an egg at eleven o'clock p.m., fresh meat for
dinner, tea in the afternoon, and gruel for supper. He took
a dose of almond emulsion three times a day; slept on a
flock bed ; and used tepid sponging with vinegar and water
every night, whilst he had profuse perspirations ; bed-clothes
light.
May 18th. — Improved ; cough diminished ; slept well last
night ; pulse 80, softer, fuller ; breathing more free ; stronger ;
expression of countenance much improved ; rode on horseback
six miles ; continue treatment as before.
21s^. — Kode on horseback ; rose at half-past five ; walked
out for an hour, to the farm-house near, drank a little new
milk ; imi)roving ; sleeps well ; appetite better ; pulse 80 ;
cough much diminished ; breathing more free ; no night per-
spirations ; omit the sponging ; continue treatment as before.
Mth. — He walked this morning four miles ; pulse 86 ; cough
nearly gone ; appetite good.
OF PULMONARY CONSUMPTION. 143
21 th. — Continues improving.
30i/i. — Walked again four miles without feeling fatigued ;
sleeps well ; coughs at j&rst rising in the morning ; after
discharging mucus, remains free from the cough till the
afternoon, when he has another fit of it ; strength increasing
daily.
June 1st. — Is well, with the exception of a slight cough,
and expectoration of mucus, on rising in the morning ; wishes
to be allowed to return to work, as a groom, gardener, &c.
Sth. — Walked four miles again, feeling no fatigue ; coughs
occasionally in the morning; appetite good; breathes with
freedom.
11th. — Has resumed his daily occupations ; his strength
being restored, wine no longer needful ; appetite good ; diges-
tion easy ; drinks toast and water.
ISth. — Called at the surgery ; quite recovered.
A young man about nineteen years of age, after having a
year before suffered from haemoptysis severely, and sub-
sequently from slighter attacks of that disease from time to
time, became the subject of a very severe hypochondriacal
affection, which, in the month of August, 1839, terminated in
the development of tubercular consumption, characterised by
frequent cough and expectoration of mucus and pus, or
matter of an ashy colour, sinking in water ; by nocturnal
profuse perspirations, shortness of breathing, emaciation and
great debility; pulse ranging from 130 to 150 beats in a
minute ; respiratory murmur, almost imperceptible ; percus-
sion over the clavicles gave a dull sound ; internal resonance
of the voice and cough on right side ; the whole symptoms
physical and natural clearly demonstrating the existence of
ulceration and excavation of a portion of the lungs, constituting
the last stage of consumption.
Treatment. — Aug, 6th, 1839. — Takes a glass of new milk
before breakfast ; rises at six a.m., and walks in the garden ;
breakfast, tea and toast ; rides out afterwards ; lunch, milk
and toast ; dinner, fresh meat and bread ; three glasses of
sherry wine daily, at eleven a.m., at two p.m., and at seven
p.m. ; afternoon, exercise in the open air, riding or walking ;
144 BODINGTON ON THE TREATMENT AND CURE
retires to bed at eight ; takes an anodyne draught of mur.
morphinse ; pulse 180.
Sth. — Milk diet disagreeing with the stomach, takes beef-
tea, sago, fresh meat ; sherry wine and water after dinner
and in the evening ; eight p.m., much reheved by the omission
of milk in the diet ; pulse 120, fuller and softer ; cough,
expectoration, and night perspirations continue ; repeat ano-
dyne draught at bedtime.
Sept. Srd. — Patient continues under treatment, pursuing
in all respects the plan daily as above, namely, three or four
glasses of wine daily, with a good supply of fresh animal food,
sedatives, demulcents, early rising, and going daily out of
doors, when the weather permits, and when at home sitting
for the most part with the window wide open, and without a
fire, except occasionally in the evening ; under this treatment
the disease appears arrested in its progress ; there is improve-
ment as regards the cough, the quantity of expectoration, and
the night perspirations, but the pulse continues to beat from
120 to 130 in a minute ; and when at all excited even 140.
This is the most difficult case I have hitherto encountered,
and the most doubtful as to its favourable termination,
arising from the complication of morbid affections the patient
has been subject of, namely, of hsemoptysis, hypochondriasis,
and a few years since of a fistula in ano, some effects of which
he still suffers from; but I purpose to publish, if I have
opportunity, a faithful account of the result of this, and of
every case of this description which I may happen to have the
opportunity of treating, upon the principles herein described,
on a future occasion.
One case more — which I shall describe from reminiscence,
having no notes of it — will show the applicability of the treat-
ment to acute consumption. About two years ago I was desired
to see Ml s. L., the wife of a tradesman, about thirty years of
age, tall in person, and of fair and florid complexion. She
was lying in bed, in extreme agony from difficulty of breathing,
arising from an internal tumour which she described she felt
pressing upon the lower part of the throat. She was pale,
and bathed in perspiration, large drops hanging about her
OF PULMONARY CONSUMPTION. 145
forehead and face. The pulse was exceedingly quick and
small, and the breathing terribly oppressed. Eight or ten
leeches were quickly applied to the lower part of the neck,
just above the sternum ; and shortly after their application
her mouth suddenly became filled with matter of a purulent
character, which she ejected ; the breathing became free,
cough and expectoration remaining. She took a sedative
draught at night, and slept well. In the morning the cough
returned, and the expectoration was great, consisting of
mucus and pus mingled. The irritative fever had greatly
declined. A large bronchial abscess had been the cause of
the symptoms, and its bursting afforded the relief which the
patient felt. The question now was, as to the best means of
healing the cavity, and preventing the acute attack de-
generating into chronic consumption. The means employed
were these. As she had been much exhausted, she was
directed now to take occasionally a little wine and water,
good beef-tea, sago, &c. ; sedatives were given her in small
doses, and a full dose at bedtime. She was advised imme-
diately to quit the bedroom, and go into the open air as much
as possible, that she might obtain the benefit of the soothing
and sedative properties of cool air applied to the inner surface
of the lungs, being well clothed and guarded from wet and
damp. She strictly followed this advice ; and in one week's
time I met her driving several miles from home, and heard
her express very cheerfully that she considered herself quite
well. Her general appearance and expression was decidedl}^
of that character which is indicative of a tuberculous habit ;
and the bronchial abscess was probably the result of tuber-
culous deposit, and the case altogether a specimen of the
acute form of consumption.
The method of treatment in the foregoing cases is, then, I
think, entitled to be called natural and rational; that it is
successful is obvious, each of the individuals thus treated,
except the last but one, still under treatment, has remained
since their cure in good and comfortable health, and they
have obtained this advantage, that they now know themselves
so well the best means of cure, and they employ those means
L
146 BODINGTON ON THE TREATMENT AND CURE
effectually to ward off any fresh attack. Several years have
elapsed since the restoration to health of the two young ladies,
and they neither of them have since suffered seriously from
any disease of the lungs. They go as much as they can into
the open air, walk much, live well, and avoid every source of
bodily debility as much as possible, especially that which
might arise from the imprudent use of that kind of medical
treatment which goes by the term of *' antiphlogistic," well
knowing that if they should sink below a certain degree of
vigour and health from this cause, or any other, consumption
would immediately make inroads upon their constitutions,
and endanger their existence.
The generality of the medical profession have not the
opportunity of thus treating their consumptive patients ; if
they are to succeed, they should have country houses in
proper situations, well ventilated, and provided with all
*' appliances and means to boot," where their patients should
be under their own eyes, and strictly watched and regulated
in all respects as regards exercise, air, diet, medicine, &c. ;
or, there should be a certain class of practitioners who should
exclusively pursue this practice as a distinct branch, to whom
those in the large towns should confide their consumptive
patients, instead of sending them, as many now do, to take
their chance, or probably to fall into the hands of mercenaries
at some distant sea-port, where they commonly die, far away
from friends and home.
With respect to the consumptive poor patients, those who
cannot afford to pay for a proper treatment of this sort,
hospitals should be established in the vicinity of large towns,
in fit situations, and properly appointed in all respects for
their reception and treatment. In these there should be
provision made for affording them carriage or horse exercise ;
and gardening and farming occupations for the convalescent.
The common hospital in a large town is the most unfit place
imaginable for consumptive patients, and the treatment
generally employed there very inefficient, arising from the
inadequacy of the means at command.
With respect to the grinders at Sheffield, who, from the
destructive effects of consumption amongst them, arising
OF PULMONARY CONSUMPTION. 147
from the inhalation of the metallic and stone dust, do. not
live beyond the age of thirty years, the necessity for a
hospital for their exclusive use and treatment is most urgent,
on the score of common humanity and justice. These
individuals actually throw away half the term of their natural
life in the pursuit of an occupation by the results of which
the rest of mankind may feed themselves delicately. As the
immediate cause of the development of consumptive disease
in these individuals is obvious, their removal from its influence,
and early treatment under a combination of favourable cir-
curnstances in a hospital properly chosen for them, and well
conducted, would most likely be productive of a great extension
of the present average term of their lives.
Connected with such a hospital, provision should be made
for the employment of the convalescent and cured patients, who
ought never to return to their former occupation, but should be
employed after as agricultural labourers, gardeners, or in any
other pursuit, rather than return to their former occupation.
One-fourth of the deaths which occur in Birmingham,
Manchester, and other large towns are from consumption;
and if ever there was a necessity for an effort to arrest an
evil of extraordinary magnitude, that necessity is urgent in
regard to this most fatal of all diseases.
I have learned by experience that the surest way in which
a successful treatment can be arrived at by the medical man
is by the reception under his own roof of the consumptive
patient ; at the same time his house should be in the country,
in a situation airy and dry; he should have every means
about him for the proper exercise of the patient, in a carriage,
on horseback, or a donkey, according to the ability and taste
of the invalid; a swing boat is a good exercise, and one
which I have employed with much advantage. The bedroom
should be cool and airy, and properly ventilated ; everything
relating to the patient's health should be strictly watched
and regulated by the practitioner ; above all, in the medical
treatment, there should be no bias in the mind arising out
of the theory prevalent in the schools, and in medical practice,
and termed "phlogiston," giving rise to a treatment called
*' antiphlogistic."
L 2
148 BODINGTON ON THE TREATMENT AND CURE
I have called the treatment herein adopted, natural ; and
not exactly in accordance with the received and adopted
theory of inflammation, but in accordance with the natural
phenomena presenting themselves to observation ; thus, the
whole structure being viewed as composed of so many parts,
the several parts differing from each other in function and
structure, the question presents itself, — How would each be
affected by the presence of a particular morbid affection ? as,
for instance, a deposition of tuberculous matter; — taking,
first, the higher order of organisation, the nervous filaments,
spread out on the organ thus affected, we should infer that
their power would be so affected by the presence of the foreign
body as to be wasted or lost ; so that, by diminished power,
they could no longer control and preserve in healthy action
the blood-vessels, cellular tissue, and other portions of the
common organization ; and as this action of the deposited
matter would occur upon the extremities of the nerves, the
capillary vessels would be affected by the loss of nervous
power, and losing, in consequence, their contractility, or
some portion of it, become dilated, swollen, and congested;
and then would follow the usual phenomena, commonly called
inflammation, terminating in suppuration or ulceration ; that
is, these vessels, losing the aid of nervous influence, are no
longer able perfectly to perform the office of hydraulic tubes,
carrying a fluid containing solid particles in solution — the
blood; hence congestion, obstruction, and collection of the solid
parts of the blood in these vessels takes place, terminating in
abscess, ulceration, gangrene, or re-solution. The principles
of treatment I have ever found most suitable for the removal
of this diseased action are founded neither exclusively on the
doctrines of Brown nor on the theory of inflammation ; the
truth, as far as my experience goes, lies between the two ; as
regards the condition of the nerves of an organ, and the
supply of nervous energy, the reigning power, and governing
principle, without a due supply of which healthy actions in
the lower grades of organization cannot be maintained ; it
depends mainly upon a healthy and vigorous state of the
nutritive organs, by which the sensorium is supplied with
the nourishing fluid, and maintained in vigour. As far as
OF PULMONAEY CONSUMPTION. 149
this system, then, is concerned, the Brunonian theory, and
the treatment founded thereon, is the correct one ; as regards
the dilated, loaded, and distended capillaries, with the heat,
and congestion, and deposition of the solid parts of the blood,
the treatment founded on the theory of inflammation is the
most serviceable ; hence, local bleeding, by leeches or cupping,
may be useful and necessary to relieve congestion of the
blood-vessels in pulmonary consumption ; but this is not
inconsistent with the steady employment of means for the
purpose of maintaining the integrity and perfection of the
sensorial functions, and of the whole nervous system, on
which, in fact, will at last depend the chances of a permanent
cure ; and for this object it will be necessary to stimulate and
preserve in due force the natural powers of the system, by
the stimulus of wine and generous diet ; and to prevent any
undue exhaustion of nervous energy, by the exhibition of ano-
dyne and sedative medicines upon a regular and systematic
plan ; and by the avoidance of all common causes of nervous
exhaustion and debility, especially those of close rooms and
confined air, and of too exclusive a use of the medical treatment
termed ''antiphlogistic." As an illustration of my meaning,
I may mention the experiment of Majendie, who divided the
orbital branch of the fifth pair of nerves within the cranium
of a living animal ; the consequence of which was, that the
eye became affected with all the symptoms and appearances
of what is called intense inflammation, and blindness ensued.
It is plain that the whole course of antiphlogistic treatment,
carried to its fullest extent, would fail in such a case to cure
the eye ; but a restoration of the nervous power, by reunion
of the divided branch, if that could have been effected, would
have cured it ; the antiphlogistic means would have assisted,
by unloading the distended vessels, and facilitating their re-
storation to the natural calibre. These would be the secondary
means, but not the principal ; and this is the view I take of
the treatment of pulmonary consumption, to restore and
preserve the perfection of the sensorial functions, by which
the due quantity of nervous energy may be conveyed to the
affected organ, by the nerves supplying it; secondarily to
this, as much of the antiphlogistic treatment as may be
160 BODINQTON ON THE TREATMENT AND CURE
deemed needful to relieve congestion and to remove local
obstruction, without in any way compromising the normal
state of the sensorial and nervous functions.
The powerful effect of the early morning air, in allaying
excitement, and preventing the exhaustion of nervous energy,
in the nervous extremities or filaments spread out and inter-
woven with the substance of the lungs, with which it comes
into immediate contact, is so great and superior to all other
means, that it should, in my opinion, under the eye and by
the regulation of the medical attendant, form the foundation
of the whole course of treatment ; without it, he will not be
enabled to administer the due proportion of stimulating and
nutritious aliment; it is the proper preparation for the
administration of medicinal sedatives ; by it the muscular
power is preserved from undue exhaustion, and the san-
guiferous system from running away in waste ; for this course
of treatment I have invariably found to diminish the rapidity
of the pulse. The profuse nocturnal perspirations are also
soon subdued by this method of treatment, and the great
debility they occasion avoided. The skin assumes a healthier
action in proportion to the extent of exposure to the external
atmosphere, particularly to the morning air.
If these views are in any wise correct, it is obvious that
the present position of medical men generally is unequal to
the task of undertaking the cure of pulmonary consumption ;
they live in the towns, for the most part, or large villages,
and are compelled on this account to discharge the cases of
consumption which they meet with to the sea-coast or some
watering-place, where probably but little interest is taken
with a view to cure them. I think in the neighbourhood of
every large town, sufficiently distant to be clear of its con-
tamination from smoke, &c., and in well-chosen spots, medical
men should be established with all the means about them for
the treatment of the disease in question, to whom those who
live in the towns should confide their patients of this kind, at
the same time rendering them the benefit of their advice as
far as needful, rather than that they should be dismissed
to the care of nurses and lodging-house keepers, in distant
situations ; and again I repeat, I do think that for the poorer
OF PULMONARY CONSUMPTION. 151
classes, on account of the magnitude of the evil as regards
them, hospitals especially for their use and treatment ought
to be established in fit situations. For my own part, from a
decided conviction of the benefit to be derived, and the great
advantage arising, from the reception of the consumptive
patient under the roof of the medical attendant, provided the
situation of his house is what it ought to be, and all the
means needful for the treatment are at his command, I shall
continue, if I have opportunity, as heretofore, to receive
patients into my house, that they may have an opportunity
of obtaining whatever benefit is to be derived from the plan of
treatment herein described. From the foregoing observations
it will be observed that the medicinal treatment has been
confined almost entirely to the exhibition of sedatives. Anti-
mony and ipecacuanha I decidedly object to ; they do not
go to the root of the evil, are mere temporary remedies, if
remedies at all, and they have a direct tendency and do
indeed always produce excessive debility. With regard to the
use of prussic acid, and hydriod. potassse, both of which have
been extolled, there may be cases in which their exhibition
might be serviceable, providing always that the system herein
laid down, of air, exercise, diet, &c., formed the chief part of
the treatment, but I have not hitherto found it necessary to
resort to their use, therefore can say but little regarding
their efficiency.
As far as my experience goes in the use of carbonate of
soda, which has also been extolled, I decidedly object to it,
believing, from closely watching its effects, it has a tendency
to cause congestion and infiltration in the substance of the
lungs, when given for any length of time. I infer thus much
from having observed increased dyspnoea and cough, and a
purple look of the skin, with a labouring small pulse, to be
the result of its exhibition. I believe therefore in the correct-
ness of Majendie's experiment, wherein by the injection of
this salt into the veins of living animals, the post-mortem
examinations invariably showed a congested state of the
lungs, with infiltration into their substance. Coupling this
with my own observations of its effects on the human frame,
in cases of pulmonary disease, I have a great aversion to its
152 BODINGTON ON THE TREATMENT AND CURE
exhibition, or to that of the nitrate of potass. I have found
it advantageous to avoid the use of all neutral salts, with the
exception of common salt, as a condiment. Since the foregoing
was written, the case of the young man before mentioned
as under treatment has terminated fatally. Gurgling and
pectoriloquy of the left lung, with increased dyspncea, and
every symptom indicative of the almost total destruction of
that portion of the organ, with the occurrence of diarrhoea
on the 17th and 18th of September, terminated in death on
the 20th. Thus the sixth case treated in the way herein
recommended has proved unsuccessful. It remains to be
seen whether, in future, five cases out of six can be cured
by this plan. Whatever occurs under my own observation,
if I have opportunity, shall be faithfully recorded, whether in
favour of or against this method, to recommend and extol
which, at the expense of truth, is neither my wish nor intention,
but that there are ample grounds to justify an extended trial
of the system I think will be admitted generally, and with
fair hopes of improved results comparatively.
The chances against recovery in the last case mentioned
were great. The patient had from early youth grown up with
unusual rapidity, being when about seventeen or eighteen
years of age nearly six feet in height. He had suffered from a
succession of serious and dangerous diseases — namely, fistula
in ano, haemoptysis for several years, and, a few months
previous to the development of the pulmonary disease, intense
hypochondriasis. Thus had the constitution been undermined
and weakened previous to the attack of disease on the lungs,
so that this could hardly in fairness be admitted as a case to
test the efficacy of the treatment applied.
In conclusion, I have to add that the natural, rational, and,
so far as to my knowledge of it has been tried, the successful
treatment of pulmonary consumption appertains exclusively
neither to the theory of phlogiston, or inflammation, nor to
that of the Brunonian system ; but it is a mixture of both.
As I believe, both theories have truth in them, but are not
exclusively true, and independent one of the other. Further,
physiological investigations into the nature of nervous power,
and the influence it exercises over the sanguiferous and
OP PULMONARY CONSUMPTION. . 153
other tissues, by its presence or absence, or undue exhaustion
or irritation, will probably develope the true nature of those
changes of structure which occur under the influence of
disease, which are designated by the term *'phlogosis" or
inflammation, language which not improbably is destined at
some future period to be expunged from medical science and
literature ; or, at least, to be understood as conveying very
different ideas of the nature of disease than are commonly
implied in those terms at present, as well as to effect a great
change in the mode and application of remedial agents
generally. The experimental labours of Majendie in France,
in relation to the operation of the nervous power in animal
life, and the investigations of Kiernan and others in England,
as to the condition of the capillary vessels in diseased parts,
have both a direct tendency to weaken the faith hitherto so
universally and implicitly placed in the old theory.
BIOGRAPHICAL NOTICE OF DE. BODINGTON
[The following short biographical notice of the Author of the
Essay reprinted in the preceding pages may be of interest to the
reader. It is taken from the ' British Medical Journal ' of March
11th, 1882.]
GEOEGE BODINGTON,
M.D. ERLANGEN, L.R.C.P. EDIN., L.S.A.
Dr. George Bodington, whose death occurred on Feb-
ruary 5th, at Sutton Coldfield, in his eighty-third year, was
a well-known and widely-respected practitioner. He was a
descendant of one of the old yeoman families of Warwickshire,
the Bodingtons of Cubbington, who have tilled their own land
in that parish since the time of Henry VIII. As a boy, he
was sent to Magdalen College School, at Oxford ; and, when
seventeen years old, was apprenticed to a Mr. Syer, a surgeon
of Atherstone, by whom he was transferred, a year later, to
a Mr. Wheelwright, a surgeon in the City of London. He
afterwards became a student at St. Bartholomew's Hospital,
and obtained the L.S.A. in 1825. On this qualification Dr.
Bodington began to practice in Birmingham ; but in a very
short time he removed to a neighbouring village of Erdington,
where he carried on a very successful practice until 1843.
In this year he determined to devote his whole time to the
treatment of the insane at the Driffold House Asylum, Sutton
Coldfield, of which he had become proprietor in 1836. At
this work he continued until his retirement in 1868, when
he handed the Asylum over to his son. Dr. G. F. Bodington.
Since that date he mainly occupied himself with public work
BIOGRAPHICAL NOTICE OF DR. BODINGTON. 155
in connection with the royal borough of Sutton Coldfield, of
which he was warden in the years 1852-3, 1853-4, and, up
to 1881, one of its most active members and magistrates.
Dr. Bodington was not a silent member of the profession.
An acute observer, a vigorous thinker, and a good, solid, and
fluent speaker, he was always able to take his share in the
public work connected with his position. In politics he was
a man of strong opinions, and to the last was an ardent
Protectionist, never wavering in his faith, but ever earnest
in advocating the theories in which he believed. It is more
especially, however, as a forgotten medical author that we
would speak of Dr. Bodington. His first medical essay
was a letter on a case of Asiatic Cholera, addressed to the
President and Council of the Central Board of Health,
London, and published in 1831. This pamphlet was a
vigorous protest against the use of bleeding and calomel, and
displayed the same tendency to think and reason for himself
which made his later essay on the Treatment and Cure of
Pulmonary Consumption, 1840, so very noteworthy. In this
little book, Dr. Bodington anticipated by many years the
modern views on the treatment of phthisis. In 1840, con-
sumptives were closely and carefully confined, from a fear
of the evil influence of cold fresh air. Against this, Dr.
Bodington earnestly protested, as " forcing them to breathe
over and over again the same foul air, contaminated with
diseased efiluvia of their own persons." Arguing against the
value of antimony, calomel and bleeding, he urged the free
adminictration of nutritious food and stimulants, with plenty
of exercise in pure air, and, if possible, dry, " frosty air."
He did not value sea-air highly, but contended for the drier
air of inland districts. His great specific was cold, dry air,
which, he said, had a most powerful influence in "healing
and closing of cavities and ulcers of the lungs." It is
remarkable that a village doctor should have arrived, in
1840, at these conclusions, which anticipate some of our
most recent teachings. He was severely handled by the
reviewers, and so discouraged from pursuing observations
which might have been of the greatest value.
In 1857, some years after he had given up general practice,
166 BIOGRAPHICAL NOTICE OF DR. BODINGTON.
a writer in the * Journal of Public Health' unearthed Dr.
Bodington's treatise, and did him tardy but ample justice.
We are glad again to claim for a general practitioner the
high credit of having been the first, or among the first, to
advocate the rational and scientific treatment of pulmonary
consumption. Dr. Bodington was for many years a member
of the Birmingham and Midland Counties Branch of the
British Medical Association.
ON SOME MORBID APPEARANCES
ABSOKBENT ULANDS AND SPLEEN
DR. HODGKIN.
[Reprinted by permission from the original paper in the 'Trans-
actions of the Royal Medico- Chirurgical Society,' vol. XVII., 1832.]
ON SOME MORBID APPEAEANCES
OF THE
ABSOEBENT GLANDS AND SPLEEN
The morbid alterations of structure which I am about to
describe are probably familiar to many practical morbid
anatomists, since they can scarcely have failed to have fallen
under their observation in the course of cadaveric inspection.
They have not, as far as I am aware, been made the subject
of special attention, on which account I am induced to bring
forward a few cases in which they have occurred to myself,
trusting that I shall at least escape severe or general censure,
even though a sentence or two should be produced from some
existing work, couched in such concise but expressive lan-
guage as to render needless the longer details with which I
shall trespass on the time of my hearers.
Case I.
November 2, 1826. Joseph Sinnott, a child of about nine
years of age, in Lazarus's ward, under the care of J. Morgan.
His brother, his constant companion with whom he had
habitually slept, died of phthisis a few months previously ;
he was much reduced by an illness of about nine months,
during which time he had been subject to pain in the back,
extending round to the abdomen. On his admission his belly
was much distended with ascites. He had also effusion into
the prepuce and scrotum. On the latter was a large ulcer
induced by a puncture made to evacuate the fluid.
Head. — There was a considerable quantity of serous effusion
under the arachnoid and within the ventricles. There were a
M
162 DR. HODGKIN ON THE
few opake spots in the arachnoid, but this membrane was in
other respects healthy. The pia mater appeared remarkably
thin and free from vessels. The substance of the brain was
generally soft and flabby, but no local morbid change was
observable.
Chest. — The pleura on the right side had contracted many
strong and old adhesions, in addition to which there were
extensive marks of recent pleuritis. On the left the pleura
was nearly or quite free from adhesion, but there was some
fluid effused into the cavity. There was some little trace of a
tubercular cicatrix at the summit of the right lung, but the
substance of both lungs was generally light and crepitant,
with a very few exceedingly small tubercles scattered through
them.
The mucous membrane exhibited an excess of vascularity ;
the bronchial glands were greatly enlarged and much in-
durated.
The heart appeared quite healthy.
Abdomen. — There was extensive recent inflammation of the
peritoneum, in the cavity of which there was a copious sero-
purulent effusion, and the viscera were universally overlayed
with a very soft light yellow coagulum, too feeble to effect
their union, though evidently having a tendency to do so.
The mucous membrane of the stomach and intestines was
generally pale and of its ordinary appearance, but in some
few spots it was softened and readily separated itself from
the subjacent coat. The contents of the intestines were
copious and of an unhealthy character, overcharged with
bile. The mesenteric glands were generally enlarged, but
one or two very considerably so, equalling in size a pigeon's
egg, of semi-cartilaginous hardness and streaked with black
matter. The substance of the liver was generally natural,
but contained a few tubercles somewhat larger than peas,
white, semi-cartilaginous, and of an uneven surface. The
pancreas was firmer than usual, more particularly at its head,
which was somewhat enlarged. The spleen was large and
contained numerous tubercles. The absorbent glands about
both the two last-mentioned organs were much enlarged.
Both kidneys were mottled with a light colour, but were free
ABSORBENT GLANDS AND SPLEEN. 168
from induration. A continuous chain of much enlarged
indurated absorbent glands of a light colour accompanied the
aorta throughout its course, closely adherent to the bodies of
the vertebrae, and extended along the sides of the iliac vessels
as far as they could be traced in the pelvis. None of these
vessels had been sufficiently compressed to occasion the
coagulation of the contained fluids. The coats of the thoracic
duct, which was large, were perfectly transparent and healthy.
Case II.
September 24, 1828. Ellenborough King, aged ten years,
was admitted into Luke's ward on the 6th of August, 1828,
under the care of Dr. Bright. He was the youngest of six
children, of whom the first five were reported to be all
healthy. This child had also been healthy till about thirteen
months ago, when his strength, flesh, and healthy appearance
began to fail. He was at that time living in the West of
England. A tumour was observed in the left hypochondrium
in the situation of the spleen, the glandulae concatenatae on
the right side were observed to be considerably enlarged, but
under the treatment employed, these tumours, as well as that
in the situation of the spleen, were at times very considerably
reduced in size.
It does not appear that he was ever subject to haemorrhage,
nor till very lately to dropsical effusion ; his appetite was
generally good. After his admission into the hospital the
tumour on the left side was observed to extend considerably
below the left hypochondrium, but was reported not to be so
large as it had formerly been. The glands on the left side of
the neck were swollen, as well as those on the right ; the
abdomen was somewhat distended, and there was considerable
oedema of the scrotum.
The head was not opened.
The glands in the neck had assumed the form of large
smooth ovoid masses, connected together merely by loose
cellular membrane and minute vessels : when cut into they
exhibited a firm cartilaginous structure of a light colour and
very feeble vascularity, but with no appearance of softening
or suppuration. Glands similarly affected accompanied the
M 2
164 DR. HODGKIN ON THE
vessels into the chest, where the bronchial and mediastinal
glands were in the same state and greatly enlarged. There
were some old pleuritic adhesions. The substance of the
lungs was generally healthy. There was a good deal of clear
serum in the pericardium, but this membrane, as well as the
heart, was quite health}' .
In the peritoneal cavity there was a considerable quantity
of clear straw-coloured serum mixed with extensive, recent
thin diaphanous films. The mucous membrane of the
stomach and intestines was tolerably healthy.
The mesenteric glands were but slightly enlarged, and but
little if at all indurated ; but those accompanying the aorta,
the splenic artery, and the iliacs were in the same state as the
glands of the neck.
The liver contained no tubercles, and its structure was quite
healthy. The pancreas was rather firm, and the glands
situated along its upper edge were, as before stated, greatly
enlarged. The spleen was enlarged to at least four times its
natural size, its surface was mammillated, and its structure
thickly sprinkled with tubercles, presenting the same struc-
ture as the enlarged glands already described.
Case III.
BY H. PEACOCK, ESQ.
November 28, 1829. William Burrows, aged about thirty
years. He was admitted into Naaman's ward on the 26th
of September, 1829, under Mr. J. Morgan, for ulcers of a
scrofulous character in the axilla and neck, accompanied
with general cachexia ; he had previously been a patient in
Samaritan's ward with secondary symptoms of syphilis, and
was supposed to have taken large quantities of mercury.
About four months before his death, which occurred on the,
27th of November, abdominal dropsy made its appearance.
The body was extremely emaciated, some ragged excavated
ulcers were situated about the right axilla and thorax; the
ulceration extended beneath the neighbouring skin, and
between the pectoral muscles. The muscles of the body were
pale.
The head was not examined. , .
ABSORBENT GLANDS AND SPLEEN. 1H5
The left cavity of the chest contained about a pint of
serum. The lung was rather oedematous, but otherwise
healthy, with the exception of some puckering and apparently
chalky deposit at its apex. The lung on the right side
adhered closely to the walls of the cavity, the adhesions being
firm and cellular. The lung resembled that of the left side,
and was also slightly disorganised at its apex. The pericar-
dium contained about an ounce of clear and straw-coloured
fluid. The heart was small and flabby.
The abdomen contained about two pints of clear serum.
The stomach and alimentary canal were much distended with
flatus. The liver was of a shrunken irregular shape, and
was connected to the diaphragm by a few firm adhesions. Its
structure was indurated, pale, and thickly pervaded with a
substance having a white, hard, tuberculous character, which
in some parts had the form of defined rounded masses of the
size of large pin heads, but for the most part was diffused.
Some sections exhibited parts apparently stained with a dark
ecchymosis as if from extravasated blood.
From some portions of liver seen after the inspection by
Dr. Hodgkin, it appeared to him that the liver was in that
state in which the acini become dense, rounded, and of a
light colour, resembling small tubercles, and are readily
detached : a condition of liver which is almost peculiar to
those who have laboured under a cachectic condition from
mercury. The gall-bladder was small and filled with a dark
coloured green bile. The pancreas was not diseased. The
spleen had contracted several firm adhesions to the neigh-
bouring peritoneum ; it was enlarged to about twice its usual
size, and was unusually firm. Sections exhibited its structure
dense, rather dry, and of a dark red colour, but homogeneous.
Dr. Hodgkin examined this spleen, a short time after its
removal from the body, and found its substance generally
pervaded by numerous minute translucent bodies somewhat
resembling incipient miliary tubercles of the lung, but con-
siderably smaller than these generally are.
The kidneys were pale, flabby, and slightly mottled.
A few small miliary tubercles were found in the peritoneum,
about the inguinal region, resembling those which have been
166 DR. HODGKIN ON THE
noticed above in the liver. Some of the mesenteric glands
were much enlarged and filled with a firm white deposit.
The inguinal, lumbar, and aortic glands were similarly
affected. The bronchial glands were in a similar state, and
also extensively ossified (or loaded with earthy matter). The
axillary glands were in a state of suppuration, and exposed
by ulceration at the part. The thoracic duct presented nothing
unusual.
Case IV.
January 8, 1830. Thomas Westcott, aged apparently about
fifty years, by trade a carpenter, a patient of Dr. Addison in
the Clinical Ward, admitted 30th of December, 1829. He
was not at all wasted, but was rather plump than otherwise ;
he had a pale and peculiar, cachectic countenance, which,
without minute description, may be suggested to the mind by
comparing it to what is seen in some cases of confirmed
disease of the spleen. The most remarkable feature in his
case was the great enlargement of nearly, if not quite, all of
the absorbent glands within reach of examination, but more
especially in the axillae and groins. Those at the side of the
neck were scarcely less so. Most of these glands which were
within reach were of about the size of pigeon's eggs, a few
somewhat larger, and others rather smaller. They were of a
smooth rounded or ovoid figure, and were only moderately
firm, rather than indurated. An enlargement was also to be
felt in one epididymis. The abdomen was distended, but the
substance of the parietes appeared thick, no distinct tumour
could be felt in the region of the spleen, or in any other part
of the abdomen.
The functions of the brain had been somewhat disturbed,
and the left eye did not see so well as the right.
It did not appear that this patient had been liable to any
particular exposure, nor could any circumstance be referred to
as the exciting cause of his malady. His death took place
very suddenly in the morning of the 8th, and the examination
was made four hours and a half after.
The veins of the head and neck were turgid. There was
no lividity of the face. There were some ecchymosed spots on
one of the legs.
ABSORBENT GLANDS AND SPLEEN. 167
The arachnoid was remarkably thick and opake. On the
surface of the right hemisphere there was a diffused light
rose-red colour, occupying the space of about the size of a
crown piece ; it appeared to depend on infiltration of the pia
mater. This membrane separated readily from the surface of
the brain. No morbid appearance was discovered in the sub-
stance of the brain, and no undue quantity of fluid in the
ventricles. The cerebellum seemed to be, proportionately,
rather small.
The right optic nerve was rather smaller than its fellow.
The glands in the axillae and neck, as might have been
expected, were found prodigiouslv enlarged, the deepest seated
being in general the largest. The cellular structure around
these was loose and free from any morbid deposit. These
glands were smooth and of a whitish colour externally, with a
few small bloody spots. When cut into, their internal struc-
ture was likewise seen to be of a light, nearly white, colour
with a few small interspersed vessels. They were of a soft
consistence, which might be compared to that of a testicle.
They possessed a slight translucence, and were nearly or
quite uniform throughout, exhibiting no trace of partial
softening or suppuration. Although in appearance and con-
sistence these enlarged glands bore considerable resemblance
to some fungoid tumours, they presented nothing of the
encysted formation. The alteration in this case seemed to
consist in an interstitial deposit from a morbid hypertrophy
of the glandular structure itself, rather than on a new or
adventitious growth. The glands in the groin presented
precisely the sanie character as those just described ; the
same may also be said of those in the thorax and abdomen,
the situation and extent of which will be presently stated.
The pleurae were nearly, if not altogether, free from ad-
hesions and effusion. There were a few ecchymosed spots on
the posterior part of the right lung ; both lungs were spongy
and crepitant, but rather emphysematous, and of a light
colour, from the small quantity of blood which they contained.
The bronchial tubes contained some thick mucus.
The pericardium was healthy. The heart was greatly
enlarged, and the right cavities particularly dilated ; but the
168 DR. HODGKIN ON THE
left were also large and distended, with thickened parietes.
The muscular structure however did not appear to he diseased.
The blood in the heart was barely coagulated, resembHng that
recently drawn into a basin. The glands along the subclavian
arteries and about the roots of the bronchi were much
enlarged.
In the abdomen nothing particular was noticed about the
peritoneum. The glands at the small curvature of the
stomach, several in Glisson's ^capsule, and a large mass of
them along the entire course of the abdominal aorta and iliac
arteries were greatly enlarged. There was a marked difference
in the mesenteric glands, which, though larger than is natu-
ral, were none of them of the prodigious size of those above
mentioned; they were however of a light colour, and their
increase of size evidently depended on an interstitial deposit
similar to that of the other glands. One of the enlarged
glands in the lumbar region had a good deal of superficial
ecchymosis. The absorbent vessels connected with it were
enlarged and distended with a bloody serum. A similar fluid
less deeply tinged was found in the thoracic duct.
The liver was very large, pale, and slightly granular. The
spleen was very greatly enlarged, being at least nine inches
long, five broad, and proportionally thick; its colour was
lighter and redder than is natural, and more firm and close.
On cutting into it an almost infinite number of small white
nearly opake spots were seen pervading its substance ; they
were of irregular figure, but a few appeared nearly circular.
They appeared to depend on a deposit in the cellular struc-
ture of the organ. There were no tubercles in the spleen,
but the spots just mentioned were perhaps a commencement
of this kind of formation.
The pancreas was large and pale, but otherwise healthy.
The mucous membrane of the stomach and bowels offered
nothing remarkable.
Case V.
Inspection of a middle-aged man who had latterly been a
patient of Dr. Back. He had long been in bad health, and
had been for some time a patient under Dr. Bright. His last
ABSORBENT GLANDS AND SPLEEN. 169
most urgent symptoms were referable to the chest. When in
the hospital the former time, he was observed to have the
glands of the neck, and more particularly those near the
upper part of the thyroid cartilage, considerably enlarged.
The body was emaciated. The glands before mentioned
were still much enlarged, those in the axillae were not observed
to be particularly so, those in the groins were somewhat so.
The abdomen was distended.
The head was not examined.
The greater part of one lung was distended, solid and void
of air, its texture was rather soft and readily lacerable. Its
colour seemed to be the result of the acute white hepatization
very deeply soiled with reddish brown. The other lung was
far from healthy, but it was rather engorged and softened
than hepatized, and still contained air. One, if not both,
pleurae exhibited traces of recent inflammation with little or
no effusion.
Nothing remarkable is remembered to have been noticed in
the heart or pericardium.
In the abdomen there was a large quantity of serum with
little appearance of coagulable lymph. In the stomach the
mucous membrane was not quite healthy, presenting some
indications of chronic inflammation; it, as well as the
intestines, contained unhealthy secretions. The liver was of
remarkably large size, weighing upwards of seven pounds.
Its form and the smoothness of its surface were little if at all
altered. The colour was somewhat mottled with a mixture of
darkish green and yellow. The acini were manifestly en-
larged, and it was suspected that they had undergone the
fatty degeneration; but on exposure to heat, they appeared to
contain little, if any, greasy substance. The spleen was very
large, its weight is not known, but it appeared to be four or
five times the average size ; its texture was rather more solid
and compact than is natural ; it contained no tubercles, but
the cellular structure interspersed through the parenchyma
was more conspicuous than is usual, in some parts appearing
in the form of specks, in which it was soft and easily broken
down. The absorbent glands accompanying the aorta were
greatly enlarged, some equalling at least the size of a pullet's
170 DR. HODGKIN ON THE
egg ; some, but more especially those in the abdomen, were
reddened by injected or ecchymosed blood. The receptaculum
chyli and some of the larger lymphatic branches contained
blood mixed with dark and almost black coagula. The
thoracic duct, which was large, was filled in the same manner.
Case VI.
July 19, 1830. Thomas Black, aged about fifty years,
admitted into Barnabas Ward on the 30th of June, 1830,
under the care of Dr. Bright. He was affected with large
tuberose swellings of considerable firmness on both sides of
the neck, in both axillae, and in both groins. His abdomen
was greatly distended, he suffered from difficulty of breathing,
and was pale and rather emaciated.
It appeared that about two years before he had laboured
under fever. That, being exposed to cold, shortly after he
observed the glands swell on one side of the neck ; not long
after on the other side, and, in succession, those in the situa-
tions above mentioned.
The body presented considerable lividity, especially the
extremities on the left side. The left side of the neck and the
left axilla presented the largest tumours.
The head was not examined.
The tumours evidently depended on greatly enlarged ab-
sorbent glands along the course of the carotid and axillary
arteries. On raising the sternum they were found to extend
along the subclavians and internal mammaries ; they were
also found, though in less number and size, along the aorta in
the posterior mediastinum ; but it did not appear that the
bronchial glands were at all similarly affected. There was
some appearance of recent pleuritis and serous effusion into
the chest.
In the peritoneal cavity there was a large quantity of yellow
serum mixed with some flakes of lymph. A large and con-
tinued mass of nodulous glandular tumours surrounded the
aorta and iliac arteries, but the mesenteric glands were very
slightly affected. The omentum was corrugated. The liver
was rather small, with an irregular and uneven surface, its
colour was lighter than natural, and the acini were converted
ABSORBENT GLANDS AND SPLEEN. 171
into rounded fleshy masses, without any very great change
in the intervening cellular membrane. It also contained two
or three white tubercles, which resembled fungoid tubercles of
the liver, and were situated at the surface of the organ. The
structure dependent on cysts was not demonstrable in them,
but from their form it might be suspected. The spleen was of
moderate size, and appeared to be quite free from any adven-
titious deposit, which is a fact worthy of remark, as in very
many cases of glandular disease bearing resemblance to the
present case, this organ has been affected, and generally
tubercular. The pancreas was imbedded in the tumours, but
appeared pretty healthy.
The kidneys were livid and congested.
The tumours which formed the most striking features in
this case very nearly resembled each other in structure ; there
appeared to be merely a little difference in firmness ; they
were of various sizes, from that of a horse-bean to that of a
hen's egg; they had a round or ovoid figure, and were
invested by a thin membrane, pretty smooth externally, and
connected to the loose and apparently healthy cellular mem-
brane which surrounded the tumours ; the other surface
intimately adhered to the structure of the tumour. This
texture was apparently pretty uniform throughout, and was
pale and slightly translucent, and could not be said to evince
traces of the mode of formation dependent on cysts ; they
showed no disposition to suppuration or softening ; some,
when just taken from the body, were of a semi-cartilaginous
hardness, but became considerably softer after a little
maceration.
The aorta appeared to be a little compressed by the tumours.
This patient had an old reducible hernia on the right side,
on which side there appeared to be hydrocele also.
It may be observed that, notwithstanding some differences
in structure, to be noticed hereafter, all these cases agree in
the remarkable enlargement of the absorbent glands accom-
panying the larger arteries ; namely, the glandulse con-
catenatse in the neck, the axillary and inguinal glands, and
those accompanying the aorta in the thorax and abdomen.
That as far as could be ascertained from observation, or from
172 Dll. HODGKIN ON THE
what could be collected from the history of the cases, this
enlargement of the glands appeared to be a primitive affection
of those bodies, rather than the result of an irritation pro-
pagated to them from some ulcerated surface or other inflamed
texture through the medium of their inferent vessels; and
that although in some instances the glands so enlarged may
contain a little concrete inorganizable matter, such as is
known to result from what is called scrofulous inflammation,
it is obvious that this circumstance is not an essential
character, but rather an accidental concomitant to the idio-
pathic interstitial enlargement of the absorbent glandular
structure throughout the body. That unless the word inflam-
mation be allowed to have a more indefinite and loose meaning
than is generally assigned to it, this affection of the glands
can scarcely be attributed to that cause, since they are un-
attended with pain, heat, and other ordinary symptoms of
inflammation, and are not necessarily accompanied by any
alteration in the cellular or other surrounding structures, and
do not show any disposition to go on to the production of
pus or any other acknowledged product of inflammation
except where, as in the cases above alluded to, inflammation
may have supervened as an accidental affection of the hyper-
trophied structure. Nor can the enlargement in question,
with any better reason, be attributed to the formation of any
of those adventitious structures, the production of which I
have already had occasion to describe, and have referred to
the type of compound adventitious serous cysts. Notwith-
standing the different characters which this enlargement may
present, it appears in nearly all cases to consist of a pretty
uniform texture throughout, and this rather to be the conse-
quence of a general increase of every part of the gland than
of a new structure developed within it, and pushing the
original structure aside, as when ordinary tuberculous matter
is deposited in these bodies. At the same time it must be
admitted that the new material by which the enlargement is
effected presents various degrees of organizability, which in
some instances is extremely slight, and appears incompetent
to maintain the vitality of the affected gland. In such cases
the new structure will generally become opake, soften, or
ABSORBENT GLANDS AND SPLEEN. 17B
break down, and acting as a foreign irritating body, excite
irritation and lead to the formation of abscess. The case of
William Burrows (No. III.), and also that of a native of
Owhyhee, who died in Guy's Hospital with extensive abscess
in the axilla, are, I believe, to be considered of this kind.
The remarkable appearance of blood in the thoracic duct
and some of the absorbents, observed in the case of Thomas
Westcott (No. IV.), although it sufficiently attracted my
attention to induce me to have a drawing immediately made,
was only regarded as an accidental occurrence ; but the
recurrence of the same phenomenon to a much more con-
siderable and striking extent in the recent case (No. V.),
induces me to suppose that it is intimately connected with
this glandular disease. It may also be observed that in the
last-mentioned case the enlarged glands from which the
lymphatic vessels containing blood proceeded, were particu-
larly loaded with blood; and if my recollection does not
deceive me, a tendency to the same state was present in the
case of Westcott, although it escaped notice in the record of
the inspection.
Another circumstance which has arrested my attention in
conjunction with this affection of the absorbent glands is the
state of the spleen w^hich, with one exception, in all the cases
that I have had the opportunity of examining, has been found
more or less diseased, and in some thickly pervaded with
defined bodies of various sizes, in structure resembling that
of the diseased glands. We might, from this circumstance,
be induced to suspect that these bodies in the spleen, like the
enlarged glands themselves, are the result of the morbid
enlargement of a pre-existing structure, an idea which may
derive some support from the fact that, although in human
spleens no glandular structure is distinguishable, in those of
some inferior animals a multitude of minute bodies exist
which appear to be of that nature. Malpighi indeed con-
sidered the acini or granulations in the spleen to be glands.
In one instance it may be remarked that although the glandu-
lar derangement had advanced very far, the depositions in the
spleen were extremely minute, assuming the appearance of
miliary tubercles. Hence, we may conclude that if, as I
174 DR. HODGKIN ON THE
conceive to be the case, there be a close connection between
the derangement of the glands and that of the spleen, the
latter is a posterior effect, and on this account may not
always have been produced when that of the glands or some
other disease carried off the patient. In other instances, the
spleen, although much enlarged, contained no regular defined
bodies, although the white cellular structure was very evident
in increased quantity pervading the dense and enlarged mass
of the organ. In such cases it might still be doubted whether,
had the patient's life been protracted, the deposits in question
might not ultimately have taken place, yet I am inclined to
believe the contrary, and to suspect that either the previous
derangement of the structure of the organ or the greater age
of the patients may have opposed their production. I men-
tion this effect of age merely as a suspicion or idea, founded
on the fact that I have very rarely, if ever, met with any kind
of tubercles, excepting those of malignant character, in the
spleens of adults, whilst they have been by no means un-
frequent in a far less number of spleens of children and young
persons which it has fallen to my lot to examine. The only
exceptions which I can call to mind, as having been furnished
by my own observation, have been in the case of one or two
foreigners from warm countries, on whom the change of
climate may have had considerable effect.
Some further confirmation of my suspicion that a connec-
tion exists between the glandular derangement of which I
have been speaking, and the state of the spleen, has occurred
to me since the preceding observations were written. Whilst
examining the unrivalled collection of pathological drawings
made by my friend Dr. Carswell, I was struck with one re-
presenting a greatly enlarged spleen, loaded with large tuber-
cles of a rounded figure and light colour. I immediately
recognised it as a fine example of the affection I have been
describing, and my suspicions were presently confirmed by
the Doctor's showing me another fine drawing of the greatly
enlarged glands of the neck, axillae, and groins of the same
subject.
The Doctor has favoured me with a copy of the case, and
allowed me to place the drawings themselves before you.
ABSORBENT GLANDS AND SPLEEN. 175
Case VII.
** Cancer Cerehriforinis of the Lymphatic Glands and of the
Spleen.
*' The delineations of this very remarkable case were taken
from a man who died in the hospital St. Louis at Paris, in
the month of April. Monsr. Lugol, one of the phj^sicians of
the hospital, and under whose care the patient was, has
promised to give me the particulars of this case. I was told
however that the patient, who was between thirty and forty
years of age, stout made, and not lean, had been affected
with swelling of the glands under the jaws, along both sides
of the neck, in the axillae and groins for between three and
four months, from which he had suffered but little inconveni-
ence, to which he had paid but little attention, and had
employed no remedies. It was only a short time before he
applied to be taken into the hospital that he felt a difficulty in
swallowing, which rapidly^increased, and for the the last two
or three days was such as to prevent him from taking any
kind of food whatever. As his appetite had never been
affected by the disease, he was, when he came to the St. Louis
hospital, in a state of great suffering, not only from want of
food and from debility, but from the idea that he was rendered
incapable of satisfying the cravings of hunger, together with
the prospect of inevitable death.
" He lived rather more than two days.
'* Inspection of the body. — On each side of the neck were
large groups of glands extending from the angle of the jaw
down to the clavicle, where they were joined to another group
coming up from the axillae and passing under the clavicle.
The submaxillary and sublingual glands were greatly enlarged,
and, united with the other lymphatic glands, formed an
almost continuous chain stretching along the border of the
jaw and uniting under the chin. These glands were of various
sizes, some of them were not larger than a pea, while others
were as large as a hen's egg ; they were round, oval, or of an
irregular form, particularly where they were united by a
176 DR. HODGKIN ON THE
common capsule. A great many of them presented the colour
which distinguishes them in the healthy state ; others were
of a yellowish tinge, with more or less redness and vascu-
larity; whilst a few were of a deep red colour and highly
vascular. The greater number of them when pressed between
the fingers felt pretty firm and somewhat elastic ; those that
were red and vascular were softer. All of them were enclosed
in a thin but firm capsule, which contained a substance of
the colour and consistence of brain, and in which were
distributed a considerable number of blood-vessels. In the
softest the vascularity was such as to give to the cerebriform
matter an appearance resembling a mixture of equal parts of
brain and blood. A similar state of the glands was observed
in both groins. The greater number of them were as large as
pigeon's eggs, and could be followed passing upwards under
Poupart's ligament, surrounding the great blood-vessels, and
terminating in the diseased lymphatic and mesenteric glands.
The diseased appearances observed in the glands of the groin
are represented in No. 4-6, Fig. I. ; those of the neck and
axillae No. 4 a. In No. 4-6 is seen the appearance of the
substance of which the glands were formed ; in one of them
the vascularity of this substance is seen to be very great,
whilst in the other the vessels are few in number, long, and
slender. The quantity of cerebriform matter is also seen to
differ considerably in each. Besides, in the lower figure the
lobulated structure which it presents is pretty well marked.
In Fig. III. two of the glands are represented after having
been injected. In the upper one a large vein is seen coming
out from it, and arising from a great number of minute
vessels, which apparently are situated near the surface of the
gland. In the lower one, the corresponding artery is shown,
dividing and subdividing into an immense number of extremely
fine branches, which are distributed throughout the substance
of the gland. No. 4 c. Fig. I, represents an enormous tumour
formed by the lymphatic glands situated under the liver,
duodenum, pancreas, and great blood-vessels of these parts.
It was as large as an adult's head, projecting forwards on a
level with the convex surface of the liver, and carried before
it the duodenum, pancreas, and gall-ducts, which passed over
ABSORBENT GLANDS AND SPLEEN. 177
its anterior surface. Fig. 11. represents a section of this
tumour, which is seen to be formed of a great number of
glands, some of which are as large as a small orange. Like
those of the neck and axillae, they were composed of cerebriform
matter, possessing a greater or less degree of vascularity. In
the centre of the tumour considerable haemorrhage had taken
place, the centre of the haemorrhagic effusion was occupied by
coagulated blood, and the circumference by layers of fibrine.
The vena cava and aorta passed through the tumour, and
the former was nearly perforated by one of the diseased
glands.
" No. 4 c represents the same pathological condition in the
glands situated in the posterior fauces. The glands situated
around the root of the tongue were so much enlarged as to
shut up completely, by their projecting upwards, backwards,
and forwards, the posterior nares and superior aperture of
the oesophagus. I could not ascertain the precise state of the
epiglottis, but it must to a certain extent at least have been free,
as it did not appear that inspiration had been much impeded.
The amygdalae, formed entirely of cerebriform matter, pre-
sented a pale-yellow colour tinged here and there with red
specks, produced apparently from the rupture of minute
blood-vessels. They have also lost that characteristic ap-
pearance from which they derive their name, having become
almost perfectly smooth from the accumulation of the cere-
briform matter and the distention of their envelope.
" The spleen was the only organ apart from the lymphatic
glands which presented a similar, or indeed any, disease in
this remarkable case. The external surface of this organ is
shown in No. 4 a. Fig. I. Besides great increase of its bulk,
it presented externally a great number of irregular elevations
surrounded by redness and vascularity. When divided longi-
tudinally, Fig. II., it appeared to be formed entirely of
cerebriform matter and fine blood-vessels; hardly any trace
of its natural structure being observable. It presented a
lobulated structure ; the lobules varying from the size of a
small pea to that of a large gooseberry ; these being again
divided and subdivided into smaller ones — the boundaries of
the lobules and the intersections of the latter were the parts
N
178 DR. HODGKIN ON THE
in which vascularity was greatest — it did indeed appear as if
the lobulated structure had been the result of a vascular
net-work so disposed as to inclose and separate more or less
completely portions, of different sizes, of the cerebriform
matter. It depended however, in all likelihood, on the struc-
ture of the spleen, in the cells of which, or in the blood
which they contain, the cerebriform matter was deposited or
formed, whilst the blood-vessels which surrounded the lobules
and ramified in their intersections arose from those which
belong to the splenic cells.
** The body having been removed by inadvertence before I
had time to examine the chest, I did not ascertain the state
of the bronchial glands, but I was informed by one of the
house-physicians that they were not diseased."
Although the Doctor has employed the term "cerebriform
matter," which conveys a ready idea of the texture of the
diseased glands, he will excuse my differing from him so far
as to regard the affection in this case as distinct from
cerebriform cancer. I feel the less difficulty in doing so
in the recollection that one of the cases of which I had
given the details was, like Dr. Carswell's, considered as
fungoid until a special and close inspection had detected the
difference.*
Besides .the preceding cases, of which I have been enabled
to obtain the inspections, I have met with other examples in
the living subject which, as far as the glands were concerned,
were evidently of the same character with those I have been
describing. One of the most remarkable occurred in the
person of a Jew, apparently between forty and fifty years of
age ; the glands in the neck were prodigiously enlarged,
forming smooth ovoid masses, unaccompanied by inflamma-
. tory symptoms or thickening of the surrounding cellular
structure. The glands in the axillae and groins were in the
same state ; in fact, in this case the enlargement was more
considerable than in any other that I have witnessed. His
l"^' The portraits here referred to have already been published by
the New Sydenham Society from Carswell's original drawings. They
constitute Fasciculus XII. of the Society's ' Atlas of Pathology.']
ABSOBBENT GLANDS AND SPLEEN. 179
general health was much impaired ; I do not recollect that
there were any dropsical symptoms at the time I saw him.
I accidentally lost sight of him, but afterwards learnt that
he died about two months from the time of my seeing
him.
Another case occurred in a cachectic, rather emaciated
child, who was brought, on one occasion only, as an out-
patient to Guy's Hospital. The glands in the neck, axillge,
and groins were considerably enlarged, and as far as I could
judge were of the firm character observed in the cases of
Joseph Sinnott and Ellenborough King, rather than the softer
and more fleshy character noticed in the glands of Westcott,
Black, Case V., and, as far as I could observe, in that of the
Jew just mentioned.
A pathological paper may perhaps be thought of little
value if unaccompanied by suggestions designed to assist in
the treatment, either curative or palliative ; on this head
however I must confess that I have nothing to offer.
Most of the cases, it may be observed, were those of
patients in the hospital, where they had not sought admission
until the disease had reached an advanced and hopeless
stage. The Jew was the only individual whom I had an
opportunity of treating myself, and him only for a short
period, when his case had already become hopeless. The
cascarilla and soda which were given with a view to improve
his general health, and the iodine employed as the agent most
likely to affect the glands, appeared to be productive of no
advantage, on which account it is probable the patient
withdrew himself from my observation. Were patients thus
affected to come under my care in an earlier and less hopeless
period of their malady, I think I should be inclined to
endeavour as far as possible to increase the general vigour
of the system ; to enjoin, as far as consistent with this object,
the utmost protection from the inclemencies and vicissitudes
of the weather ; to employ iodine externally, and to push the
internal use of caustic potash as far as circumstances might
render allowable. I mention this last part of the treatment
N 2
180 DR. HODGKIN ON THE ABSORBENT GLANDS AND SPLEEN.
in consequence of the strong commendation which Brandrish
has bestowed on the use of this caustic alkali in absorbent
glandular affections. The views which I have been induced
to take respecting the functions of the absorbent vessels would
make me the more disposed to adopt it.*
* Shortly after the reading of this paper, I was favoured with the
following communication from my friend G. 0. Heming, of Kentish
Town :—
" Dear Sir,
" You will, I am sure, be pleased with the following extract from
Malpighi. Yours truly, G. 0. Heming.
" ' In homine difficilius emergunt [speaking of the granules in the
spleen]: si tamen ex morbo universum glandularum genus turgeat,
manifestiores redduntur, aucta ipsarum magnitudine, ut in defuncta
puella observavi, in qua lien globulis conspicuis racematim dispersis
totus scatebat.' "
BIOGEAPHICAL NOTICE OF DE. HODGKIN.
[The following biographical notice of Dr. Hodgkin is taken
from the ♦ Lancet ' of April 21st, 1866.]
THOMAS HODGKIN, M.D.
On the 5th instant, at Jaffa, whither he had gone on one of
those missions of love and mercy in which he delighted, died,
at the age of sixty-eight. Dr. Thomas Hodgkin. His medical
brethren will feel his loss as that of a physician of rare talent ;
as one who was a fine scholar, an accomplished linguist, and
a large-minded philanthropist. To his more immediate friends
his loss is irreparable. Few men were more beloved than Dr.
Hodgkin : his truly Christian charity, his unostentatious piety,
his utter self-abnegation, won and kept the love and esteem
of all who knew him.
Thomas Hodgkin was born at Tottenham, January 16th,
1798. His father, of whom he always spoke with much
affection, was a member of the Society of Friends, and
engaged in tuition. Under his care the son, although a
prematurely born and delicate child, became a perfect Latin
and Greek scholar, whom the late distinguished Dr. Prichard
was proud to own as friend and equal. In after years. Dr.
Hodgkin learned to write and speak fluently French, German,
and Italian.
In 1821, after studying in Paris, Dr. Hodgkin took his
degree as doctor of medicine at Edinburgh ; in 1825 he
became a member of the College of Physicians of London.
He never acknowledged the title of Fellow of the College,
refusing, as did his friends Sir James Clark and Dr. Arnott,
182 BIOGRAPHICAL NOTICE OF
to accept an honour which he thought involved an invidious
distinction.
Dr. Hodgkin was an ardent yet patient student in the
wards of Guy's Hospital; he was, while yet a young man,
appointed curator of its Museum, and his many pathological
preparations, still within its walls, and, above all, his catalogue
of its contents, attest the knowledge and zeal with which he
fulfilled his duties. He had naturally looked forward to the
office of Physician ; to his great mortification, however, his
claims were passed over, and Dr. Babington, whose death
occurred within a few days of his own, obtained the post, at
that time almost entirely in the gift of the treasurer of the
hospital.
In spite of the prejudice raised in some minds by his dress
and opinions, which were those of a sincere member of the
Society of Friends, Dr. Hodgkin's talent and professional
knowledge made his way. His work on the "Morbid Anatomy
of the Mucous and Serous Membranes " was already an ac-
knowledged text-book, and he was invited to undertake the
task of reorganizing the medical school at St. Thomas's
Hospital, in which he was appointed Lecturer on the Practice
of Physic. On the formation of the University of London, he
was appointed one of the Senate, an office which he retained
to the last. His name appears, not undistinguished, on the
roll of nearly every medical society in this country or abroad.
Although possessing the entire confidence of those who
knew his worth and talent, Dr. Hodgkin never obtained a
large share of practice. He had no worldly wisdom, and
did himself, and, perhaps, others injustice by a disregard of
due professional remuneration, which amounted almost to
eccentricity. On one occasion, after sitting up all night with
a man of very large fortune. Dr. Hodgkin offended him by
filling up a blank cheque with the sum of £10, and made the
offence still greater by telling him that " he did not look as if
he could afford more." Dr. Hodgkin was never again sent
for to the gentleman. It was difficult to make Dr. Hodgkin
take the fees he had earned, and for this reason alone many
of his friends would not consult him.
Dr. Hodgkin was an enthusiastic lover of his profession :
DR. HODGKIN. 183
most unselfishly, most earnestly he ever laboured for its
advantage ; with what success his published works manifest,
with what self-denial one instance will illustrate. In 1857
some friends, Sir James Clark at their head, set on foot a
subscription for a testimonial to Dr. Hodgkin, which soon
amounted to nearly three hundred guineas. He would not
accept this in any form, and at his reiterated entreaty it was
made over to the Medical Benevolent College.
The most important works of Dr. Hodgkin are his two
volumes, entitled " Lectures on the Morbid Anatomy of the
Serous and Mucous Membranes," and " Means of Preserving
Health," and his translation, with notes and additions, of
Edwards " On the Physical Agents of Life." There are,
besides, many papers of his published in the various medical
periodicals ; and during his whole life he maintained a con-
stant correspondence with many of the leading scientific men
at home and abroad.
Ethnology, intimately connected as it was with philanthropic
feelings and pursuits, was Dr. Hodgkin's favourite study. To
his patient and persevering exertions the present position of
the Ethnological Society is almost entirely due; he was several
times president, and always one of the vice-presidents of it
and of the Geographical Society, and a constant attendant
and speaker at the meetings of both.
Although, as before observed, not robust. Dr. Hodgkin was
a man of untiring energy, and retained all his powers of mind
and vigour of thought in unabated force. He had accompanied
his friend Sir Moses Montefiore on a successful mission to
Morocco : and this year, with the object of relieving the miseries
of the Jews in Palestine, had again lent his valuable assistance.
He died of dysentery — this much the telegraph had told us ;
but, strange to say, no details have as yet reached England.
Dr. Hodgkin was emphatically a good man, and a sincere
and devout Christian. We may believe that his end was
peace, and that the manner of his dying was consistent with
the tenour of his blameless life.
THREE SELECTED PAPERS
BY
SIR JAMES PAGET, BART.,
F.R.S.
1. — On the Eelation between the Symmetry and the
Diseases of the Body. December, 1841.
2. — On Disease of the Mammary Areola preceding
Cancer of the Mammary Gland. 1874.
3. — On a Form of Chronic Inflammation of Bones
(Osteitis deformans). November, 1876.
ON THE
RELATION BETWEEN THE
SYMMETKY AND THE DISEASES
OF THE BODY.*
The relation between the processes of disease and the
symmetrical form of the body has usually been studied only
with a view to determine the circumstances in which one
lateral half of the body is more frequently affected with a
given disease than the other is. And, with this view, many
interesting facts have been observed : so many, indeed, that
they have drawn away the attention of pathologists from
those which, though they are less numerous, are sufficient
to render it highly probable that it is a law of the animal
economy, that, when uninfluenced by disturbing causes, all
general or constitutional diseases affect equally and similarly
the corresponding parts of the two sides of the body.
Of this last class of facts, the following are examples : —
I. In the body of a woman, fifty-one years old, who died of
a disease in no degree affecting the elbow-joints, I found both
of them exhibiting exactly the same morbid changes. In each
a portion of the cartilage, of an irregularly triangular form,
had been removed by a chronic diseased process from the
middle of the great sigmoid cavity of the ulna ; and into
each of the spaces thus formed there had grown a process of
synovial membrane and fat, which accurately fitted into it.
Above each of these larger ulcerations of the cartilage there
was a smaller one. The rest of both the joints was healthy,
and bore no trace of having been recently affected by any
* Read before the Royal Medico-Chirurgical Society of London,
Dec. 14th, 1841.
188 MR. PAGET ON THE RELATION
acute disease. On comparing the two ulnse, the exact re-
semblance of the alterations in each was most striking :
except by the position of the bones, the one could scarcely
have been distinguished from the other, for the likeness
extended to nearly every one of the numerous minute irregu-
larities in the outline and depth of the ulcerations, and of the
processes of membrane that had grown into them. (A pre-
paration of the diseased parts is before the Society.)
II. In two knee-joints from a woman aged seventy, I found
exactly similar morbid changes. In each the cartilages of
the patella, the femur, and the head of the tibia were affected
with the well-known fibrous degeneration, in precisely the
same extent and degree, and in each the edges of the semi-
lunar cartilages were similarly and equally affected by the
same disease. There was also on each outer condyle a spot
of exactly the same form and size, from which the cartilage
was completely removed, and where the exposed and hardened
bone formed a shallow depression into which a corresponding
elevation on the top of each tibia accurately fitted. There
was no morbid change in either joint that was not exactly
repeated in the other.
III. A preparation which I made some years ago exhibits
similar effects of disease in the heads of two femora from the
same subject. From each the ligamentum teres is entirely
removed, and on each there are, just above the cavity in
which it had been fixed, two small and almost exactly similar
losses of substance in the cartilage. The rest of both joints
is healthy.
IV. A similar, but yet more striking instance of sym-
metrical disease was presented in two hip-joints (of which
the preparation is before the Society), which I recently
examined in the body of a woman, aged sixty-eight, who died
of general dropsy, and of which, as well as of most of the
diseases mentioned in this paper, preparations are preserved
in the Museum of St. Bartholomew's Hospital. In each of
these joints there was attached to the head of the femur
a similar, very slender shred of fibrous tissue, the remnant of
the ligamentum teres ; on each femur there were similar
small spots, from which the cartilage had been removed ; and
BETWEEN SYMMETRY AND DISEASE. 189
more than these, there was a spot on the exactly corre-
sponding part of the neck of each femur, from which the
investing fibrous tissue had been removed by ulceration,
leaving an aperture into which an irregular elevation of bone
had grown. The aperture and the elevation in each were
so alike, that, although their forms were far from simple, the
naked eye could barely discern a difference between them.
V. The number of examples of similar morbid changes
which I have seen in corresponding right and left joints is
greater than it can be necessary to detail. I shall therefore
mention only three others, in which the symmetry is par-
ticularly well marked, and of which preparations have been
made. These are the femora and patellae of the same subject,
on the cartilages of each of which the gouty secretion of urate
of soda is deposited in the same quantity, and the same
irregular form ; two humeri, on each of which uneven- knobbed
growths of bone of the same form and general characters rise
up by the sides of the bicipital groove ; and two femora and
two patellae, from which exactly corresponding parts of the
cartilage have been removed, and of which precisely similar
portions have acquired the peculiar porcelain-like surface.
VI. I have made a preparation of the two hind legs of
the same dog, on each of which the femora, patellae, and
other bones exhibit exactly similar growths, of a coral-like
exostosis.
VII. Another preparation exhibits the two ovaries of a
woman from whom a carcinomatous breast had been removed
some years before death. Both of them are occupied by large
growths of cancerous hardness, and exactly alike in size,
form, and all other characters. And I have lately met with a
similarly symmetrical development of small carcinomatous
tubercles in the ovaries of a woman who died of carcinoma of
the gall-bladder.
In advancing these few facts as the chief, though not the
only evidence for the existence of such a law as that which is
supposed, it must be remarked that each of them involves a
coincidence of two events, and a coincidence so exact that, if
often repeated, it is impossible to imagine it to be the result
of chance. It is obvious that, if there be no such law, the
190 MR. PAGET ON THE RELATION
probabilities are greatly against any slight disease ever occur-
ring coincidently on two exactly corresponding parts of the
body, and leading to exactly the same results in each of them.
I do not deny that such an accidental coincidence may hap-
pen, and probably an example of it was presented in two
exactly similar bands of adhesion which I once found passing
from the surface of each lung to the corresponding part of the
third rib on each side. Still the chances are almost infinitely
against such a coincidence occurring several times in a limited
number of cases. But, on the other hand, it is not at all im-
probable that, although such a law may exist, the numerous
disturbing forces to which the economy of the living body is
subject may commonly, or even most frequently, prevent the
law from having effect. It is, indeed, only reasonable to sup-
pose that such a law would be more often evaded than followed,
for its observance requires the exact concurrence of a great
number of delicate processes, each of which is liable to be
interfered with by accidents, whose number is incalculable,
and of whose mode and extent of operation we are ignorant.
This being the case, a single example of symmetry must be
of much more weight to affirm the existence of a law of
symmetry than a hundred, in which it is absent, are to
deny it.
If therefore there were no other facts than those already
related, I think the symmetry of certain diseased processes
should be regarded as the result of a general law. But the
evidence of these facts is corroborated by many others which,
though separately less remarkable, are, when taken together,
scarcely less conclusive. For, to establish a law of symmetry
in disease, it is not essential that all the facts adduced should
be examples of exact similarity in the results of the morbid
processes on each side of the body, since a great number of
examples of general, or even of slight, resemblance could not
happen by chance. I could add to the instances of symmetry
in the chronic diseases of joints already mentioned many
others, only rather less perfect than they are. A resemblance
more or less exact in the chronic diseases of corresponding
bones is also not unfrequently observed ; and the fact that
the bones of the lower extremities of those who have had
BETWEEN SYMMETRY AND DISEASE. 191
rickets are almost always similarly curved is a proof that
those of both sides were affected in an equal degree, and
therefore yielded equally under the pressure of the body. It
has been often observed — and it is true — that the transparent
cysts so commonly found on the choroid plexuses are sym-
metrical in form and arrangement ; and I have often seen an
equal resemblance in opaque spots with the Pacchionian
glands, as they are called, in the pia mater covering the
hemispheres of the brain. I may also refer to the general
similarity of the diseased changes in the two kidneys and the
two ovaria, in most of the cases in which they are both
affected, and to the occasional, though rare, occurrence of
equal degrees of phthisical degeneration, and of pneumonia
in both lungs. But the most remarkable example of a general
resemblance in the results of disease on the two sides of the
body is furnished by the admirable researches of M. Bizot,*
which I have in several cases been able fully to confirm. He
found that in 2171 cases of yellow spots in the arteries, a
symmetry of the morbid changes was wanting only sixty-two
times ; that in 659 cases of lesions consecutive to such spots,
it was wanting only fifty-one times ; and that many of even
these few exceptions were connected with an absence of
symmetry in the affected arteries, or some similar modifying
circumstance.
I have selected the evidence for the law of symmetry in
general diseases from facts of morbid anatomy, because a
similarity in the results of two diseased processes affords much
more reason to believe that those processes were the same in
kind and equal in degree than can be afforded by a similarity
of symptoms. There can be no doubt that the signs of disease
in the cases detailed, if they were at all appreciable, were the
same on each side of the body ; but there are some affections
whose symptoms are more remarkable than their permanent
consequences, and of these many afford evidence in favour of
a law of symmetry. Such are the cases in which gout and
rheumatism pass by metastasis from one part of the body to
'•' "Eecherches sur le Coeur et le Systeme Arteriel" {^Mem. de la
Societe Medicale d' Observation,'' t. i. p. 408).
192 MR. PAGET ON THE RELATION
the corresponding part on the opposite side, but to no other ;
cases also in which erysipelas, beginning on the bridge of the
nose, pursues a similar course over each side of the face,
head, and neck ;* inflammations of the tonsils and of the
Schneiderian membrane, which often pass rapidly from one
side to the other, and of the eyes and testes, in which the
same metastasis more rarely oocurs, and some others. But
the evidence of these similar signs of disease is of less import-
ance than that drawn from similar results, because we cannot
accurately appreciate their degree or their nature, and in
many of them there is a failure of coincidence in time which,
it is probable, did not happen in the first set of cases.
There is yet another class of facts of which the value for
my present purpose may be disputed, — those, namely, which
relate to changes of structure occurring so commonly in ad-
vancing age that they are not usually regarded as the results
of disease. Such are the blanching of the hair, baldness, the
arcus senilis, the flattening of the cornea, the falling of the
teeth, the atrophy of bones, muscles, and other tissues. It
may be a question whether these and other changes of the
same kind affecting more important organs are not the mere
results of regular laws, by which men are late in life as
normally degraded towards death as in earlier years they are
developed into manhood ; but, if they can be taken in evidence
on the present subject, they are all strongly confirmatory of
the existence of the supposed law ; for in a very large majority
of cases these changes of function and of structure occur
equally and similarly on both sides of the body.
On the whole, then, I think the evidence adduced is
sufficient to prove that, when not disturbed from their natural
course, all diseases, such as scrofula, secondary syphilis, gout,
rheumatism, and others, including all those which are de-
pendent on a morbid condition of the whole economy, or of
some part whose influence is felt by all others, such as the
blood or the nerves, produce similar local effects in the corre-
sponding parts of the two sides of the body ; in other words,
that there is the same natural tendency to symmetry in the
-'' Dr. Graves's Clinical Lecture, * London Medical Gazette,' Jan. 14th,
1837, and Oct. 20th, 1838.
BETWEEN SYMMETRY AND DISEASE. 193
diseased changes of form and structure as there is in the
normal development of the body. The probability of the
existence of such a law is very obvious, for it involves
nothing more than this— that the same influence exerted on
two similar parts will produce in both the same results.
That it should have been generally lost sight of must be due
to the influence of disturbing causes being so constantly and
powerfully exerted on the several portions of the body, that
those which are originally formed symmetrical rarely remain
exactly so throughout life, and therefore commonly fail to
exhibit the same results when the same morbid influence is
exerted upon them.
Should the existence of this law be admitted, there is
probably no one in science to which the exceptions are so
numerous. But its existence can be no objection against the
truth of other general laws, in accordance with which a part
on one side of the body is more liable to a particular disease
than the corresponding part on the other side : as the left
lung to phthisis, the right to pneumonia, the left lower
extremity to phlegmasia dolens, the left testicle to varicocele,
&c. Some of these greater liabilities — the two last mentioned,
for example — are probably the consequences of the peculiar
anatomical relations of the part most obnoxious to the disease ;
for the relations of the two common iliac and the two sper-
matic veins are not the same, and the parts from which they
bring the blood are hence (if by no other circumstance) not
perfectly symmetrical. For others of these diversities, how-
ever, I can imagine no sufficient reason ; but it seems very
probable that they result not from a natural and innate ten-
dency to disease in the one part more than in the other, but
from various influences acting in different degrees upon them
both, and so far destroying the exactness of their symmetry
of operation, if not of visible form, that when they are both
subjected to a common excitant of disease they react dif-
ferently.
From the facts just cited there appear to me to be at least
three different conditions in which diseased changes are sym-
metrical.
In a first class of cases they are the result of the gradual
194 ON THE RELATION BETWEEN SYMMETRY AND DISEASE.
degeneration of the tissues in the course of time, or after
their functions have ceased, or when, through some general
disorder in the economy, the whole body fails of being
duly nourished. Such are emaciation, the changes of old
age, &c.
In a second class the symmetrical changes are the result of
a morbid condition of the blood, in which some new material
bears a peculiar chemical or organic relation to the whole or
a part of some symmetrically arranged tissue or organ, so
that when they come in contact the mode of nutrition in the
tissue is altered, or the new material is deposited in it. These
changes are symmetrical, because the same morbid material
acts similarly with all similar substances. They are sym-
metrical and general, when the whole of the seemingly
similar tissue has really the very same structure and other
properties. But, more commonly, they are symmetrical and
local, because the corresponding parts on the opposite sides
of the body are the only parts in which the symmetry is, in
respect of every property of the tissue, perfect. To this class
belong the rheumatic, gouty, scrofulous, tuberculous, can-
cerous, medullary, and some other symmetrical diseases.
In a third class the symmetrical changes are the con-
sequences of diseases passing by metastasis from one part to
the exactly corresponding part on the opposite side. In some
of these a morbid condition of the blood exists, in others it
probably does not. In all, I believe that the influence which
determines the situation occupied by the diseased process after
metastasis is one conveyed from the part first affected through
its nerves (which are in a state of morbid organic excitement)
to the nervous centres, and thence reflected and conveyed
through its nerves to the part secondarily diseased. To this
class must be referred the metastatic affections of the eyes,
tonsils, testes, and probably some cases of rheumatism and
gout.
ON
DISEASE OF THE MAMMAEY AREOLA
PRECEDING
CANCEE OF THE MAMMAEY GLAND.*
I BELIEVE it has not yet been published that certain chronic
affections of the skin of the nipple and areola are very often
succeeded by the formation of scirrhous cancer in the mam-
mary gland. I have seen about fifteen cases in which this
has happened, and the events were in all of them so similar
that one description may suffice.
The patients were all women, various in age from forty to
sixty or more years, having in common nothing remarkable
but their disease. In all of them the disease began as an
eruption on the nipple and areola. In the majority it had the
appearance of a florid, intensely red, raw surface, very finely
granular, as if nearly the whole thickness of the epidermis
were removed ; like the surface of very acute diffuse eczema,
or like that of an acute balanitis. From such a surface, on
the whole or greater part of the nipple and areola, there was
always copious, clear, yellowish, viscid exudation. The sensa-
tions were commonly tingling, itching, and burning, but the
malady was never attended by disturbance of the general
health. I have not seen this form of eruption extend beyond
the areola, and only once have seen it pass into a deeper
ulceration of the skin after the manner of a rodent ulcer.
In some of the cases the eruption has presented the
characters of an ordinary chronic eczema, with minute vesi-
cations, succeeded by soft, moist, yellowish scabs or scales,
and constant viscid exudation. In some it has been like
psoriasis, dry, with a few white scales slowly desquamating ;
''= From ' St. Bartholomew's Hospital Keports,' vol. x., 1874.
o 2
196 MR. PAGET ON DISEASE OF
and in both these forms, especially in the psoriasis, I have
seen the eruption spreading far beyond the areola in widening
circles, or, with scattered blotches of redness, covering nearly
the whole breast.
I am not aware that in any of the cases which I have seen
the eruption was different from what may be described as
long-persistent eczema, or psoriasis, or by some other name,
in treatises on diseases of the skin ; and I believe that such
cases sometimes occur on the breast, and after many months'
duration are cured, or pass by, and are not followed by any
other disease. But it has happened that in every case which
I have been able to watch, cancer of the mammary gland has
followed within at the most two years, and usually within one
year. The eruption has resisted all the treatment, both local
and general, that has been used, and has continued even after
the affected part of the skin has been involved in the cancerous
disease.
The formation of cancer has not in any case taken place
first in the diseased part of the skin. It has always been in
the substance of the mammary gland, beneath or not far from
the diseased skin, and always with a clear interval of ap-
parently healthy tissue.
In the cancers themselves, I have seen in these cases
nothing peculiar. They have been various in form ; some
acute, some chronic, the majority following an average course,
and all tending to the same end ; recurring if removed,
affecting lymph-glands and distant parts, showing nothing
which might not be written in the ordinary history of cancer
of the breast.
The single noteworthy fact found in all these cases is that
which I have stated in the first sentence, and I think it de-
serves careful study. For the sequence of cancer after the
chronic skin-disease is so frequent that it may be suspected of
being a consequence, and must be always feared, and may be
sometimes almost certainly foretold. I believe that a nearly
similar sequence of events may be observed in other parts.
I have seen a persistent "rawness" of the glans penis, like a
long-enduring balanitis, followed after more than a year's
duration by cancer of the substance of the glans. A chronic
THE MAMMARY AREOLA. 197
soreness or irritation (of whatever kind) on the surface of the
lower lip often long precedes cancer in its substance ; and,
with a frequency surpassing all other cases of the kind, the
superficial syphilitic diseases of the tongue are followed, and
not superseded, by cancers which do not always appear to
commence in a diseased part of the tongue.
For an explanation of these cases it may be suggested that
a superficial disease induces in the structures beneath it, in
the course of many months, such degeneracy as makes them
apt to become the seats of cancer ; and that this is chiefly
likely to be observed in the cases of those structures which
appear to be, naturally, most liable to cancer, as the mammary
gland, the tongue, and the lower lip. One may suspect that
similar surface-irritation has much to do with the frequency
of cancer of the rectum, pylorus, and ileo-caecal valve, in any
of which parts the degeneracy, which might come naturally
in old age and make them apt for cancer, may be hastened,
and made prematurely sufficient, by an adjacent disturbance
of nutrition.
In practice, the question must be sometimes raised whether
a part through whose disease or degeneracy cancer is very
likely to be induced should be removed. In the member of a
family in which cancer has frequently occurred, and who is at
or beyond middle age, the risk is certainly very great that
such an eruption on the areola as I have described will be
followed within a year or two by cancer of the breast. Should
not, then, the whole diseased portion of skin be destroyed or
removed as soon as it appears incurable by milder means ? I
have had this done in two cases, but, I think, too late. Or,
again, when one with a marked family-liability to cancer has
syphilitic disease of the mucous membrane of the tongue,
with frequent recurrences of inflammation, should not all the
worst pieces of the membrane be removed ? I should cer-
tainly advise it, especially if the membrane was ichthyotic, if
it were not that the disease is commonly so extensive that
good scar-tissue would not be likely to be formed, and that
bad scar-tissue, often irritable and ulcerating, is as likely to
induce cancer as the syphilitic or ichthyotic patches would
have been.
ON A FOBM OF
CHKONIC INFLAMMATION OF BONES
(OSTEITIS DEFORMANS).-
I HOPE it will be agreeable to the Society if I make known
some of the results of a study of a rare disease of bones.
The patient on whom I was able to study it was a gentle-
man of good family, whose parents and grandparents lived to
old age with apparently sound health, and among whose
relatives no disease was known to have prevailed. Especially,
gout and rheumatism, I was told, were not known among
them ; but one of his sisters died with chronic cancer of the
breast.
Till 1854, when he was forty-six years old, the patient had
no sign of disease, either general or local. He was a tall,
thin, well-formed man, father of healthy children, very active
in both mind and body. He lived very temperately, could
digest, as he said, anything, and slept always soundly.
At forty-six, from no assigned cause, unless it were that
he lived in a rather cold and damp place in the North of
England, he began to be subject to aching pains in his thighs
and legs. They were felt chiefly after active exercise, but
were never severe ; yet the limbs became less agile, or, as he
called them, "less serviceable," and after about a year he
noticed that his left shin was misshapen. His general health
was, however, quite unaffected.
I first saw this gentleman in 1856, when these things had
been observed for about two years. Except that he was very
"^ Read before the Royal Medico -Ohirurgical Society of London,
November 14th, 1876.
200 SIR JAMES PAGET ON
grey and looked rather old for his age, he might have been
considered as in perfect health. He walked with full strength
and power, but somewhat stiffly. His left tibia, especially in
its lower half, was broad, and felt nodular and uneven, as if
not only itself but its periosteum and the integuments over it
were thickened. In a much less degree similar changes could
be felt in the lower half of the left femur. This limb was
occasionally, but never severely, painful, and there was no
tenderness on pressure. Every function appeared well dis-
charged, except that the urine showed rather frequent deposits
of lithates. Kegarding the case as one of chronic periostitis,
I advised iodide of potassium and liquor potassae ; but they
did no good.
Three years later I saw the patient with Mr. Stanley. He
was in the same good general health, but the left tibia had
become larger, and had a well-marked anterior curve, as if
lengthened while its ends were held in place by their attach-
ments to the unchanged fibula. The left femur also was now
distinctly enlarged, and felt tuberous at the junction of its
upper and middle thirds, and was arched forwards and out-
wards, so that he could not bring the left knee into contact
with the right. There was also some appearance of widening
of the left side of the pelvis, the nates on this side being
flattened and lowered, and the great trochanter projecting
nearly half an inch further from the middle line. The left
limb was about a quarter of an inch shorter than the right.
The patient believed that the right side of his skull was
enlarged, for his hats had become too tight ; but the change
was not clearly visible.
Notwithstanding these progressive changes, the patient
suffered very little ; he had lived actively — walking, riding,
and engaging in all the usual pursuits of a country gentleman
— and, except that his limb was clumsy, he might have been
indifferent to it. He had taken various medicines, but none
had done any good ; and iodine, in whatever form, had always
done harm.
In the next seventeen years of his life I rarely saw him,
but the story of his disease, of which I often heard, may be
briefly told, and with few dates, for its progress was nearly
CHRONIC INFLAMMATION OF BONES. 201
uniform and very slow. The left femur and tibia became
larger, heavier, and somewhat more curved. Very slowly
those of the right limb followed the same course, till they
gained very nearly the same size and shape. The limbs thus
became nearly symmetrical in their deformity, the curving of
the left being only a little more outward than that of the
right. At the same time, or later, the knees became gradually
bent, and, as if by rigidity of their fibrous tissues, lost much
of their natural range and movement.
The skull became gradually larger, so that nearly every
year, for many years, his hat and the helmet that he wore as
a member of a Yeomanry Corps needed to be enlarged. In
1844 he wore a shako measuring twenty-two and a half inches
inside ; in 1876 his hat measured twenty-seven and a quarter
inches inside (PL I., fig. 4). In its enlargement, however,
the head retained its natural shape, and to the last looked
intellectual, though with some exaggeration.
The changes of shape and size in both the limbs and the
head were arrested, or increased only imperceptibly, in the
last three or four years of life.
The spine very slowly became curved and almost rigid.
The whole of the cervical vertebrae and the upper dorsal
formed a strong posterior, not angular, curve ; and an anterior
curve of similar shape was formed by the lower dorsal and
lumbar vertebrae. The length of the spine thus seemed
lessened, and from a height of six feet one inch he sank to
about five feet nine inches. At the same time the chest
became contracted, narrow, flattened laterally, deep from
before backwards, and the movements of the ribs and of the
spine were lessened. There was no complete rigidity, as if by
union of bones, but all the movements were very restrained,
as if by shortening and rigidity of the fibrous connections of
the vertebrae and ribs.
The shape and habitual posture of the patient were thus
made strange and peculiar. His head was advanced and
lowered, so that the neck was very short, and the chin, when
he held his head at ease, was more than an inch lower than
the top of the sternum.
The short narrow chest suddenly widened into a much
202 SIR JAMES PAGET ON
shorter and broad abdomen, and the pelvis was wide and low.
The arms appeared unnaturally long, and, though the
shoulders were very high, the hands hung low down by the
thighs and in front of them. Altogether, the attitude in
standing looked simian, strangely in contrast with the large
head and handsome features.*
All the changes of shape and attitude are well shown in
sketches from photographs taken six months before death
(see PI. I., figs. 1 to 3). Only the lowering of the necks of
the femora is not shown. In measurement after death the
axes of the shaft and neck of the right femur formed an
angle of only 100° instead of 120° or 125°, and this change
of shape added to the appearance of increased width of the
pelvis.
But with all these changes in shape and mobility of the
head, spine, and lower limbs, the upper limbs remained
perfect, and there was no disturbance of the general health.
In 1870, when the disease had existed sixteen years, the
left knee-joint was for a time actively inflamed, and its cavity
was distended with fluid. But the inflammation soon subsided,
only leaving the joint stiffer and more bent.
About this time some signs of insufficiency of the mitral
valve were observed, but the patient now lived so quietly, and
moved with so little speed, that this defect gave him no con-
siderable distress.
In December, 1872, sight was partially destroyed by retinal
haemorrhage, first in one eye, then in the other, t and at nearly
the same time he began to be somewhat deaf. In the summer
of 1874 he had frequent cramps in the legs, and neuralgic
pains, which were described as "jumping over all the upper
* An attitude somewhat similar is given by a rare form of what I sup-
pose to be general chronic rheumatic arthritis of the spine involving its
articulations with the ribs. The spine droops and is stiff, the chest is
narrow, the ribs scarcely move, the abdomen is low and broad, but there
is no deformity of head or limbs.
f Mr. Brudenell Carter saw him in January, 1873, and observed "the
right retina sprinkled with small dots of arterial haemorrhage, chiefly in
parts remote from the centre" ; and '* there was no other change." The
left retina was at this time healthy, but in February Dr. Clifford Allbutt
found " several little plugs " in its vessels.
CHRONIC INFLAMMATION OF BONES. 20B
part of the body except the head," but change of air seemed
to cure them.
In January, 1876, he began to complain of pain in his left
forearm and elbow, which, at first, was thought to be neuralgic.
But it grew worse, and swelling appeared about the upper
third of the radius and increased rapidly, so that, when I saw
him in the middle of February, it seemed certain that a firm
medullary or osteoid cancerous growth was forming round the
radius.
Still the general health was good. Auscultation could
detect mitral disease, but the appetite and digestion were
unimpaired, the urine was healthy, the mind as clear, patient,
and calm as ever. As letters about him at this time said,
"his general health has been excellent"; "he is free from
pain except in the left arm ; he sleeps well, enjoys himself,
and does not know what a headache is."
After this time, however, together with rapid increase of
the growth upon the radius, there were gradual failure of
strength and emaciation, and on the 24th of March, after
two days of distress with pleural effusion on the right side,
he died.
The body was examined five days after death, and showed
no marked signs of decomposition. As it lay on a flat board
its posture was remarkable, for the head was upraised to the
level of the sternum, being supported by the rigid and arched
spine, ond the lower limbs, with the knees bent and stiff,
rested on the heels and nates.
The pericranium, dura mater, and all the substance of the
brain appeared healthy.
The right pleural cavity contained at least a pint of pale
serous fluid, with flakes and strings of inflammatory exuda-
tion. The lung was compressed, and in its pleural covering
were numerous small nodular masses of pale cancerous sub-
stance. The proper pulmonary structure appeared healthy,
and so did the left lung and its pleura, except that in the
pleura and anterior mediastinum there were many small
masses of cancer.
The heart was enlarged, but thin-walled. The tricuspid
and pulmonary valves and artery were healthy ; the mitral
204 SIR .TAMP]8 PAGET ON
valve was opaque, contracted, stiffened with atheromatous
and calcareous deposits.
The aortic valves were slightly opaque but pliant, and both
in them and in the first part of the aorta were numerous
small patches of atheroma.
The liver and digestive canal and kidneys, examined ex-
ternally, appeared healthy.
The right femur, the left tibia, the patellae, and the upper
part of the skull, were taken for separate examination, and
will be separately described.
In the other bones of the skeleton, except the left radius,
no signs of disease appeared externally, but I regret that they
were not all more carefully examined, for I think that, at least
in the clavicles and pelvis, some changes like those in the
long bones of the lower limbs would have been found.
The upper third of the left radius was involved in a large
ovoid mass of pale grey and white soft cancerous substance,
similar to that of the nodules in the pleurae and mediastinum,
but with growths of bone extending into it. The rest of the
radius and the ulna appeared quite healthy.
Some nodules of similar cancerous substance were imbedded
in the bones of the vault of the skull.
Microscopic sketches of these structures' by Mr. Butlin are
appended (Plate II., figs. 1-3).
The curvatures of the spine and its rigidity appeared due
to shortening and hardening of its fibrous structures. The
vertebrae appeared healthy; there was no appearance of over-
growth or anchylosis among them.
In no part, whether near or far from the diseased bones,
was there an indication of any change of structure in skin,
muscle, tendon, or fascia ; but in the right hip-joint and in
the left knee-joint there was some thinning and wasting of
articular cartilage, such as one sees in chronic rheumatic
arthritis. The other hip- and knee-joints and both ankle-
joints were healthy.
In the arteries of the lower limbs there was extensive
atheromatous and calcareous degeneration.
The enlargement of the skull may be estimated by com-
parison of the following measurements : —
CHRONIC INFLAMMATION OF BONES. 205
Diseased skull. Average skull.
Circumference at the level of the middle of the
temporal fossa 26^ in. 21 in.
From occipital spine to base of nasal bones . 15 in. 13^ in.
From mastoid to mastoid process . . . 18^ in. 15^ in.
All the sutures, at least all those of the vertex, were
obliterated. The outer surface of the upper part of the
skull was lowly bossed by the predominant thickening of
the hinder part of the parietal bones. The thickness was in
every part increased to the extent shown in these following
measurements.
In a median vertical section the thickness of the frontal bone was 11-13 lines.
„ „ „ parietal „
14-16
„ ,, ,, occipital ,,
8-12
In a horizontal section, through the middle of the temporal
fossa, the thickness of the frontal bone was .
8-9
,, „ temporal „ . . .
6-9
„ ,, at their junction ....
2
,, ,, of the occipital bone was
10-12
Comparing these measurements with those of average
healthy skulls, it may be said that the bones of the vault
of this skull were in every part increased to about four times
the normal thickness.
The whole outer surface of the skull-cap was finely porous ;
in the least changed parts, such as the squamous bone, per-
forated with innumerable apertures for blood-vessels ; in the
most changed, finely reticulate, as with delicate cancellous
and medullary texture.
The inner surface was comparatively smooth, and appeared
little changed, except by the enlargement of all channels and
apertures for blood-vessels, and especially by the deepening
of all the grooves for the middle meningeal artery and its
branches.
On the cut surface, in the median vertical section, that
which might be regarded as the altered internal table of the
skull was a layer, having a very unequal thickness varying
from two to six lines, consisting of hard white bone, close-
textured, in some parts porous or finely reticulate, in more
looking compact and dense like limestone or white brick (PI. V.).
206 SIR JAMES PAGET ON
The rest of the thickness of this part of the skull, repre-
senting probably the altered diploe and outer table, was
made up of bone in various degrees porous, cancellous, or
cavernous, with spaces filled with soft reddish substance, a
kind of medulla. Its surface was covered with a very thin
layer, a mere coating of more finely porous bone.
In the horizontal section, at the level of the upper part
of the squamous bone, the same altered characters were
observable, but a larger proportion of the substance of the
skull was finely porous or reticulate.
By the cavities in the skull-cap in which cancerous growths
were lodged, the structure of the bone was neither more nor
less altered than in other parts.
A portion of sphenoid bone showed changes of structure
very similar to those already described, but with a much
more uniform and regular finely porous condition.
The bones of the face were not uncovered, but they showed,
neither to sight nor touch, any appearance of disease ; not a
feature was unnatural.
The conditions of all the -long bones were so similar that
one description may serve for the altered structure of both
femora and tibiae.*
The periosteum was not visibly changed, not thicker or
more than usually adherent.
The outer surface of the walls of the bones was irregularly
and finely nodular, as with external deposits or outgrowths of
bone, deeply grooved with channels for the larger periosteal
blood-vessels, finely but visibly perforated in every part for
transmission of the enlarged small vessels. Everything seemed
to indicate a greatly increased quantity of blood in the vessels
of the bone.t
The medullary structures appeared to the naked eye as
little changed as the periosteum. The medullary spaces
were filled with soft, yellow, ruddy, and bright crimson
medulla, of apparently healthy consistence. The medullary
" Their changes are shown in PI. IV. The specimens are in the
Museums of the Eoyal College of Surgeons and of St. Bartholomew's
Hospital.
i But see p. 209 in the account of the microscopic examination.
Lines.
Lines.
3-6
6-10
. I
3-10
. i-3
4-6
. i-i
3-5
. i-i
3-5
i-i
2 and more
CHRONIC INFLAMMATION OF BONES. 207
laminse and cancelli had a normal aspect and arrangement,
and in the shafts of the long bones the medullary spaces were
not encroached upon.
The compact substance of the bones was, in every part,
increased in thickness. Taking, for example, the femur, the
thicknesses of its walls and those of a healthy femur of about
the same length and age are compared in the following tables.
Healthy. Diseased.
Thickest parts of the wall
Articular covering of head, about .
Wall of neck, about ....
Wall of the trochanter major, about
Articular covering of the condyles, about
Lateral w^alls of the condyles .
Changes in similar proportions were found in the walls of
the tibia. In the patellae the walls were from three to five
lines thick.
The thickening of the walls of the shafts of the bones
appeared due chiefly to outward expansion and some super-
ficial outgrowth. In some places there were faint appearances
of separation of parts of the outer layers of the walls, and of
these becoming thick and porous, while the corresponding
parts of the inner layers were less changed ; but in the
greater part of the walls the whole construction of the bone
was altered into a hard, porous, or finely reticulate substance,
like very fine coral. In some places, especially in the walls
of the femur, there were small ill-defined patches of pale,
dense, and hard bone, looking as solid as brick.
In the compact covering of the articular ends of the long
bones, and in those of the neck and great trochanter of the
femur, and in the patellae, the increase of thickness was due
to encroachment on the cancellous texture, as if by filling of
its spaces with compact porous, new-formed bone.
Mr. Butlin was so good as to make careful microscopic
examination of the diseased bones, and to give me the
following report on them, together with the annexed drawings
of their minute structure.
*' Microscopical examination was made of sections cut from
208 SIR JAMES PAGET ON
the skull and from the tibia, some of them from the recent
bones, but the majority of them from portions of bone
deprived of earthy salts, and rendered sufficiently soft to be
cut with a razor. The appearances observed were essentially
the same in both bones, but most of the drawings and de-
scription were taken from the tibia, the sections of which
were much clearer than those of the skull.
*' The examination was conducted from a twofold point
of view : first, to discover the changes which the bone had
undergone ; second, to discover, if possible, the nature of
the process which had led to such changes.
"With a low power the number of Haversian systems and
canals in any given section was seen to be much diminished
(Plate II., fig. 8; Plate III., fig. 9). The space between the
Haversian canals was occupied by ordinary bone-substance,
containing numerous lacunae and canaliculi. The Haversian
canals were enormously widened, many of them were con-
fluent, and thus the appearance of a number of communicating
medullary spaces was obtained, an appearance which was
rendered still more striking by the presence in the canals of a
large quantity of ill-developed tissue in addition to the blood-
vessels (Plate II., figs. 4-6). With a high power the contents
of the Haversian canals were seen to consist generally of a
homogeneous or granular basis, containing cells of round or
oval form, about the size and having much the appearance of
leucocytes. Larger nucleated cells were also present, and
fibres or fibro-cells, sometimes in considerable quantity.
Myeloid cells were occasionally observed, but they were not
plentiful ; fat also existed in many of the larger spaces,
especially in the skull. The vessels were usually small
compared with the channels in which they ran ; indeed, they
did not seem to be much larger than those of normal bone
(Plate II., fig. 6). The walls of some of the canals were
lined by a single layer of osteoblasts, a condition precisely
similar to that observed in the normal ossification of bone in
membrane. The presence of new bone was most evident in
the periosteum of the tibia, external to the ordinary compact
layer of the shaft (Plate II., fig. 7). This external layer was^
of course, but thin, and was much softer and less developed
CHRONIC INFLAMMATION OF BONES.
209
than the cortex of the bone from which it sprung ; it evidently
was not nearly sufficient to account for the great increase in
the diameter of the tibia. From the diminution in size of
the medullary canal it was thought that a similar recent
formation of bone would be found on its outskirts, but this
expectation was not justified by observation.
" With a medium power the number of (Plate III., fig. 12)
lamellae surrounding the Haversian canals was easily seen to
be not larger than in normal bone, whilst the arrangement of
the intervening space was most complex, and totally different
from that of healthy bone. The lacunae and canaliculi through-
out the sections did not strikingly differ from those of ordinary
bone."
I am indebted to Dr. Eussell for the following chemical
analysis of portions of the diseased skull and tibia, and of a
healthy tibia in comparison with them.
Inorganic constituents (Ash) .
Organic ,, . . . .
Phosphoric acid (P^O^) ....
Carbonic „ (COg) . . . .
Fat
Moisture in the sample (dried at 115° C.)
The CO 2 calculated as calcium carbonate
(CaCOa)
The P2O5 calculated as calcium phosphate
(Cag^POJ
Specific gravity
SkuU.
Tibia.
Normal
tibia.
60-59
61-22
63-62
39-41
38-78
36-38
22-76
25-45
25-50
3-59
3 95
3-59
6-83
3-45
—
15-49
11-83
9-73
8-17
8-99
8-16
49-70
65-56
55-66
1-895
1-889
1-886*
Cases of the disease which I have described are so rare
that I believe no one has seen a sufficient number of them to
enable him to distinguish this disease, either clinically or
anatomically, from some which seem like it. Specimens
illustrating it are commonly included under a general name
of hyperostosis, osteoporosis, senile rachitis, or the like.
But I hope that, if I add to the description I have just given
some notes of similar cases which I have seen or found on
* Specific gravity of normal skull 1'990.
210 SIR JAMES PAGKT ON
record, the disease may be so distinguished as to deserve iri
pathology a separate place and name.
Case 2. — Some ten years ago I saw a gentleman, between
fifty and sixty, very active, tall, thin, and muscular, a master
of hounds. For many years before his death he had curvature
of the thighs and legs, exactly like that already described, and
stooping of the spine. The changes of the limbs were attended
with severe pains, which he used to relieve with hard rubbings
but the general health was unimpaired. In the last years of
his life the upper part of his right humerus became very
large, and as he was riding and suddenly raised his arm the
bone broke near the shoulder. The evidence of a large tumour
now became clear, and I amputated the arm at the shoulder-
joint. The tumour was a well-marked and very vascular
medullary cancer investing and infiltrating the upper part
of the humerus. The rest of the humerus was healthy, and
the fracture, which was just below its neck, was evidently
due to muscular force acting on its structures spoiled by the
cancerous growth. He died a few days after the operation,,
but was not examined after death. The similarity of his.
case with that which I have described is, I think, certain.
Case 3. — I saw, with the late Dr. Brinton, a gentleman
between forty and fifty who may be still living. He was a
sturdy and quite healthy man ; his tibiae were curved and
enlarged exactly like those in the first case, and he had
similar pains, but there was more thickening of periosteum
and an appearance of more external formation of bone. He^
was treated with iodide of potassium and many other things
as for periostitis, but without avail.
Case 4. — A case is recorded by Dr. Wilks in the * Transac-
tions ' of the Pathological Society,* and through the kindness
of Sir William Gull, whom the patient occasionally consulted,
I am enabled to add some facts to those in Dr. Wilks's report,
and to show photographic portraits.
A summary of Dr. Wilks's report is that the patient waa
* Vol. XX, p. 273, 1869.
CHRONIC INFLAMMATION OF BONES. 211
sixty when he died. Signs of the disease, beginning with
pains like those of rheumatism in the legs, were first observed
fourteen years before his death. It was soon found that the
tibiae were enlarged, and in subsequent years the cranium
and nearly all the bones of the skeleton underwent similar
changes. About a year before death the general health
began to suffer from the thorax having become implicated in
the disease. Gradually the chest became more contracted,
and at last quite fixed ; the breathing became more difficult,
until at last the respiratory apparatus altogether stopped.
Sir William Gull's notes tell that the patient consulted
him when fifty-six years old, and said that he first noticed
enlargement in the left tibia when he was forty-five years
old; that he had seven brothers well and strong, and was
eldest in the family. He complained chiefly of weakness,
inability to make exertion, feeling of nervousness with occa-
sional vertigo, shortness of breath, stiffness in neck, hoarse-
ness, and feebleness of voice. His general health was good ;
he was not much troubled with pain anywhere ; but had
occasional strange sensations about the head, and much
cough. His height, when a young man, was five feet three
and a half inches, now four feet eleven and a half inches.
The urine was normal and of normal colour. The cranium
was enlarged and thickened; the clavicles much thickened,
as also the long bones ; the phalanges and facial bones, and
perhaps the lower jaw, were not altered. The ribs were
thick and immovable, as was also the sternum. There was
general dulness over the chest on percussion. The respiration
was chiefly diaphragmatic.
Less than a year before the patient's death Sir William
Gull recorded that he was breathless, and had occasional
attacks of mental confusion, in which he remarked that he
could not understand the sense of words. His voice was
hoarse and feeble, and the hyoid bone seemed thickened.
The head had continued to enlarge, and he maintained that
he was still losing in height. The neck was fixed, and some-
what forward. All the viscera appeared normal. The urine,
repeatedly examined, was always found normal, and of normal
colour.
p 2
212 SIR JAMES PAGET ON
The record of the post-mortem examination by Dr. Goodhart
leaves no doubt that the disease in this case was the same as
that which I have described, and it may be important that
this patient also had cancerous disease. " A growth ....
corresponding to the growth described as epithelioma of the
arachnoid surface of dura mater," grew from the inner
surface of the dura mater, was as large as a chestnut, and
made a pit in the brain near the left Sylvian fissure.
The description of the changed structure of the bones, for
which I may refer to the ' Pathological Transactions,' seems
to me to indicate that the disease was more advanced in the
direction of degeneracy than that which I have described, or
that it had not been in any degree repaired.
Case 5. — I owe to Mr. Bryant the opportunity of seeing a
similar case which was under his care in Guy's Hospital, and
of which Mr. Yiney was so good as to give me notes.
The patient was a carpenter, sixty years old, a hard-
working married man, and had seven children. "When about
sixteen years old he had a slight attack of gonorrhoea, but
without sores, and no history of syphilis could be learned.
When thirty-five years old he received an injury to his
pelvis. Shortly after this he had trouble with his bladder,
which become much distended; a large quantity of clotted
blood was washed out. He lay in bed for this six weeks, and
at the end of three months was able to go to work again.
For the last five years he had been troubled with gout in
his left great toe. His father suffered from this. The attacks
had been short ; a few days' rest always sufficed for recovery.
About three years before admission he first felt pains of a
shooting description about the tendons of the popliteal space,
whenever he straightened his legs. At this time also he first
noticed a swelling of the legs, which began at the ankles.
These symptoms, without his taking any special notice of
them, continued for about a year.
In the last year and a half the tibiae had become much
swollen and curved forwards, and on account of the pain he
had in them from standing he had been obliged to give up
his regular work. Until admission he did not notice any-
CHRONIC INFLAMMATION OF BONES. 213
thing wrong with his other bones, but he had lost about half
an inch in height.
The tibiae presented a marked curve forwards. The anterior
border of each was rounded to a very marked degree, so that
it could not be felt at all distinctly. The right tibia was
slightly larger than the left. The inner surface of each
measured about four inches at its widest part. The veins
above the ankle were in a varicose condition.
The fibulae were very much enlarged ; the femora enlarged
in their shafts and bowed outwards. The great trochanter
was drawn up to the level of a vertical line drawn from the
anterior superior spinous process of the ilium to the horizontal
line of the body, instead of being about two and a half inches
below this line. The patellae were little larger than natural.
The bones of the upper extremity were enlarged, but not to
so marked a degree as those of the lower. The enlargement
was most marked in the humeri, and the left was thicker
than the right. He could not straighten his arms, probably
owing to the enlargement of the olecranon. In the clavicles
the natural curves were very much increased and the bones
thickened, the left more so than the right. In the scapulae
the spines and acromion processes were very much enlarged.
The chest was slightly flattened from side to side, but
moved fairly whilst breathing. The ribs on the right side
were slightly larger than those on the left.
There was a general curve backwards from the cervical to
the dorsal vertebrae, so that the patient's usual position in
bed was with his head bent forwards, and his legs in a semi-
extended position.
The bones of the hands and feet did not seem to have
shared in the general thickening.
There seemed to be a slight thickening about the external
protuberance of the occipital bone, but there was no other
evidence of the cranial bones being involved.
The patient had cold perspirations over his legs in the
evening. His urine had a specific gravity of 1014, was
strongly acid, contained a little albumen, but no excess of
phosphates.
[Six months later Mr. Bryant told me that this patient's
214 SIR JAMES PAGET ON
bones were still enlarging, and that there were evidences of
enlargement of the skull.]
I have looked for records of cases similar to these in nearly
every work that seemed likely to contain them, but in vain.
I have found only three cases, and the first two of these are
doubtful.
Saucerotte* relates the case of a man who died at forty,
and in whom all the bones, those of the head, face, orbits,
ribs, vertebrae, and limbs, had begun to enlarge about seven
years before death. He increased in weight from 119 livres
to 168, wholly from increase of bones ; he had rheumatic
pains; for a time sleepiness, oppression at the chest, and
very small pulse; but these passed by, and he died with
some acute illness. No examination was made.
Rulliert tells of a man, aged seventy-eight, who died in
the Hotel Dieu of empyema. He had previously been in
good health, and nothing had indicated any derangement of
cerebral function. The skull was very large, osteoporotic,
and heavy, and, except the lower jaw, all the bones of the
face were healthy. The ribs were thicker and larger than
usual ; the sternum narrow and very thick ; the pelvic bones
changed like those of the skull. The clavicles were thick,
curved, and solid. The other bones were healthy.
Wranyl has fully described the condition of the bones in
a case of spongy hyperostosis of the skull, pelvis, and left
femur, taken from a woman fifty years old, of whom, how-
ever, nothing is told but that she died of pyaemia, and that
she had *' spongy hyperostosis of the skull with atrophy of
the facial skeleton, spongy hyperostosis of the vertebral
column, pelvis, and left femur, with elongation of the latter
bone ; kyphoscoliosis of the upper dorsal part of the spine ;
pelvic abscess; emphysema and oedema of both lungs, abscess
of the left ; marasmus."
I cannot doubt that this disease was the same as I have
here described, and the paper is valuable, both for the many
'■^ ' Melanges de Chirurgie,' Paris, 1801.
f ' Bulletin de I'Ecole de Medecine de Paris,' t. ii, p. 94, 1812.
I * Prager Vierteljahrschrift,' 1867, B. i, p. 79.
CHRONIC INFLAMMATION OF BONES. 215
signs indicated in it that the bones softened and yielded to
pressure in the early part of the disease, and for the careful
comparison of the distortion of the pelvis with the dissimilar
distortions in rickets and mollities ossium. The spine was
very curved ; the chest small and too arched ; the whole
trunk very short.
From these cases, which, though few, are well marked,
and in some chief points uniform, as well as from a recollec-
tion of two more of which I have no notes, I think we may
believe that we have to do with a disease of bones of which
the following are the most frequent characters : — It begins in
middle age or later, is very slow in progress, may continue
for many years without influence on the general health, and
may give no other trouble than those which are due to the
changes of shape, size, and direction of the diseased bones.
Even when the skull is hugely thickened, and all its bones
exceedingly altered in structure, the mind remains unaffected.
The disease affects most frequently the long bones of the
lower extremities and the skull, and is usually symmetrical.
The bones enlarge and soften, and those bearing weight yield
and become unnaturally curved and misshapen. The spine,
whether by yielding to the weight of the overgrown skull,
•or by change in its own structures, may sink and seem to
shorten with greatly increased dorsal and lumbar curves ;
the pelvis may become wide ; the necks of the femora may
become nearly horizontal, but the limbs, however misshapen,
remain strong and fit to support the trunk.
In its earlier periods, and sometimes through all its course,
the disease is attended with pains in the affected bones,
pains widely various in severity, and variously described as
rheumatic, gouty, or neuralgic, not especially nocturnal or
periodical. It is not attended with fever. No characteristic
conditions of urine or faeces have been found in it. It is not
associated with syphilis* or any other known constitutional
disease, unless it be cancer.
In three out of the five well-marked cases that I have seen
* There has not only been no history of syphilis in any of the cases,
but no known syphilitic changes have been observed in any patient.
216
8IR JAxMES PAGET ON
or read of, cancer appeared late in life ; a remarkable pro-
portion, possibly not more than might have occurred in
accidental coincidences, yet suggesting careful inquiry.*
The bones examined after death show the consequences of
an inflammation affecting, in the skull the whole thickness,
in the long bones chiefly the compact structure, of their
walls, and not only the walls of their shafts, but, in a very
characteristic manner, those of their articular surfaces.
The changes of structure produced in the earliest periods
of the disease have not yet been observed, but it may certainly
be believed that they are inflammatory, for the softening is
associated with enlargement and with excessive production of
imperfectly developed structures, and with increased blood-
supply. Whether inflammation in any degree continues to
the last, or whether, after many years of progress, any re-
parative changes ensue, after the manner of a so-called
consecutive hardening, is uncertain.
The inflammatory nature of the disease is evident also in
the changes of minute structure in the affected bones. t On
these Mr. Butlin writes : — " With regard to the nature of the
process by which these changes were accomplished, there are
probably only three things which could produce so great an
increase in the size of a bone — namely, new growth (tumour) ,
hypertrophy, and chronic inflammation.
" The first of these may be at once set aside as out of the
question.
" Nor is the second much more probable than the first, for
the process is evidently no mere hypertrophy. The whole
microscopical architecture of the bone has been altered ; the
structure appears to have been almost entirely removed and
laid down afresh on a different plan and in a larger mould.
* See also Sandifort, quoted at p. 61 ; Museum of St. Bartholomew's,
ser. i, 111 and 112, sections of a femur, large, curved, porous, with a
tumour growing around its shaft ; and 49, a hyperostotic skull from a
man who died with cancerous disease of the eyeball, heart, and other
organs ; and Museum of Guy's Hospital, specimens of symmetrical
osteoid cancer of the ilia, with cancer of the spine and cranium, asso-
ciated with hypertrophy of the cranium. Dr. Goodhart was so good as.
to give me a report of this case.
f And this is also the opinion of Wrany, I. c.
CHRONIC INFLAMMATION OF BONES. 217
" Of the three causes, chronic inflammation alone remains,
and upon examination one or two facts will be found to bear
strongly upon the theory of this being essentially an inflam-
matory disease. Not only the absorption of the old structure
which has taken place, but also the manner of this absorption,
point to its inflammatory nature. Traces of this are not, of
course, always discernible, as the process is almost everywhere
far advanced. But still, careful observation not uncommonly
discovers that the sides of the widened canals, instead of being
smooth and even (Plate III., fig. 10), are eaten out in a series
of curves or concavities with the production of what are called
Howship's lacunae, so characteristic of inflammation. The
tissue contained in the canals, too, almost precisely resembles
the tissue found in the spaces of inflamed bones, only differing
from it in being generally more fibrillar and less rich in cells,
a fact easily to be accounted for by the very long duration of
the disease, and the general tendency towards organisation
which was displayed throughout. The apparent cessation of
the process of absorption, and the gradual process of repair,
may be regarded as still further leading towards the same
conclusion.
" Further than this, the microscopical observations do not
extend."
The chemical analysis by Dr. Kussell may be regarded as
confirming this conclusion. It shows, at least, that there
is no such change of composition in the bone as would be
expected in any merely degenerative softening.
Holding, then, the disease to be an inflammation of bones,
I would suggest that, for brief reference, and for the present,
it may be called, after its most striking character. Osteitis
deformans. A better name may be given when more is
known of it.
It remains that I should point out the distinctions between
this disease and the several forms of hyperostosis, osteoporosis,
and other diseases among which it has been confused.*
* Many of the statements here made are derived from the examinations
of the collections of diseased bones in the College of Surgeons and St.
Bartholomew's Hospital, which T made while writing the catalogues of
their pathological museums.
^18 SIR JAMES PAGET ON
1. Among cases of hyperostosis are included those of simple
overgrowth or hypertrophy of bones in adaptation to increase
or change of office. The distinction of these from any form
of disease is plain enough ; they show a mere increase of
natural structure.*
2. Scarcely different from these, and as easily distinguished,
are the hyperostoses, best seen in the skull, in which the bones
have more than normal thickness, hardness, and weight, and
marks of greater vascularity, yet preserve a just relation of
their several parts and a scarcely changed structure. They
probably illustrate the effects of simple inflammation of bone
recovered from.!
3. A group of hyperostoses consists of those cases in which
bones are enlarged in consequence of an increased supply of
blood or lymph. Such a case is that recorded by Dr. Day, I
in which the bones of a boy's limb with obstructed lymphatics
are much longer than those of the sound limb ; § and such are
all those in which bones near inflamed joints, or with partial
necrosis, or in limbs long hypersemic, from whatever cause,
grow in length and circumference till they considerably
surpass the bones of the healthy limb.H These are easily
distinguished. They have not signs of disease proper to
themselves ; they occur in the young alone ; they may
present a healthy texture, or one only slightly changed as by
partaking of the adjacent inflammatory process; and, with
the exception of the tibia, they do not become deformed.
The tibia, when it lengthens more than the fibula, is almost
compelled to curvature by the fixed unyielding attachment
* Mus. Coll. Surg., 379, 380, 2838, 2839, 2842, 2843, &c.
f Mus. Coll. Surg., 2840, 2841.
I * Transactions of the Clinical Society,' vol. ii, p. 104, 1869.
§ Broca, ' Des Anevrysmes,' 8vo, p. 76, 1856, gives a case of femoral
arterio-venous aneurism attended with considerable elongation of the
limb.
II I believe these were first described by Mr. Stanley, ' On Diseases of
Bones,' p. 20, et seq., and myself, 'Lectures on Surgical Pathology,' p. 64,
ed. 3, and in the catalogues already referred to. Langenbeck has pub-
lished a very interesting paper on them in the ' Berliner Klin. Wochen-
schrift,' 1869, No. 26. Cases are also cited from Weinlechner, Schott,
and Bergmann, in Virehow and Hirsch's * Jahresbericht fur 1869.'
CHNROIC INFLAMMATION OF BONES. 219
of its ends ; * and the curve is usually similar in shape and
direction to the curve of the tibia in the osteitis deformans.
But there is no other likeness between the two conditions.
4. A very large number of cases of hyperostosis are con-
sequences of inflammations of bone ; some of simple inflam-
mation, others of scrofulous, syphilitic, or gouty inflammation.
It is not necessary here to distinguish these from each other, f
but there are sufficient signs for the distinction of all from the
osteitis deformans.
It is clear that the summary which I have given of the
clinical characters of this osteitis would not tally with that
of any case of simple osteitis, such as might ensue in a
healthy person after injury, or in the neighbourhood of a
sequestrum ; and the clinical difference is as complete between
it and any case that could justly be regarded as strumous, or
syphilitic, or gouty osteitis.
The anatomical differences are as well marked : chiefly in
the facts that in these inflammations the bones do not become
curved! (unless in the case of the tibia already explained) ;
that they commonly display much more considerable ex-
ternal periosteal outgrowths or deposits, as if from a greater
participation of the periosteum in the inflammatory process ;
that the rarefied, or, it may be, porous structure of the
swollen shafts of bones usually shows appearances of sepa-
ration and expansion of the component layers ; that the
medullary canals are commonly invaded by the thickening
walls, or are as much changed as the walls themselves ; that
the whole length of a bone-shaft is very rarely affected ; and
that the thin articular layers of bones are, I believe, never
thickened as they are in the osteitis deformans. §
'■' Such curved tibiae are in the museum of St. Bartholomew's, Nos. A.
3, A. 46.
f An attempt to do so is made in the pathological catalogue of the
College of Surgeons.
I The absence of curving in bones round sequestra is remarkable, for
they are long and often acutely inflamed, and those of the lower limbs
are commonly used and bear weight.
§ Among the specimens in which these changes may be studied are,
in the College Museum, Nos. 3085, 3089, 598, 3090, 3091 ; in the museum
at St. Bartholomew's, A. 1, and ser. i, 56, 132, 138, 196-198.
220 SIR JAMES PAGET ON
It may be added that it is very improbable that any form
or degree of scrofula, or syphilis, or gout should exist in
bones or any other textures for ten or more years without
affecting other parts, and without impairing the general
health. The retention of good general health during many
years of localised disease is, indeed, one of the most striking
characters of the osteitis deformans. The only parallel known
to me is in the rheumatoid or chronic rheumatic arthritis,
and the likeness between the two in this respect may suggest
that they are nearly related ; yet they are not found con-
current. In the case that I have related, the amount of
chronic rheumatic arthritis was trivial, and (which is more
important) in all the records and specimens of the arthritis
which I have seen, I have not found an instance in which
there were any of the morbid changes characteristic of the
osteitis.*
5. There are, I think, only two other diseases — namely,
rachitis and osteomalacia, from which it can be necessary
to discriminate the osteitis deformans, and the differences
between them are very wide. They have scarcely a feature
in common, except that in all of them the bones bearing
weight become curved or misshapen, and the spine is usually
deformed, and the skull may become very thick and porous.
But in rachitis the bones are too short, not too long ; too
small, not too large ; and their curvatures are quite unlike
those of the osteitis. And in the osteomalacia the walls of
the bones become exceedingly thin, wasting with an acute
atrophy ; and when they yield it is not with regular curving,
but with angular bending or breaking. By these and many
other differences, as well clinical as anatomical, the diagnosis
of the osteitis from rachitis and osteomalacia is sufficiently
clear. With rachitis it may be judged to have no affinity
whatever ; with osteomalacia only so much as may exist
between a chronic inflammation and an acute atrophy of any
part. Yet by one character which all these three diseases
have or may have in common, namely, the osteoporosis of
the skull, they are constantly confounded in museums, if not
-f^ There is not even any mention of them in Mr. R. Adams's elaborate
' Treatise on Rheumatic Gout," 1873, 8vo and folio.
CHRONIC INFLAMMATION OF BONES. 221
in practice, with each other, and with diseases different from
them all.
The study of the osteitis deformans led me to learn what I
could of the various recorded descriptions of large, thick, and
porous skulls often found in museums. Nearly every large
museum contains one or more specimens of such skulls whole
or in fragments. They are all big, thick, porous, or spongy,
with obliterated sutures, and wide apertures, and grooves for
blood-vessels. Very few of these specimens have any life-
histories ; they are all, in many respects, alike, and usually
are all named alike. Many of them it may be impossible to
name or classify without much better knowledge of them
than may now be had, but I believe that among them are the
results of several different diseases ; and it may save some
trouble to future students if I refer to some of the specimens
and records which have led me to this belief.
1. Some are examples of the osteitis deformans which I
have described.*
2. Some are derived from cases of osteomalacia. Mr.
Durham! has written on these, and Mr. Solly's t well-known
paper gives a good instance of them. In general, I think
that these may be distinguished, at least in the recent state,
by their softness and lightness ; the abundance of soft
medulla contained in them, and the comparative brittleness
of the bones when dry.
3. Some are from rachitis ; they are, unless after recovery
and repair, very light, almost friable, and on their surface
not porous, but like fine cloth or felt.§ Like these are the
* To those already referred to, these, I think, may be added : Sandifort,
' Museum Anat. Acad.' ; Lugd.-Bat., fol., 1835, vol. i, p. 142, vol. ii, tab.
xiii. Skull of a man forty-three years old, with a "fungus" over the
left orbit (? a cancerous growth). Other similar skulls are here referred
to. Similar specimens are, probably, Nos. 2840 and 2858a in the College
Museum ; and, more uncertainly, 2841 and 2858, which, perhaps, belong
rather to the fifth group.
f ' Guy's Hospital Reports,' ser. iii, vol. x, 1864.
I ' Med. Chir. Trans.,' vol. xxvii, p. 435, Mns. Coll. Surg., 395.
§ See Mus. Coll. Surg., 390-394, 2844, and 2857. I believe that
Huschke, ' Ueber Craniosclerosis,' 1858, quoted by Virchow, contains
facts on the rachitic osteoporoses, but I have not been able to refer to it.
222 SIR JAMES PAGET ON
skulls of some lions and monkeys which have died young, in
confinement, of what is considered rickets. A collection of
these skulls and other similarly diseased bones in the College
museum* deserves careful study, especially because of their
likeness to the cases included in the next group, t
4. These are the results of a disease of early life, sometimes
even of childhood, in which all the bones of the face as well
as those of the cranium are affected, and, it is said, the bones
of the limbs. All the affected bones, facial as well as cranial
(and herein is a clear ground of diagnosis), become hugely
thickened, porous, or reticulate. The whole skull is very
large, clumsy, and featureless. Commonly the cranial cavity
is diminished. The orbital and nasal cavities are contracted,
the antra are often filled, by the ingrowth of their several
walls; the apertures for nerves are narrowed or obliterated.:^
Of these cases, which are among those named by Virchow,§
Leontiasis ossea, the best are related by Ilg |1 and Jadelot.lT
Their descriptions are very scanty, yet they give sufficient
facts to distinguish the disease by their account of the cerebral
symptoms associated with it. In Ilg's case, for example, the
patient, who died at twenty-seven, after seventeen years*
disease, had amaurosis, epilepsy, severe general headache,
delirium, convulsive attacks, and at last total deafness, wit-
lessness, difficulty of swallowing, and loss of smell.
5. Some cases, perhaps not different from these, though
* Nos. 383-333, 2854-2856, 2855a. &c.
■f- Although bones such as these are not described by Paul' Gervais,
yet his paper quoted below should be studied on all that relates to
hyperostosis in animals.
I Among the casts in the museum of St. Bartholomew's, No. 10, is
that of a skull affected with this disease, and in ser. i, 36, are fragments
of a bone, which, I think, may be referred to it.
§ 'Die krankhaften Geschwiilste,' B. 11, 1864-5. I need not say that
this contains a very complete account of all forms of overgrowth of
bone.
II * Einige Anatomische Beobachtungen,' 4to, Prag, 1821.
H Quoted by Ilg from Meckel. The best of many accounts of this
specimen is given by Paul Gervais, " De I'hyperostose chez I'homme et
chez les animaux," in the ' Journal de Zoologie,' t. iv, 1875. He has
carefully re-examined the skull and face and described them.
CHRONIC INFLAMMATION OF BONES. 22B
they have occurred in later life, are those by Schiitzenberger,*
Otto,t and Wrany.I
6. And, lastly, there are cases not so much of thickening
of the cranial and facial bones as of enormous bossed and
nodular hard bony outgrowths overspreading them or pro-
jecting from them. The leading case among these is that
published in the ' Transactions ' of the Pathological Society
by Dr. Murchison,§ with a report on the specimens by Mr. De
Morgan and Mr. Hulke.li The disease in which the facial
more than the cranial bones are affected is clearly distinct
from any of the foregoing, or, if it be in any way connected
with them, especially with those of the fifth group, may be
regarded as transitional from them to the exostoses, especially
the massive tuberous and bossed ivory exostoses, which grow
on or among the bones of the face and skull. The same
approach to the character of hard exostoses is shown in the
disease of the fibula in Dr. Murchison's case, a section of
which, from the museum of the Middlesex Hospital, is now
before the Society.
'■'■' ' Gazette Medicale de Strasbourg,' and in Canstatt's ' Jahresbericht
fur 1856,' B. iii, 34, with references to cases by Breschet and Nelaton.
f Otto, 'Neue seltene Beobachtungen,' 4to, 1824, p. 2. Both head
and face are affected ; the bones are described as, after softening, very
hard, dense, and almost ivory-hke. Six hyperostotic skulls are mentioned
in his 'Neues Verzeichniss der Anat. Sammlung zu Breslau,' 1841.
I Wrany, "Hyperostosis maxillarum," in ' Prager Vierleljahrschrift,'
1867, B. 1, similar affections of the facial and cranial bones, with cerebral
symptoms. Doubtful cases by Eibelt are quoted by Ilg, I. c. ; Malpighi,
' Opera Posthuma,' 4to, Amstel., 1700, p. 68 ; Kilian, ' Anat. Unters. iiber
den neunten Hirnnerv«npaar,' Pesth, 4to, 1822, p. 133; Quekett, reported
by Hewett, 'Medical Times and Gazette,' Sept. 8th, 1855, p. 229.
§ Vol. xvii, 1866, p. 243.
Ij Similar cases are illustrated by Forcade, quoted in Virchow's ' Die
krankhaften Geschwiilste,' B. 2, p. 22 ; Weber, from a specimen in the
Dupuytren Museum, in v. Pitha and Billroth's 'Handbuch,' B. 3, Abth. 1,
Lief, ii, p. 257 ; Howship, ' Practical Observations in Surgery and Morbid
Anatomy,' 1816, p. 26 ; Adams in ' Trans, of the Pathological Society,'
vol. xxii, p. 204, 1871 ; Lysthay, in Canstatt's ' Jahresbericht fiir 1858 ' ;
Mus. Coll. Surg. Eng., 3093. Virchow has a full account of nearly all
these cases, and of the analogies of the disease with elephantiasis of
soft parts.
DESCRIPTION OF PLATES I. TO V.
Chronic inflammation of bones (Osteitis deformans).
Plate I. See pp. 201-202.
Figs. 1-3. From photographs of the patient (Case 1) taken six
months before death.
Fig. 4. From photographs of the same patient's cap worn in 1844,
and hat worn in 1876.
Plate II. See pp. 204-205 and 208.
Figs. 1, 2. From tumour of forearm. Fig. 1. Oc. 3, obj. 4. x
about 62. Fig. 2. Oc. 3, obj. 7. Tube drawn out. x 260.
Fig. 3. From secondary tumour of pleura. Oc. 3, obj. 7, t. dr. o.
X 260. See pp. 204-205.
Figs. 4, 5. To show tissue in widened canals of tibia (4) and skull
(5). Oc. 3, obj. 7, t. d. o. x about 260.
Fig. 6. Trabecula of bone (tibia) lined by osteoblasts, x about 260.
Figs. 7, 8. From transverse section of tibia. (A. i. in.) Fig. 7
shows new bone growing in periosteum. Fig. 8. Taken from
immediately beneath the periosteum.
Plate III. See pp. 208-209.
Fig. 9. From perpendicular section of skull. (A. i. in.)
Fig. 10. From section of tibia, to show eaten-out border of widened
Haversian canal. Oc. 3, obj. 7. x 200. See p. 217.
Figs. 11, 12. From transverse section of tibia. Fig. 11. At some
distance from surface. Fig. 12. From a little way beneath
the periosteum. Oc. 3, obj. 4, t. dr. o. x 87.
Fig. 13. Transverse section of normal tibia. Oc. 3, obj. 4, t. dr. o.
x about 87.
Plate IV. — Upper and lower ends of femur. See p. 206. (College of
Surgeons Museum, No. 395b. Half diameter.)
Plate V. — Cranium. See p. 205. (College of Surgeons Museum, No.
395a. Real size.)
Plate I.
Fi ii. 3
Fi g.4.
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Plate II
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Plate IV.
Plate V.
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Q
UNILATERAL HYPEKTEOPHY OF
THE GUMS,
ASSOCIATED WITH OTHER ABNORMALITIES,
CHIEFLY HYPERTROPHIC AND
UNILATERAL.
BY
G. M. HUMPHRY, M. D., F. R. S.,
PROFESSOR OF SURGERY IN THE UNIVERSITY OF CAMBRIDGE.
UNILATEEAL HYPERTROPHY OF THE GUMS
ASSOCIATED WITH OTHER ABNORMALITIES, CHIEFLY
HYPERTROPHIC AND UNILATERAL.*
BosANNAH Allington, Set. 12, from Isleham, a rather
pale, but healthy, well-made, intelligent girl, was admitted
into Addenbrooke's Hospital in January, 1885, with great
hypertrophy of the gums on the left side of the upper jaw,
both internal and external to the teeth, but more particularly
on the outer side, where was formed a coarsely lobulated
mass, bulging the cheek and protruding between the lips. It
affected the whole length of the gum as far forward as the
left middle incisor tooth, and extended as high as the
reflexion of the mucous membrane over the cheek, on the
one side, and over the hard palate a little beyond the middle
line on the other. It was about the usual consistence of
gum, except at the fore part, where it was softer, and
resembled ordinary venous nsevus. It projected between,
and partially covered the teeth, so that one bicuspid and one
molar only could be seen.
On the right side, above, were two molars, two bicuspids,
one canine, and two incisors. The incisors were pressed
towards the right by the abnormal growth.
In other respects these teeth and the gums were natural.
In the lower jaw there were, on the right side, two molars,
one bicuspid, two incisors ; on the left side two molars, one
bicuspid, one canine, and two incisors. The gums on the
left side, below, were rather thicker than those on the right,
and a hypertrophied prolongation from behind extended over
the crowns of the left molars.
■'' Annals of Surgery, January, 1886.
230 G. M. HUMPHRY ON
There was no difference in size between the corresponding
teeth on the two sides, above or below, and no discoverable
difference between the bones on the two sides of the face
or head.
The left tonsil and side of the soft palate were somewhat
larger than the right. The upper and lower lips, on the left
side, protruded and somewhat everted by the growth over
which they could not be closed, were rather thick and coarse.
This was the case also with the skin of the alee of the nostrils,
especially of the left, causing a slight deviation of the septum
to the right. The hair on the head was thick and rather
coarse. The vibrissas in both nostrils were long, The left
eyelids were somewhat larger, and the eyelashes decidedly
larger and thicker than the right, though there was no
increase in their number. The fold of skin above the left
eyelid was larger than on the right side, which caused slight
drooping of the lid.
The hairs of the eyebrow on the left side were coarser,
more numerous, and extended more nearly to the median
line than on the right, but there was no apparent difference
between the eyes. The pinna of the left ear was a quarter of
an inch larger and a little thicker than that of the right.
This was most marked in the helix and the tragus. The
hair of the scalp came down rather lower in front of the ear
on the left side. The whole of the skin of the face was rather
fuller on the left side than on the right, and was rather more
covered with hair. The papillae on the left side of the tongue
were rather larger than those on the right.
The second digit on the left foot terminated in a soft,
bulbous extremity of skin covering a cushion of fat ; without
trace of nail, and without apparently any terminal phalanx ;
it was a little shorter than the corresponding toe on the right
foot. The right thumb ended in a similar soft bulb, but
there was here a rudimentary nail in the form of a short,
hard flake of epithelium, and the ungual phalanx could be
felt.
There was a small (a quarter of an inch in diameter) brown
mole on the palmar aspect of the right thumb, over the distal
end of the metacarpal bone, and another over the carpal end ;
UNILATERAL HYPERTROPHY OF THE GUMS. 231
and on the instep of the left foot was a third mole, flat, and
of about the size of a farthing. All these moles were hairless.
On January 16th, having drawn the middle incisor tooth
and made an incision through the cheek, I removed freely
with a saw the whole of the left alveolar border, including a
portion of the hard palate and the teeth, and cleared away
with a Volkmann's spoon the hypertrophied mucosa which
extended upon the right side of the hard palate, thus com-
pletely taking away the diseased structure from the upper
jaw. There was a good deal of haemorrhage, which was
checked, partly by ligature and partly by cautery.
The child was very faint, but soon recovered. The wound
healed quickly, and she was discharged on February 7th.
October 3rd, 1885. — She came to the hospital that I might
see her. There was no return whatever of the disease in the
upper jaw, but the hypertrophy of the gums on the left side
of the lower jaw had rather increased.
Her mother, who has a double upper lip (on both sides),
but who is in other respects well-formed and is a very healthy
woman, states that the upper gums in the child on the left
side were observed to be larger at, or soon after, birth.
She attributes the condition to the fact of a mouse having
sprung out of a flour bin which she was opening, and startled
her when she was in an early stage of pregnancy with the
child. Her belief, therefore, is that the affection is congenital.
The swelling had increased out of proportion to the growth
of the child, laterally more especially, and had produced so
much deformity and inconvenience that she wished it to be
removed.
The following microscopical report was made by my assist-
ant, Mr. A. Francis, who also wrote the details of the case
from which the foregoing has been chiefly taken.
The part of the growth at the posterior alveolar edge
consisted of coarse trabeculse of fibrous tissue, running in
various directions, with staff-shaped nuclei here and there,
indicating the position of the connective tissue corpuscles.
The deeper part of the growth was very dense, with a
slight amount of vascularity. The superficial part was more
vascular, of looser texture, and with more numerous connective
232 G. M. HUMPHRY ON
tissue corpuscles. The growth was covered by very hyper-
trophied, simple and branched papillae, rather vascular and
cellular. Epithelium not excessive : there was a well-marked
stratum lucidum on the surface, which was smooth. The
texture of the palatine growth was looser, with smaller
trabeculae, and was more vascular, with abundant fat-cells,
blood-vessels, and connective tissue corpuscles, but with less
marked hypertrophy of superficial papillae.
The following are abstracts of the accounts of ten cases of
this disease, which I have found recorded : —
(1.) Gross. System of Surgery. Sixthedition.Vol.il. P. 431.
Lad, aet. 10, stunted development, ill-shaped head, large
abdomen, feeble intellect. Gums of both jaws largely affected.
Kemoval by scalpels and scaling instruments, several times
repeated. Growing again four years afterwards.
(2.) Pollock's case. Holmes's System of Surgery. Third
edition. Vol. 2, p. 457.
Girl, aet. 8. Epileptic. One tooth cut two weeks after
birth, and six within five weeks. Gums thin, face thick and
puffy. Unusual quantity of hair from birth on head, arms,
and legs. When aged 2, the gums were cauterized and
temporary teeth extracted. Gums of both jaws appeared
largely protruding from the mouth, and alveolar processes
expanded and prolonged. Portions of projecting mass cut
away with scalpels and bone-nippers, repeated as the patient
could bear it, till alveolar borders were curtailed within
moderate limits. Some tendency to return subsequently, but
Mr. Salter {Dental Pathology and Surgery, p. 195) says that
after a few months it grew no more. A fibrous mass with
enormously long papillae and very thick epithelium.
(3.) Erichsen. Heath's Diseases of Jaws. Third edition.
P. 127.
Girl, aet. 2J. Incisor gums of both jaws and teeth hyper-
trophied ; began at 7 months. Exuberant growth removed
and teeth extracted. A fibrous mass with enlarged papillae
and thick epithelium. Disease progressed, and when seen by
Dr. Murray (Medical and Chirurgical Transactions, Vol. 6,
p. 138 ; Vol. 56, p. 250), aet. 7, affected the gums everywhere.
UNILATERAL HYPERTROPHY OF THE GUMS. 233
Soft, flattened tumors in skin of forehead, nose, axillae, and
arms, legs, and feet. Elevations, like smooth warts, on back,
and sides of neck. Hypertrophied, nodular conditions of ends
of fingers (except left forefinger) and thumbs of both hands,
and of third and fourth toes of both feet. Nails also large
and furrowed. The right forefinger less affected than the
others. Ecchymosed appearance over scapulae, buttocks, and
backs of thighs. Small exostosis on each tibia. Deaf, but
intelligent, and in good health. The peculiar condition of
fingers and neck not noticed till she was two years old, the
tumours on head a year afterwards, fresh ones appearing at
various periods.
Microscopical examination showed the tumours to belong to
the connective tissue group, developing into fibrous tissue
and cartilage.
(4.) Dr. Murray {loc. cit.). Brother of No. 3, aet. 3 years
9 months. Had gums like No. 3, but affected to a greater
extent ; observed when 3 months old.
Tonsils enlarged and deep cervical glands. Bottle nose,
with bluish discoloration. Patches of thick, glistening skin
on cheek, eyelid, and neck. End of right middle forefinger
enlarged and hard. Noticed recently. Small warty growth
on dorsum of finger. In good health, but sullen, stubborn,
and rarely makes attempts to speak.
(5.) Dr. Murray {loc. cit.). Sister of 3 and 4, aet. 2. Swelling
of gums, and warty patch on skin at back of neck, observed
when 2 months old, increasing ; and skin at back of ear
and, more recently, at junction of nose and left cheek, had
become the seat of growth. Slight rachitis, but otherwise
good health and intelligent. Mr. Jonathan Hutchinson, Dr.
Kobert Liveing, and Dr. Tilbury Fox examined these three
patients, and argued that their affections ought to be placed
in the family group of molluscum fibrosum.
The three children were born under unfavourable hygienic
conditions, the eldest boy born under more favourable con-
ditions, though from infancy living with the rest of the family,
quite healthy. The fifth child, an infant, born in another and
better house, was healthy, but with naevi materni on sides
of face.
234 G. M. HUMPHRY ON
(6.) MacGillivray {Australian Medical Journal. August,
1885. P. 240).
Woman, aet. 29. Two teeth appeared at 12 months, no
other after that. The affection was in both jaws from birth,
mainly from the palatal portion of the gums. At set. 10,
parts of gums cut away above and below, and nine teeth
extracted at nine operations. Severe haemorrhage, checked
by cautery. Hypertrophied gums, and alveolar processes
which were enlarged in fore part of lower jaw removed with
success, nine operations being required. Disease consisted
of increased development of gums and papillae.
(7.) Heath [hijuries and Diseases of the Jaws. Third
edition. P. 230).
Girl, set. 4J. Hypertrophy of gums equal in both jaws ;
began two years ago by the side of the temporary molars
which were just coming through. Epileptic with good health,
one of five children. Others healthy, Hypertrophied gums
and alveolar margins removed successfully.
(8.) Heath {loc. cit., p. 231). Man, set. 26, affection of
right side of lower jaw from early childhood. Eemoved with
affected alveolus.
(9). Waterman {Boston Medical and Surgical Journal.
April 8, 1869).
Female, set. 27, of average mental capacity, never good
health. Affection said not to have been congenital, but
commenced early in life. Kepeatedly had abscesses and
gum-boils, gums of both jaws hypertrophied, chiefly in front,
involving and overhanging the palate. Teeth had been ex-
tracted at various times. Twenty-six teeth extracted, and
parts of gums overhanging palate removed. Six months after
whole of outgrowth removed and dental border of superior
maxilla sawn off. Under microscope, a purely fibrous growth.
(10.) Waterman adds to preceding account : " A very
remarkable specimen of this disease presented itself in the
person of a female of feeble intellect, covered with a remark-
able hairy growth, who was exhibited by a showman in this
city (Boston) ten years ago under the name of the Bear
Woman. The hypertrophy of the gums was greater than in
the recorded case."
UNILATERAL HYPERTROPHY OF THE GUMS. 235
(It will be observed that nine of the eleven — including my
own — above recorded cases were females.)
The disease app'ears to be a simple, but spreading hyper-
trophy of the gum-tissue, differing therefore from epulis,
which is an affection of a similar kind of the fibrous tissue
of the alveolar processes and tooth sockets. It is congenital,
or commences in very early life, perhaps at the time of the
cutting of the first teeth.
It commonly involves the entire gums of both jaws, on
both the buccal and the palatal sides ; in No. 6 it was most
marked on the palatal side, but it usually attains the maximum
near the opening of the mouth where the restraining influence
of external pressure is least. In No. 2, and also in No. 6,
the alveolar processes are said to have been involved in the
disease ; and in No. 3 the teeth also are stated to have been
hypertrophied, which is not mentioned to have occurred in
any of the other cases. Complete removal by knife or cautery
is required, and to do this effectually it is commonly necessary
to take away more or less of the alveolar processes with bone
forceps or saw.
In its general pathological character, as a congenital,
local, and spreading hypertrophy, it is allied to naevus, and
some moles ; but an additional curious and interesting feature
is the frequency of its association with certain other abnormal
conditions. Nos. 1, 4, and 10 were of feeble intellect, No. 1
being also stunted, with ill- shaped head and large abdomen.
Nos. 2 and 7 were epileptic. No. 3 was deaf. No. 5 was
slightly rachitic, with warty patches on skin of head and
neck. In Nos. 2 and 10, and the case I have given, there
was unusual development — a hypertrophic condition — of the
hair on the head, and in No. 2 on the arms and legs also.
And in Nos. 3 and 4 there was a hypertrophied nodular con-
dition of the ends of the fingers, and various abnormalities of
the skin and subcutaneous tissue.
My case is further remarkable in that it was unilateral,
affecting the gums of the left side of the upper jaw much,
and of the lower jaw slightly, and was associated with hyper-
development on the same side of the soft palate, tonsil, lips.
236 UNILATERAL HYPERTROPHY OF THE GUMS.
alae nasi, eyelids, pinna of the ear, and of hair of the head,
eyebrow and eyelids, and of the left side of the face generally ;
also of the papillae of the tongue on the left side. Although
the hypertrophies on the head and face were thus, with the
exception of some enlargement of the right ala nasi, confined
to the left side, the abnormalities of the digits which were of
the nature of deficiency or atrophy, rather than of excess,
and the moles, were shared by the extremities of both sides.
Note. — Billroth, Clinical Surgery, New Sydenham Society, p. 53,
mentions a case of congenital unilateral hypertrophy of the mucous mem-
brane of the cheek and the upper surface of the tongue, combined with
cavernous lymphangiectasis, in a lad aet. 10. Dr. Friedrich, Virchow's
Archiv, XXVIII, 474, gives a case of congenital unilateral hypertrophy of
the head (right side) in a young woman. The right side of the tongue was
larger than the left, and with coarser papillae; and there was greater
growth of hair on that side. In the Journal of Anatomy and Physiology,
IV, 1868, 226, I gave a short account of asymmetry in a young woman,
the entire right side (head, trunk, tongue, palate, and limbs) being larger
than the left ; and Dr. Isambard Owen showed me the other day a similar
condition in a young woman under his care in St. George's Hospital ; see
Lancet, Oct. 31, 1885, p. 808, where report of this case is given. The
Archives Generales de Medicine, 1869, 11. 536, contains a paper on
unilateral hypertrophy of the body, partial or total, in which twelve
cases (seven in males, five in females) are collected. They include
Friedrich's case above mentioned, but not that published by me in 1868.
DANISH LAZAR-HOUSES
IN THE MIDDLE AGES.
DR. EDWARD EHLERS,
Of Copenhagen.
Contents. — 1. Monastic Hospitals. 2. Laws relative to Isolation.
3. Conditions of Admission. 4. Medical Visitation. 5. Exclusion from
Society. 6. Revenues of the hospitals. 7. Inspection. 8. Divine Service.
9. Functionaries of the Hospital. 10. Alimentation. 11. Lazar-house
Regulations at Troyes. 12. Decline of the Hospitals. B. Information
respecting Danish Lazar-houses. C. Documents.
Medical Visitation of a Leper.— Sixteenth Century.
(GrERSDORFF : Feldbuch der Wundarzney. Strassburg, 1535.)
Satan Strikes Job With Leprosy.
(Gersdorff : Feldbuch der Wundarzney. Strassburg, 1535.) c31U
Leppeii with his Rattle.
(Franklin : Vie piivee d'autrefois, hygiene.)
DANISH LAZAR-HOUSES
IN THE MIDDLE AGES.
I.— MONASTIC HOSPITALS.
In the Middle Ages the care of the sick and the poor
devolved upon the clergy, aided by voluntary donations or
the alms collected by the begging friars. At a period when
hospitals were not yet in existence, the sick and needy, rich
or poor, resorted to the convents, taking with them all their
possessions. The monks maintained all manner of sick
persons, even those whose sufferings were merely of a moral
nature, supplying all their wants out of the funds of their
own property, which, upon the death of the patients, lapsed
to the convents.
Not only did the sick thus secure themselves from all
material anxiety, but they frequently entered into contracts
with their hosts, the monks, of the nature of life-annuities.
These contracts were often drawn up with a curious amount
of detail. From time to time one finds proof that the un-
fortunate person who, when broken-down in health, sought
shelter within the silent walls of the convent, continued to
love carnal enjoyments, little in keeping with monastic rule.
Thus we find a blind gentleman of Fionia, named Ubbe,
bequeathing all his possessions to the convent of St. Canute,
of Odense, on the express condition that he should be served
each day with a dish of tripe. He wished to eat his favourite
dishes every day at home ; however, one day, when no tripe
could be obtained, his servants set a dish of beef (skin of the
242 DR. EDWARD EHLERS ON
front) before him, whereupon he got into a violent rage, and
resolved to take refuge in a convent.*
Not only, however, did the sick man find temporal advan-
tages in the seclusion of the monastery, but also the favour
of heaven and the salvation of his soul, by means of works of
charity to the monks — in other words, to the poor of Jesus
Christ.
The convents were places of refuge to many persons to
whom the world no longer afforded pleasure or profit. Infirm
old men, seeking nothing more than the repose of the tomb,
spent their last days in the peaceful quietude of the convent,
enjoying complete rest, and spending much of their time in
devotions that were too often of an exaggerated nature, bor-
dering on the superstitious.
Wealthy persons, bowed down beneath the weight of human
misery, made over their fortunes to the rich seigneurial con-
vents, where they themselves found all the care necessary
to their age and misfortunes ; while, in the hospitals of the
Brothers of St. John, and in the convents of the Holy Spirit,
the poor received the care that they could not obtain from
their relatives, their friends, or the State. t
It cannot be denied that the Catholic Church supplied in
the most perfect manner, considering the times, the lack of
legally organized public assistance. Public charity was on a
grand scale, and doubtless it was based, not only on a blind
faith in Providence, but also on the great confidence felt in
the administration of the clergy.
Luther, who cannot be accused of partiality in his judgment
as to the part played by the Catholic Church with regard to
charitable institutions, writes on this subject (Sammtliche
Werke, v. 264 f., xii. 123, xli. 131 f., xlii. 164) :—
Im Papstthum war jederman barmherzig und mild : da
gab man mit beiden Handen frohlich und mit grosser Andacht.
Zuvor konnte jede Stadfc, danach sie gross war, etliche
'- Suhm : ' Collections helpful to the study of the history of Denmark,*
Copenhagen, 1779, vol. i. page 89.
f Daugaard: 'Danish Convents in the Middle Ages,' Copenhagen,
1830, p. 91.
DANISH LAZAR-HOUSES. 243
Kloster reicblich ernahren, will geschweigen den Messepfaffen
und reichen Stift. . . .
Da schneite es mit Almosen, Stiften und Testamenten. . . .
Unter dem Papstthum waren die Leute milde und gaben
sie gern.
No doubt, by the exercise of charity after this fashion,
persons of slender means, in mediaeval times, often injured
the interests of their heirs. Daugaard makes the following
observation on this subject : —
In order that exaggerated donations in favour of the
convents and other religious endowments should not be too
prejudicial to the heirs-at-law, the legislators of the Middle
Ages fixed limits to the donors. A man in good health might
enter a convent with all his worldly goods, or might make
over all his property to a religious institution, but a sick
person might only dispose of the half of his fortune in this
way. According to the Selande law, a sick man is one
incapable of mounting his horse to go either to the Legislative
Assembly or to an Assembly of any other kind ; and a sick
woman is one who cannot carry her keys or superintend her
servants. But, the law adds, if the man or the woman
becomes invalided, he or she may be permitted to enter a
convent with all his or her worldly goods.*
As the Church continued to organize public assistance,
monasteries were created and consecrated solely for the relief
of certain maladies. I have shown in my book on Ergotism}
that the convents of St. Anthony had at that period made a
speciality of the treatment of gangrenous ergotism, which ap-
peared from time to time under the form of a violent epidemic.
But the greatest plague of the Middle Ages, leprosy, attracted
the attention of the authorities, both lay and ecclesiastic, far
sooner. It was to combat this scourge that the first hospitals
were built.
Lazar-houses were known to be in use in 460 at St. Oyan, in
570 in a suburb of Chalons-sur-Saone, and in 634 at Verdun, t
- Thorkelin : Collection of old Danish laws : ' Eccl. law for Scandi-
navia,' p. 6 ; * Eccl. law for Zealand,' p. 15-16. Compare ' King Eric's
law for Zealand,' edition Eosenvinge, p. 35.
f 'L'Ergotisme, le feu sacre et le feu St. Antoine.' Paris, 1896.
\ Chevalier : ' Notes historiques sur la maladerie de Voley,' p. 132.
R 2
244 DR. EDWARD EHLERS ON
In Denmark King Canute VII. seems fco have been distin-
guished for his largesses as a benefactor to hospitals. We
read in the Liher daticus Lund vetustior : — *
Anno Domini 1204 obiit Canutus Kex, qui inter csetera
SU8B frugalitatis beneficia universa Monasteria infra Daciam,
et loca, quse infirmorum Ospitalia instituta sunt larga muni-
ficentia ditavit.
Hospitals had then been established before his reign. Now
every time that a hospital is in question at the commencement
of the Middle Ages, one may be certain that it is a Lazar-
house. The Scandinavian word spedalskhed (in Swedish^
spitalska) indicates clearly that it is the only malady which
necessitates isolation in a hospital (morbus =^ ho-spedalis).
The celebrated monk, Paulus Helise, who lived at the time
of the Reformation in Denmark, says expressly : — t
Only such persons were admitted to the hospitals who had
the misfortune to be smitten with leprosy, then called hospitals
siwge (hospital malady).
The Germans still use the word Aussatz to indicate that it
was necessary to isolate, to set apart (aussetzen) the lepers.
The Danes, too, formerly used an expression with a similar
meaning, udsettische siwge.
In the Middle Ages the necessity for Lazar-houses made
itself felt to such an extent that each town had its own. These
hospitals were bound to be erected outside the gates of the
city, for fear of contagion from the malady, the infectious
character of which was never called in question by anyone.
They had a claustral organization, and bore the name of
certain saints, but not always of the same. In the north and
in the east of Europe they were under the segis of St. George
(St. Joergen or (Ergen in Scandinavian).!
All the courts of St. George (St. Joergensgaarde) of Scandi-
navia were originally lazar-houses. At Stockholm the great
'''- Langebeek: ' Scripta rerum danicarum,' iii. p. 568.
f Poul Eliesen : 'Danish Works,' edition Secher, i. p. 152.
I A legend makes the combat of St. George and the Dragon take place
at Svendborg, in Fionia (Denmark).
DANISH LAZAR-HOUSES. 245
hospital for venereal diseases has preserved the name of St.
Goran (in the Middle Ages, St. Gorans or St. Oriens spetal).
The combat of St. George and the Dragon was an excellent
symbol for the people ; it led them to look upon that saint as
capable of delivering them from this terrible scom-ge.
In Germany the Lazar-houses were generally placed under
the protection of the same saint. I do not think that H. v.
Hildebrand is right in saying* that they were under that of
St. Nicholas. However, there may have been exceptions in
accordance with his opinion.
In Central Europe they were under the protection of St.
James. In historic annals there is mention of the Lazar-house
of St. Jacob an der Birs, where, on the 26th August, 1444,
live hundred Swiss fell fighting against superior forces, com-
posed of Germans and Frenchmen.!
At Cracow the Lazar-houses were under the patronage of
St. Valentine and St. Leonard. |
In the south and west of Europe they were under that of
St. Lazarus, the poor beggar who, according to the Bible
story, was fed from the crumbs which fell from the rich
man's table, and whose sores were licked by the dogs. There
again is an allegory easy to interpret.
The great prison for women in Paris, the hospital of St.
Lazare, where prostitutes are received, owes its name to the
lepers who were formerly admitted there.
The lazzaroni of Naples are still the successors of lepers
living out of the city.
In France the lazar-houses had different patrons. Neret§
says, with reference to the article on Elephantiasis in the
* Dictionary of Medical Science,' that the Lazar-houses were
placed under the protection of St. Lazarus, Ste. Marthe, and
Ste. Magdalen. Certain other localities honoured other saints
as their patrons. In Berry, e. g., St. Sylvain of Livroux, was
an object of veneration on the part of the lepers.
- ' Public Charity in the Middle Ages.' ' Svenska fornminnes-forenin-
gens tidsskrift ' (1885-7, p. 207).
f Lesser : ' Die Aussatzhauser des Mittelalters,' Zurich, 1896, j). 12.
I Gliick : ' Lepra in Polen.,' Janus, 1897, p. 543.
§ ' These de Paris,' 1896, p. 14.
246 DR. EDWARD EHLERS ON
Father Charles Cahier* cites besides as patrons of lepers —
Pope Leo, St. Gaugery (Goery, Gery), Bishop of Cambray,
St. Poppon, Abbe of Starela (1068), St. Guennole (Winwal-
oens), Abbe of Landerenec, St. Ethbin, his companion, and
finally the blessed Aleyde de Schoerbeck, Cistercian at la
Cambre (1250). The seal of the Lazar-house at Copenhagen
was the effigy of the King St. Olaf.
The proceeds of the alms-box of St. Olaf, which was placed
on the sea-shore, and of which mention is made in a statute
of the 29th January, 1275, given by Bishop Peter, were dedi-
cated to this hospital.
XL— LAWS OF ISOLATION.
The first measures taken against leprosy in mediaeval times
regarded the isolation of the affected person.
Many ancient local edicts, most of which date incontestably
from the commencement of the Middle Ages, contain pre-
scriptions of this nature. Already in 630, Kotharis, King of
the Lombards, issued an edict against lepers. f The Lombards
were at that time considered to be seriously affected by leprosy.
In 770 Pope Stephen III. threatened to excommunicate Charle-
magne if he married Bertha, daughter of Dideric, King of the
Lombards, " if he corrupted the noble blood of the Franks
by mingling with it that of the perfidious and unsavoury
Lombards."
We have no data before the end of the twelfth century to
enable us to establish with any certitude the appearance of
leprosy in Denmark, Norway, and Iceland.;}:
Legislation for protection against this scourge dates from
the thirteenth century. The first law relating specially to
lepers was that of Gulathing. Clause 298 of the fifth part
of this law exempts lepers from military service. Conrad
='' ' Caracteristiques des saints dans I'art populaire.' Paris, 1867, 4 s.t.,
ii., p. 504.
f Eaymond: 'Hist, de I'eleph,' Lausanne, 1767, pp. 106-107, cit. de
Hensler.
I Ehlers : 'Leprosy in Iceland,' British Journal of Dermatology, 1894.
DANISH LAZAR-HOUSES. 247
Maurer* places the date of the promulgation of this law at
the commencement of the thirteenth century.
Coercive measures taken against lepers made marked pro-
gress in their severity. Clause 105 of the edict of the 29th
January, 1294, by Bishop Johan Krag, for Copenhagen,! is
thus expressed : —
De leprosis.
Item percussus lepra non cogetur ad leprosos intrare, quam-
diu communionem hominum publice devitaverit.
Originally, then, isolation was voluntary for the leper. He
was not obliged to submit to isolation unless he did not hold
himself sufficiently aloof from his healthy neighbours. Thus
we see that in 1297 the subject was as much a matter of
discussion as in our own day.
Later on it became necessary to assume a more severe
attitude with regard to the leper. In the edict of the 14th
October, 1443, promulgated by King Christopher of Bavaria,
and applicable to Copenhagen, clause 36 of the fifth chapter
is thus worded; — t
Every person who is infected by leprosy in the city, must
leave it and enter the House of St. George before a date fixed
by the bailiffs and the burgomasters, under pain of being
conducted there by them at his own expense, his property
being seized to defray the expenses of his maintenance.
Another law at the commencement of the fifteenth century,§
made by King John, and put in force in all the towns of Den-
mark, is of no less rigorous a nature : —
§ 112. — Lepers are not permitted to remain in the towns.
If a person attacked by leprosy will not leave the city volun-
tarily, he will be conducted by the Burgomaster at his own
expense, with all his effects, to the nearest hospital of St. George.
These prescriptions for the isolation of lepers were probably
observed as long as leprosy showed itself in the endemic state,
■'■■ 'Geschichte der Nordgermanischen Eechtsquellen,' Christiania,
1878, p. 27.
j- ' Diplomatariiim de Copenhague,' i. 59.
l Ibid., p. 173.
§ Kolderup-Roseiivinge : ' Gamle Danske Lore,' Copenhagen, 1827,
p. 100.
248 DR. EDWARD EHLERS ON
but it is certain that there was a relaxation at the commence-
ment of the seventeenth century. Towards the middle of the
sixteenth century all the convents of St. George were closed,
and reunited to the large general hospitals, but, as a few
sporadic cases of leprosy continued to appear, places of isolation
were kept up for them. The order of King Christian III., given
at Ribe in 1542,* says : —
Leprosy not being so common in this country as formerly
(God Almighty be praised and blessed). We order that all the
convents of St. George, as well as all the other lesser hospitals
founded for lepers, be amalgamated with the large general
hospitals. If any of these hospitals of St. George are given
in fief for life to any person. We will that they be estimated
and taxed at an annual rate, payable to the general hospitals.
If there be any lepers elsewhere, a house shall be built for
them near the general hospitals, either in the garden or in
some other convenient spot, so that the same pot may feed
everybody.
After this period no other legal measures were taken against
lepers than those stipulated by the ordonnance of King Fred-
erick II. on marriage. Chapter iii. of this ordonnance (given
at the Castle of Haderslev on the 27th December, 1588) is
reproduced in the Danish law of King Christian V. (chapter
iii. V. 16-18) :—
If a woman or her husband be attacked by an infectious
maladj^ such as leprosy or the disease called Franzos, she or
he must not separate from the other, but patiently bear it as
a cross inflicted by God. A true Christian infected by such a
malady would not, however, desire to contaminate his consort.
Later on, however, the Danish Government has recognized
the necessity of the principle of isolation. Hence an ordon-
nance of the 26th April, 1661, prescribed that lepers should
be isolated on the Faeroe islands, and that, if necessary, they
should be constrained to go there by force. Ten years pre-
viously four Lazar-houses had been inaugurated in Iceland
(Ehlers, I.e.).
" Hofman : ' Fondations,' vol. ii. p. 100.
DANISH LAZAR-HOUSES. 249
III.— CONDITIONS OF ADMISSION.
The Lazar-house only admitted the citizens of the town or
the inhabitants of the district within which the hospital had
the right to collect alms.
Poul Eliesen* says expressly : —
And such was the custom in former times that it was
made incumbent upon every community to provide for its
sick, and even for its infirm members, and to maintain any-
one who had lived and laboured therein.
The same conclusion may be drawn from the passage cited
from Christopher of Bavaria (Municipal Code of Copenhagen,
1443) — "Every person infected by leprosy in the town," &c.
When a town had no hospital for lepers, they were sent to
the nearest Lazar-house, conformably to Clause 12 of the law
of King John, which applied to all the towns of Denmark.
At Paris a leper could not be admitted to St. Lazare if he
had not been born within the four gates of the city and was
the legitimate child of a citizen of the same city. Bakers
were the only exception to this rule, for they paid a special
rate to St. Lazare. f
At Nimes (according to Puech), strangers were only ad-
mitted with the approbation of the Consuls, and had to pay
25 livres for admission, whilst the people of Nimes paid
fifteen only, or about 225 francs.
Admittance to a Lazar-house was, therefore, not altogether
a matter of course ; some asylums even refused admittance
to poor people incapable of paying the prescribed entrance
fee. At Lisle 60 sous had to be paid for visitation expenses.
In some cases even installation fees had to be paid : at
Bourbourg (according to Coussemaker) 7 livres, 10 sous had
to be paid, of which two-thirds went to the head of the
establishment and one-third to the patients.
It is probably this fee which is called intrdit in Denmark.
Svendborg's first document (see end) decrees that the priest
shall pay his introit like any other of the brotherhood.
-•■ Edition Secher, i. 153.
I Hery : ' Les leproseries dans I'ancienne France,' p. 61. Paris : 1896.
250 DR. EDWARD KHLERS ON
The brethren and sisters had to pay the introit if they could,
and according to their means, ** in conformity to anterior
custom."
In Svendborg's second document (see end) the entrance
fees are fixed at five marks, to be distributed among the
members of the Lazar-house, probably with the object of
enabling them (at Svendborg as at other places) to make good
cheer. This document tells us that the introit (or welcome)
being paid and distributed, the chief authority shall make
the proclamation, and the new comer, swearing by God and
all the saints, shall promise, in the presence of all his
brethren and sisters, to make a proof to them of loyalty,
deference and kindness, either in the hospital itself or outside
of it.
Besides this the patient was expected to bring with him all
the furniture he required, and to leave it to the establishment
at his death. At Nimes, for instance, the leper in question
had to furnish himself with a bed, a mattress, a pillow or
bolster, six sheets and two counterpanes, ten basins and two
tin dishes, weighing altogether thirty pounds. If he failed
to bring this furniture, this bed, or at least the mattress, he
had to get on as best he could, and to sleep on the floor or on
straw, &c. Several towns, such as Troyes, had one lazaretto
for the paying patients and another for the poor.
At St. Lazare, in Paris,* some of the patients lived apart,
either in houses outside the hospital precincts, or in buildings
erected within the same ; others, again, in rooms with a
special attendant. This category of lepers were, of course,
not supported by the hospital, but paid their own expenses.
No leper could be admitted unless he could lay claim to
citizenship, and this regulation was observed very strictly.
In 1445, Jehan de Maubeuge, secretary to Philip the Good,
being smitten with leprosy, desired to enter the Lazar-house
at Lisle. With this object in view he applied to the mighty
prince, Duke of Burgundy, of Brabant and of Limbourg,
Count of Flanders, of Artois, Burgundy, Hainault, Zealand
and Namur, and rival of the King of France. This high and
■■'• Boulle : ' Kecherches liistoriques sur la inaison de St. Lazare de
Paris ' ; ' Memoires de la societe de I'liistoire de Paris,' t. iii.
DANISH LAZAR-HOUSES. 251
mighty personage wrote to " his very dear and much be-
loved " aldermen of the city of Lisle, begging and praying
them, in the most courteous manner, to be kind enough, out
of regard for himself as Duke, to take in his servant. It was
all in vain : the citizens of Lisle refused him admission.*
Another natural consequence of this state of things was,
the Lazar-houses only admitted persons really attacked by
leprosy. The existence of the disease was attested by phy-
sicians ; or, if there were none within reach, by those who
acted as such in cases of emergency ; or, lacking these substi-
tutes, simply by the managers of the hospital, or even by
lepers who had been previously admitted, and who were
summoned to give their advice, either individually or by
means of a jury formed from among themselves.!
In Germany the diagnostic was made by a commission of
experts, called Aussatzschau (inspection of persons to be
isolated). Thus we learn from history that the people of
Zurich sent their lepers to Constance until the year 1491,
from which time Zurich had its own inspectors.
In 1396 the Municipal Council of Basle decreed that no
barber had the right to grant a certificate of leprosy. | The
examination of suspected cases must take place in the pre-
sence of the doctor, Master Berthold, or of such successor to
him as the said council should appoint.
In the country of the Khine, Frankfort was the city chosen
for the visitation of lepers, Giesen, Marburg, Wetzlar,
Bacharach, the Upper Wesel and Amberg sent their cases to
Frankfort to be examined. In 1469 Frankfort despatched a
leper to Cologne, about whom a decisive judgment was
desired. §
As regards the reporting of fresh cases of leprosy, it is
almost certain that it was generally expected that their neigh-
bours, fearing contagion, would denounce them as lepers to
be interned ; but there is no doubt whatever of the fact that
in many places doctors and barbers were expected to report
-- Hery : ch. 1. p. 59. f Id. ibid. p. 55.
t Lesser : ' Aussatzhaiiser des Mittelalters,' p. 10. Zurich : 1896.
^ Kriegk : ' Deutsclies Biirgerthum im Mittelalter,' i., p. 5. Frank-
furt a. M. : 1868.
252 DR. EDWARD EHLERS ON
any case they met with. A supplementary article of the
Corporation of Barbers of Frankfort-on-Main, in 1433,
forbids its members to shave or to bleed a leper, and orders
them to give notice to the authorities of any leper who does
not remain at home. From the fourteenth to the fifteenth
century the physicians of Metz were bound by oath to report
new cases of leprosy, and every person suspected of the
disease was immediately examined by the " myr."
How was this inspection practised in Denmark? I am
unable to furnish information on this point, and have there-
fore given the above notes as to what was done in other
countries. It must be admitted that the kind of establish-
ment in question presents itself everywhere under the same
aspect. As to the obligation to denounce lepers in Denmark,
the only mention that Svendborg's first document makes of it
(see end of this work) is that the administrators of the
hospital — that is, the trustee, the treasurer, the priest and the
warden — must enforce the sequestration of such persons of
their district as may be infected by a malady which necessi-
tates their separation from their fellows.
The rules of the Swedish hospitals (see Hedquist, 50th ch.)
prescribe that the bailiff shall keep himself informed as to
the lepers of his bailiwick, and shall intern them in the
hospital, and that if they refuse to go there, or if a third
person seeks to prevent them from going there, the delin-
quents shall be liable to heavy fines.
IV.~MEDICAL VISITATION.
Circa tamen examen et judicium leprosorum est multum
advertendum, quia maxima injuria est, sequestrare non
sequestrandos, et dimittere Leprosos cum populo. Nam
morbus est contagiosus et infectivus. Ideo medicus ssepe debet
eos aspicere et signa voivere et revolvere et videre, quae sint
univoca et quae aequivoca, et non judicet per unum signum
sed per concursum multorum, inprimis univocorum.
Guy de Chauliac,
Chirurgia magna ed. Jouhert.
London, 1585, 4, cited by Hensler.
DANISH LAZAR-HOUSES. 253
Lepers were examined according to very minute regula-
tions, submitted to print, and of which mention is made by
authors of this epoch, such as Ambroise Pare and Gersdorff.*
These regulations show a very exact knowledge of the sym-
ptoms of the malady. Writers who have asserted that the
mediaBval Lazar-houses were resorted to by incurables from
all parts, and amongst whom lepers were only in the minority,
must have been ignorant of these regulations.
I will cite here the regulations, bearing date 1555, which
are to be found in Gesner's works : — t
EXAMEN LEPROSORUM AUTORIS INNOMINATI
ex Conr. Gesneri Scriptor. de Chirurgia opt. Tiguri, 1555.
Oportet medicum providere et attentum esse circa signa
ipsius leprae, et ilia revolvere multoties, et non uni signorum
credere, sed pluribus, et videre, quae sint signa propria, et
quae sint aequivoca, unde secundum propria signa judicet, et
secundum aequivoca, secundum majorem partem. Faciat
igitur primo infirmum jurare, ut de interrogandis dicat veri-
tatem, et consoletur verbis consolatoriis, dicendo, quod haec
aegritudo salus est animae, et tales Christus non despexit, licet
mundus eos fugiat. Tunc medicus secundo quaerat de regi-
mine suo, et diaeta, et si consuevit habere aemorrhoidas, vel
mentagram, et nunc non habeat. Item quales habuit aegritu-
dines, quae ad lepram disponunt.
Primo faciat fieri phlebotomiam de cephalica, vel de basilica,
vel de ambabus, et ex depositione sanguis et ejus substantia
judicet. 1. Si sanguis foeteat. 2. Si tactu sit viscosus vel
unctuosus. 3. Si manibus et digitis totus strideat, ita quod
sit arenosus, et asper ad factum per adustionem. 4. Si, post
lotionem sanguinis per pannum lineum duplicem, consideret
carnem illam, quae est in panno, si sit arenosa, granulosa,
trumbosa, nodosa. 5. Si fila rubea- apparent ibidem, et si caro
alba, quae stridebat ad factum, et foeteat, et nigrescat, hoc est
malum signum. 6. Si color sanguinis sit niger, lividus.
De oculis.
1. Si oculi rotundantur, et maxime versus domesticam
partem. 2. Si sit palpebrarum inflatio. 3. Si sit oculorum
inflatio et superciliorum. 4. Si pili superciliorum cadunt,
et apparent crevisse pili parvi et minuti, quae nisi ad solem
* Hensler : ' Vom abendliindischea Aussatze,' p. 63. Hamburg : 1794.
t Ibidem,
254 DR. EDWARD EHLERS ON
videntur. 5. Si extractis pilis palpebrarum et superciliorum
adhaereant ejus velut frustula carnis. 6. Si albugo sit tene-
brosa et livida. 7. Si venae rubers apparent in alba, prsecipue
in angulis oculorum. 8. Oculorum aquositas.
De auribus.
Si sint rectae et rotundas propter consumptionem pulparum
ejus.
De narihus.
1. Si nares exterius secundum exteriorem partem ingros-
sentur, et interius constringantur, et coartentur. 2. Si
appareat cartilaginis in medio corrosio, et casus ejus, signi-
ficat lepram incurabilem. 3. Si foeteant. 4. Si apparet
polipus et strictura anhelitus. 5. Si multitudo sit sternu-
tationis.
De ore.
1. Extrahatur lingua, et vide, si sit granulosa de subtus,
aut etiam in extremitate linguae, et in poris appareant grana
alba, viridia, vel livida, hoc est certum signum. 2. Si
fcBteat anhelitus. 3. Si sit spiritus ejus difiicilis attractionis,
et cum difficultate attrahatur, ut in pthisi, disnia (dyspnoea),
et astmate. 4. Labiorum ingrossatio, durities, fissura, deni-
gratio, et liquiditas. 5. Si gingivae sint asperae et corrosae.
6. Si ejus sermo sit, ac si per nares loquitur.
De facie.
1. Furfures capitis fricando. 2. Color lividus totius faciei
vergens ad fuscedinem, mortificatus et terribilis aspectus faciei
cum iixo intuitu. 3. Pustulae et nodositates in facie et tuber-
ositates. 4. Formicatio et titillatio totius faciei, ac si acus
pungat eam. 5. Si sit tensio frontis et splendor, ut cornu.
De pectore.
Si in pectore apparent venae grossae. Item si sunt mamillae
durae.
De manihus et pedihus.
Si manuum musculi fuerint consumti, et maxime pollicis et
indicis. Item lividitas unguium cum sanguinis diminutione,
lividitas et scissura unguium ; quando digiti manuum et pedum
et alii sibi propinquiores, quae vocantur medii ; patiuntur
frigus, et dormitationem, et quasi quandam sensus priva-
tionem. Et aliquando accidit cuti, inter illos digitos usque
ad cubitum vel brachium, et a pede dormitatio ; ilia extendit
se ad ancham. Serpigo et impetigo se eis adsunt, et prius
pili parvi ascendunt, malum signum est. Et si impetigo et
serpigo fuerint in magna quantitate, manuum aut pedum, est
certum signum acuitatis materiae. Consumptio pulvis tibi-
DANISH LAZAR-HOUSES. 255
arum. Sensibilitas sive tibiarum sive retro tibias, quod
puncturam acus non sentiat, est signum leprae. Distortio
juncturarum, et nodositas circa illas partes.
De toto corpore hoc.
1. Si sit facilis infrigidationis. 2. Si eminentise frigoris,
sicut in ansere apparent, est signum infallibile. 3. Si sub
cute sint nodi, qui manibus tractari possunt. 4. Si sit
pruritus et scabies illic. 5. Si acqua descendit per corpus,
ac si transiret per rem unctuosam. 6. Si sit corrosio cutis,
et proprie inter spondilem (vertebram) et dorsum. 7. Sentiunt
se graves cum dormitatione membrorum. 8. Sub cute
transeunt formicationes, ac si esset urtica percussus, vel sic,
ut vermes ibi essent. 9. Plus appetunt coitum et ardent.
10. Sunt magis dolosi. 11. Somnia vident terribilia. 12. In-
cubum saepius patiuntur, ac si cor eorum claudatur in nocte,
et comprimatur.
De pulsa.
Est debilis, et rarus, et subtilis. Formicatio in palato,
lingua, genu, et palpebris, et in toto corpore : color cutis
lividus. Fsetor sudoris.
It is very plain that the visitation in question was an
excessively minute examination, and quite in keeping with the
times. The patient hardly ever got off without paying, if he
was found to have the means to pay. At Lisle, the fee for
the medical visitation was sixty sols, of which sum half went
to the examining jury, composed of seven incontestably au-
thentic lepers living in the hospital. The other half reverted
to the sergeant of the aldermen who had called this melan-
choly jury together.*
v.— EXCLUSION FEOM SOCIETY.
The result of the before-named visitation was a certificate,
of which a very characteristic specimen, from the pen of
Ambroise Pare, which has been cited by all writers, here
follows : —
We surgeons, sworn in at Paris by order of the King's
proctor, at Chastelet, given the 28th day of August, 1583, by
which we were nominated to make our report as to whether
X. is attainted with leprosy, have therefore made our exami-
nation as follows : —
In the first place we have found his face to be cyanotic,
* Hery, passage cited, p. 56.
256 DIt. EDWARD EHLERS ON
wan, and covered with blue blotches. Further, we have ex-
tracted some of the hairs of his head, beard, and eyebrows,
and have observed that a small portion of flesh was attached
to the roots of the hair. In the eyebrows and behind the
ears we have found little glandulous tubercles, the forehead
was wrinkled, the expression wanting in animation, the eyes
red and glaring ; the nostrils, distended outwardly and con-
tracted inwardly, were almost obstructed with little crusted
ulcers ; the tongue was swollen and black, while on its upper
and lower surface we found three little grains or corns, such
as are found in leprous hogs ; the gums were corroded, and
the teeth loose ; the breath very offensive, the voice hoarse,
and the speech nasal. We have also examined his body, and
have found his skin to be rough and uneven all over, like that
of a thin, plucked goose, and in certain places several tetters.
Besides this, we inserted a needle rather deeply into the
tendon of the heel, without his feeling it noticeably.
By these signs, as univocal as they are equivocal, we pro-
nounce the said X. to be a confirmed leper.
In consequence of which it will be desirable to separate him
from the company of healthy persons because the malady is
contagious.
We all certify the above to be true, witnessing the same
with our own hand here below.
Upon the receipt of the certificate from the jury of surgeons
who had examined the sick man suspected of leprosy, the
burgomaster had to order the sequestration of the leper, and
to inform the priest of it, who mounted the pulpit and an-
nounced the matter publicly.
Then it was that the poor invalid saw the terrible day dawn
when he should be excluded from all intercourse with his
fellow-men, after receiving the blessing of the priest and
taking from his hands the melancholy grey tunic, which was
to be his only clothing in the future. Until the conclusion of
the ceremony the priest kept the sick man's mantle, hood,
gloves, rattle, belt, and knife by his side. Somewhat later
the procession commenced, during which the priest had to
lead the condemned man to the church. Eelations, friends,
and neighbours took part in this sad spectacle, which rendered
the last honours to a living corpse. In the porch the leper
passed before the wicker-work bier on which he was to be
"Carried to the cemetery, while high up, behind the high-altar
and above the choir, he beheld his shroud spread out to view.
DANISH LAZAR-HOUSES. 257
A requiem was then performed, and the sick man had to
listen to it with his face veiled, isolated from his fellows, like
a dead man in his coffin. In some places, however, the cruelty
of this ritual was mitigated : the unhappy man, exempted from
the funeral service, heard instead the mass for the day, or the
office of the Holy Spirit, or a special mass, in which the pre-
vailing idea was a paraphrase of the 38th Psalm : " Thine
arrows stick fast in me, and Thy hand presseth me sore."
And for the epistle the 5th chapter of the Second Book of
Kings was chosen, the story of the leprosy of Naaman, and of
the manner in which he was cured by the prophet Elijah ;
while for the gospel the passage was read which tells of the
cure of che leper in Samaria.
When the priest had prayed, the leper recited the following
prayer : "0 Jesus, my Saviour, Thou hast created me of the
dust of the earth ; Thou hast given me earthly life ; grant
that I may awaken to eternal life at the last day."
Divine service being ended, the priest returned the leper
his mantle, gloves, rattle, belt, and knife, and conducted him
to the cemetery. There he picked up three pieces of earth
and placed them on the head of the unfortunate man, saying :
"My friend, thou art dead to this world," and, pointing to
Heaven, he charged him to have patience. Thereupon the
procession resumed its march, taking the road to the hospital,
where, before the portal, the King's proctor and the director
of the hospital awaited it. The procession halted : the King's
proctor addressed the patient, asking him what he wanted ;
to which the leper replied that, having been declared leprous,
he, a citizen of the town (in the present case, Dijon), sought
admission to the hospital, in order to enjoy there the rights ac-
cruing to such admission. The chaplain next came forward, and,
upon his giving the order, the leper placed his bare hand on the
holy books and took the vow of obedience, poverty, and chastity.
Besides this, the chaplain held forth to him a number of
prohibitions, of which the following is the gist : — *
1. I forbid thee to show thyself in the churches, markets,
bakeries, or other places of public assembly.
" Cheruel : ' Historical Dictionary,' Hery's quotation, p. 98, completed
from other sources.
S
258 DR. EDWARD EHLERS ON
2. I forbid thee to wash either thy hands or thy utensils in
the fountains and wells, and, if thou art thirsty, thou must
drink from a special vessel.
3. Thou must always wear a conspicuous garment, to warn
people who do not know thee to flee thy company.*
4. Thou must not touch anything thou desirest to buy, but
point to it by means of a little wand, and, when asking alms,
thou must sound thy rattle.
5. Thou must not enter any tavern or habitation other than
the house where thou livest, and, when thou desirest wine or
meat, it must be brought to thee in the street.
6. When begging in the city, thou must always keep to the
middle of the road and use thy rattle ; if anyone wishes to
speak with thee, or thou desirest to speak to anyone, thou
must place thyself to leeward of the wind, so that thy breath
and thy exhalations may not trouble him.
7. If thou hast to pass along a foot-path or a bridge, or to
climb a barrier, thou must wear gloves.
8. I forbid thee to touch a child, or to give him what thou
hast touched.
9. I forbid thee to eat or drink in the company of any others
than lepers ; and know this, that at thy death, when thy soul
and thy body are separated, thou wilt be interred in thine
own house, unless the establishment accord thee a special
dispensation.
Together with these prohibitions, a notary drew up a legal
document of all the conditions enjoined on the leper, who then
bade the assembly farewell. Then the prior or director took
the unfortunate man by the hand and conducted him into the
hospital.
Arrived at his destination,! the leper could say with the
Psalmist : "This is my rest for ever; here will I dwell; for
I have desired it."
Those who had been present at the ceremony were then
invited to show their compassion and their charity to the
unhappy man ; and his parents, or, failing these, the repre-
sentatives of the Church, had to place themselves at his service
'!^ Even at the present day lepers may not show themselves in Morocco
■unless veiled, mounted on asses, and provided with a little bell. Gemy
and Eaynaud, ' Leprosy in Algeria.' Algiers, 1897, p. 82.
t The end is cited from W. Schmidtz : ' Einfluss d. Eeligion auf das
Leben, etc.,' Freiburg in Breisgau, 1894, p. 109.
DANISH LAZAR-HOUSES. 259
for the next thirty hours at least, in order to help him to
reconcile himself to his solitary life.
Thereupon the people and the priests returned to the
church, and offered the following prayer : —
" Almighty God, who through the patient suffering of Thy
Son hast broken down the pride of the old enemy, grant to
Thy servant such patience as shall enable him to bear with
resignation the ill that has befallen him. Amen."
With regard to the conditions to which the leper had to
submit upon his entrance into theLazar-house, several remarks
may be made.
The clothing that the leper was bound to wear had to be
simple in kind and of dark colour, usually grey or black. In
Switzerland the additional regulation was made that the
lining must not be of a variegated material, and that the
head-covering was to have no vizor.* The wearing of gloves
and the carrying of a wand and a rattle were everywhere
enforced.
However, sometimes other things were used. Thus Lesser,
in his work already cited, page 15, mentions a miniature of
the tenth century, in which a leper carries in a bandolier on
his left shoulder a large hunting-horn. Later on, a little bell
was used, and finally a rattle. In Normandy, what was used
bore the name of Tartavelle. In Denmark,! a prescription of
Christian II., bearing date 1522, exacts (i, 116) that, in order
to be easily recognizable to the passers-by, lepers must carry
a rattle, or wooden clapper, and remain at the gates of the
city, where the public road is much frequented, and that they
must strictly observe the prescribed form about moving or
asking alms.
At the same time this same book (ii. 91, p. 35) speaks of a
wooden clapper, to make a noise ; but this denomination does
not hold good, for the expression wooden clapper is pleonastic :
"^^ In the passage cited by Lesser, p. 18, one reads that in 1511,
Matthew, Bishop of Sion, disguised himself as a leper and crossed the
French camp incognito, finally arriving at Eome, where a cardinal's hat
was the object of his ambition.
f Eesen : ' Christian II.'s Law-book.' Kopenhagen, 1684.
S 2
260 DR. EDWARD EHLERS ON
Kolderup-Eosenvinge rightly translates* Trce-Klaj^j^e (wooden
clapper) rattle.
Having entered his asylum, the leper was regarded as civilly
dead ; he no longer possessed anything; he had left the world,
and had nothing but the temporary use of his personal chattels,
which were even no longer at his own disposal. According to
the French law (Hery), he had lost the right of inheriting ;
capite diminutus ; he might neither challenge to a duel, nor be
challenged, and was outside the law of the world. Those who
wish to inform themselves as to the peculiar position of the
members of a Lazar-house, with regard to the law-courts,
have only to consult Svendborg's first document, of which the
following is the tenour : —
Every offending brother will be liable to a forfeit for the
benefit of the brethren of the hospital.
If he become deserving of capital punishment, his execution
will be in the power of the tribunal of circumscription.
In the districts where there were no special asylums, the
poor leper could be constrained to live in a horde^ or isolated
cabin, which the corporation had made for him, as was the
custom, for instance, in the Faroe Islands. Before the door
a cross was placed, bearing an alms-box, and passers-by were
requested to give of their charity to the maintenance of the
unfortunate inmate. But naturally there are no traces of
official documents or acts relating to such retreats.!
Upon the death of the afflicted person, his habitation was
burnt, and he himself was buried face downwards (Thau,
Normandy). It was in this position, the face to the earthy
that, at a later period, the bodies of lepers were found in
different places ; for, even after their death, these beings
inspired their survivors with horror.
Such lepers, however, as had sufficient means to build a
refuge for themselves, in order to shut themselves up when
smitten with this fell disease, could obtain the necessary
permission, conformably to the regulations of the hospitals
of Sweden ;]: but for this they had to pay forty marks to the
■''■ Old Danish laws, chap. 1. p. 116.
f Hery, p. 64.
\ Hedquist, in the passage already' cited.
DANISH LAZAR-HOUSES. 261
hospital. Once admitted to the hospital, no one could obtain
leave to quit it ultimately, under any pretext whatever. If
the Archbishop Andre Sunesoen, who died in 1228, benefited
by a dispensation of that kind, it is evident that he arrogated
to himself the power to dispense himself, after he was smitten
with leprosy in 1222. Suhm remarks :* " In the parish of
Iffoe (Halland, in Sweden) there was formerly at Hoiigaard a
long-shaped house, with masonic foundations and high roof,
which in 1624 had not yet become dilapidated. This house
was built by the Archbishop Andre Sunesoen, who lived in it
alone."
On the sea-coast may be seen, north of the church, the
spring whence, on a certain Christmas Eve, he ordered his
servant to go and fetch some water, which was immediately
changed into wine.
VI.— KEVENUES OF THE LAZAE-HOUSES.
These revenues were collected in the following manner : —
1. Imposts or regular rates.
2. Donations, especially those called " spiritual sacrifices,"
flowing into the hospitals in the form of legacies.
3. Alms collected in three different ways : —
A. Collections in the district.
B. Boxes and offerings.
C. Indulgences.
4. Property of admitted lepers.
5. Privileges, especially reduction of taxes or exemption
from them.
6. Current receipts (the proceeds of forfeits).
We will examine each of these categories of heterogeneous
revenues in detail.
1. PiEGULAR Taxes.
In many districts the poor-tithe reverted in part to the
hospitals, and, besides this, part of the rates on the moorings.
Further, a letter, bearing date 1440,f informs us that in
=■= * Hist, Denmark,' i. p. 118.
•j- Hedquist.
262 DR. EDWARD EHLERS ON
Sweden it is a long-established custom to come to the aid of
poor people afflicted with leprosy by the hand of God, by
levying on each household (Hionalag) a contribution of four
Swedish penninge. For example, the hospital at Slagelse
received the tithe of more than twenty parishes. At Aarhus,
the domain of St. Catherine received what was called the
hospital oats, or seed corn from seven bailiwicks.
In point of fact, the payment was rarely made in hard cash.
As the reader will see later on, Svendborg's first document
mentions that, among the revenues of the hospital, rents and
tithes were paid in grain, butter, money, cattle (sheep, &c.),
geese, fowls, and meat.
2. Donations.
Most of the hospitals were built by the help of donations,
which, besides, represented one of the principal factors of
their wealth, especially under the form called spiritual sacrifices,
which were bequeathed to them by will. These spiritual sacrifices
flowed in principally in the middle of the fourteenth century,
when the black pest aroused the generosity of the people.
The donations consisted chiefly in lands or money ; the money
was generally invested in land, in order to draw rents there-
from, as one sees from the history of certain Lazar-houses.
Besides this, most of these establishments were occupied with
cattle-breeding and agriculture on a greater or less scale.
The statutes of the hospital at Enkoeping* enjoined upon
patients, who were capable of working, to help during the
summer and autumn in carrying hay and other crops to the
granaries. The inventory of the same hospital, in the year
1407, t has the following entries : — 6 cows, 4 oxen, 1 bull,
8 old sheep, 11 sucking-pigs, 1 old mare, 2 hatchets, 4 sickles,
3 scythes, 1 harrow, 3 hay-rakes, 1 plough, 1 ploughshare, and
1 gridiron.
The estates that were far from the hospital were let out in
farms : a number of contracts for such farms are to hand.
As will be seen later on, the servants of the Svendborg
estate had to work for the hospital. Every good farm had to
^' Hedquist.
f ' Diplomatorium Suecanum,' N. F. i. 880, cited by Hedquist.
DANISH LAZAR-HOUSES. 263
contribute two horses half-yearly, and to supply the mendicant
friars with lodgings and beer, as well as forage for their horses,
when they went round collecting "God's alms." But it was
possible to be exempted from this contribution by the payment
of a " ransom " fee. The said servants were, besides, bound
by oath to work one day for the rye-harvest and two days for
the barley, besides conveying the curators of the hospitals to
the assemblies, &c.
The Lazar-houses at Naestved and Svendborg possessed
forest domains.
3. Alms.
A. Quests in 
