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THE 

BRAD SHAW LECTURE 

ON SOME POINTS IN 
HEREDITY 

Delivered before the Royal College 
oe Surgeons of England on 
December 6th, 1911 

BY 

E. CLEMENT LUCAS, B.S., M.B.Lond., F.R.C.S. 

CONSULTING SURGEON TO GUY'S HOSPITAL, AND TO THE EVELINA HOSPITAL FOR 
CHILDREN j MEMBER OF THE COUNCIL AND RECENTLY VICE-PRESIDENT OF THE 
ROYAL COLLEGE OF SURGEONS OF ENGLAND ; MEMBER OF THE SOCIETE DE 
CHIRURGIE OF PARIS; FELLOW, AND MEMBER OF THE COUNCIL, OF 
THE ROYAL SOCIETY OF MEDICINE; FORMERLY LECTURER 
ON SURGERY AND ON ANATOMY IN THE MEDICAL 
SCHOOL OF GUY'S HOSPITAL 



$oniiou 

ADLARD AND SON, BARTHOLOMEW PRESS 
BARTHOLOMEW CLOSE, E.C. 

1912 



TO THE MEMORY OF A DEAR FRIEND 

WALTER MOXON, M.D., F.R.C.P. 

PHYSICIAN TO GUY'S HOSPITAL 

WHO RKCEIVED ME INTO HIS HOUSE WHEN I FIRST COMMENCED MY 
PROFESSIONAL STUDIES, AND WHO TAUGHT ME TO CULTIVATE 
THE FACULTY OF EXACT OBSERVATION BOTH IN 
ANATOMY AND CLINICAL RESEARCH 

THIS LECTUEE IS DEDICATED 

IN GRATITUDE 

BY THE AUTHOE 



* 



THE BKADSHAW LECTURE 



Mr. President and Gentlemen, — There is, 
perhaps, nothing more remarkable in comparing 
the teaching of former years with that of the 
present day, than to note the gradual recession 
and disuse of the word diathesis, as the true 
microbic cause of disease after disease becomes 
unravelled. 

Criticism of Diathesis. 

This word was used to indicate a constitutional 
condition derived from the parents, rendering a 
person liable to a particular disease — a disease 
developed from the tissues conveyed to him by 
his parentage. Lecturers spent many hours in 
elaborating details of such diatheses as the 
strumous, cancerous, syphilitic, gouty, rheu- 
matic, nervous, plethoric, lymphatic, and so on. 
But after a time it became evident that the types 
described as characteristic were those in which a 
particular disease or habit had already com- 



6 



THE BRADSHAW LECTURE 



menced its work. And now they have passed 
away like a dream, from which the slumberer 
awakes to enter into new realms of thought. Yet 
great was their influence, and mighty were the 
struggles made by observers to force their irrer 
gular cases under the unsympathetic wings of 
some particular diathesis. 

The Gouty Diathesis. 

Of these, the gouty is almost the last survivor, 
bolstered up by its aristocratic relations, and even 
more by the parvenu's wealth, waiting, as I 
believe, only for the discovery of a particular 
ferment which causes the precipitation of sodium 
urate in the most used joint of an overfed and 
perhaps bibulous person. 

In this relation it may be interesting to quote 
Professor Laycock's account of the diathesis of 
the revered founder of this great museum. The 
Professor of Medicine of Edinburgh thus describes 
his brother Scot : 

John Hunter was of the strumous arthritic diathesis with 
.a nervous element also. [A little mixed you will observe.] 
His florid complexion indicated the vascular element, while 
his rounded forehead, thickened alse nasi, thick upper lip, and 
caries teeth in the upper jaw marked the strumous ten- 
dency. 



THE BltADSHAW LECTUEE 



He then proceeds to account for these hereditary- 
defects : 

John Hunter, it is clear, owed his strumous arthritic dia- 
thesis to the circumstance that his father was in his seventieth 
year when John was conceived and had at least one of the 
diseases of the gouty habit, namely, " gravel." 

He sums up : 

He was a typical man of his diathesis ; with a predisposi- 
tion to tuberculosis and atheroma, he, nevertheless, from the 
vigorous nutrition of his nervous system, was capable of great 
mental labour.* 

Such is the libellous description given of the 
greatest surgeon of his day.f 

Tuberculosis. 

Of diseases believed to be hereditary, the con- 
stitutional origin of none was taught with more 
dogmatic certainty than tuberculosis before the 
discovery of Koch's bacillus; and even now, 
though the various modes of entry and the 

* ' Medical Times and Gazette,' vol. i, 1862. 

t The ai-thritic diathesis has been deprived of acute rheumatism 
by the discovery of the Diplococcus rheumaticus, and if Mr. 
Goadby's observations prove correct as to a bacillus connected 
witli tooth-sockets (published in ' The Lancet ' of March 11th, 
1911) being the cause of osteoarthritis, the diathesis will be still 
further depleted. 



8 



THE BBADSHAW LECTURE 



manner of its distribution have long been studied, 
it is difficult to disentangle men's thoughts from 
this erroneous teaching. So deeply was this view 
of its constitutional origin instilled in the minds 
of the profession that acute observers shut their 
eyes to the most obvious cases of infection ; yet 
there must have been some sceptics even in those 
days of darkness, for I find the late Sir Samuel 
Wilks writing in the ' Guy's Hospital Reports,' 
for 1869 as follows :* 

It does appear most remarkable that whilst many of us 
have been speaking in the most positive terms of the inherited 
causes of consumption, there have been those who have no 
hesitation in looking upon it as. a disease, like smallpox, 
accidentally introduced from without. 

These believers in an outside cause were at that 
time in a hopeless minority. The great text-book 
authority, Sir Thomas "Watson, thundered out his 
opinion as follows : 

Is phthisis contagious ? No, I verily believe it is not. A 
diathesis is not communicable from person to person ; nor is 
the disease ever imparted to another, even by one scrofulous 
individual to another. 

He then proceeds to explain away a most obvious 
instance of infection : 

* " On the Nature and Causes of Disease," ' Guy's Hospital 
Reports,' 1869, p. 19. 



TEE BRADSHAW LECTURE 



9 



A wife watches the deathbed of her consumptive husband, 
and presently sinks herself under consumption; and there 
may be no tubercle or acknowledged examples of scrofula in 
her pedigree. Yet even here the latent diathesis may fairly 
be presumed to have existed. Very few families are perfectly 
free from strumous intermixture. 

Could the blinding effect of a predominant 
theory be more clearly exposed than by this 
explanation ? 

There is no such thing as hereditary tuberculosis. 
We are dealing with a disease both infectious and 
inoculable, the bacillus of which has been known 
for thirty years. During that period better hygiene, 
housing, and food have reduced the mortality due 
to tuberculosis from 25 to 10 in every 1000. By 
complete segregation the disease could be as 
certainly stamped out as hydrophobia was by the 
courageous muzzling order of Mr. Walter Long, 
to whom all honour is due. Of what service is it 
to inquire whether one family is more liable than 
another to this disease, when all are liable, and 
97 per cent, of 500 consecutive autopsies were 
found by Naegeli to show evidence that tuber- 
cular infection had at one time taken place. 
Statistics to prove an hereditary predisposition 
are useless, unless taken of persons removed 
immediately after birth from the tubercle-infected 



THE BBADSHAW LECTURE 



house, and from contact with relatives already 
infected. 

Syphilis. 

Another diathesis we were taught was the 
syphilitic, but we know now that there is no 
such thing as hereditary syphilis. This is an 
inoculable disease, the organism causing which 
was discovered by Schaudinn in 1905, and it may 
be transmitted through the mother to her child 
when the placental protection breaks down, but 
there is no reliable evidence of its ever havino- 
been carried on to a third generation. It is a 
disease distributed by folly and reaped by 
innocence, and those well-meaning people who 
discovered in this disease a Divine scourge to be 
carried on to the third and fourth generations 
must be disappointed by its limits. The moment 
the Spirochseta pallida was demonstrated, it 
became evident that as the greater could not be 
carried by the less, direct transmission from the 
male to the ovum was out of court. The mother 
must first be infected, though the disease may not 
have been noticed, and Colles's law, which states 
that a mother cannot be inoculated on the nipple 
by her syphilitic infant, receives additional sup- 
port by this discovery. It also emphasises the 



THE BRADSHAW LECTURE 



11 



importance of directing attention especially to 
the treatment of the mother in order that the 
children may be born free from the disease. 

Leprosy. 

Of diseases assumed to be hereditary none has 
carried this reputation through a longer period 
than leprosy, which was regarded as hereditary 
as far back as Biblical times ; and this belief will 
be kept in remembrance by Elisha's curse on his 
servant Gehazi : " The leprosy, therefore, of 
Naaman shall cleave unto thee, and unto thy seed 
for ever." Its contagiousness was also recognised 
from the earliest tiities, so that lepers became 
outcasts, and segregation has for centuries been 
the means employed to prevent the spread of the 
disease. Hansen discovered the Bacillus leprae in 
1871. An Indian commission failed to trace 
histories of the disease in the families of more 
than 5 or G per cent. ; children born of leprous 
parents are not leprous, and if removed from their 
parents seldom become so. This, again, is a 
disease which has been placed among ordinary 
contagious diseases, as the result of modern dis- 
coveries, and the belief in its hereditary trans- 
mission which held sway for tens of centuries has 
been scattered to the winds. 



12 



THE BRADSHAW LECTURE 



Malaria. 

Not many years ago malaria was described as 
a climatic diathesis, by which it was intended 
to imply that a constitutional condition was 
brought about by residence in certain climates, 
and that it became hereditary. The protozoon of 
malaria was discovered by Laveran in 1880, and 
its life history and mode of inoculation has since 
been so clearly demonstrated that any idea of its 
being associated with a diathesis would strike 
everyone now as being utterly absurd. 

Cancer. 

The diathesis of cancer was never asserted 
with the same absolute confidence as was that of 
tuberculosis, and the profession has been about 
equally divided as to whether it was an hereditary 
disease or not. Sir James Paget taught that it 
was a blood disease, which caused local manifesta- 
tions, but the evidence of its commencement as a 
local disease is now overwhelming. John Birkett, 
at one time a great authority, going over his 
cases, found cancer more common in families 
without history of cancer than in those families 
in which there was a history of the disease, and 
Paget could only trace a family history in one 



THE BRADSHAW LECTURE 13 

in three of his private patients, and one in five or 
six among hospital patients; whilst Harrison 
Cripps, thirty -three years ago, showed that if the 
evidence of heredity derived from collaterals and 
doubtful cases were excluded, there remained 
only a number similar to that expressing the 
normal frequency of cancer to the whole popula- 
tion. Dr. Bashford states that among persons 
over the age of thirty-five the chance that a 
man will die of cancer is one in eleven, and of 
a woman above the same age one in eight ; 
and so great is the frequency of cancer as a 
cause of death above that age, that in one of 
every two families a parent or a grandparent 
will, on an average, have died of cancer. The 
influence of heredity in man must therefore be 
regarded as insignificant. It is true that by 
careful selection and in-breeding Dr. Bashford 
has produced a race of mice more liable to 
spontaneous cancer than those of a sound stock, 
but he warns us that experiment shows that 
those of cancerous stock are not more liable to 
implanted cancer than others. 

To my mind we arrived half-way to the dis- 
covery of the cause of cancer when it was shown 
that the disease was inoculable in animals of the 
same species. We are dealing with a mildly con- 



14 THE BRADSHAW LECTURE 

tagious disease slowed down by age. This conceded, 
many observations fall readily into line. Thus 
Sir Henry Butlin's cases indicating that the 
instances on which heredity was based were all 
on either the father's or on the mother's side, 
would admit of the explanation that these indi- 
viduals were more intimately associated, and so 
more liable to contagion. It explains the occur- 
rence of several instances in the same house. It 
explains also the death of husband and wife of 
the same disease, of which I will mention three 
instances. A lady was operated on for cancer 
of the uterus, subsequently her husband died 
of cancer of the liver, and later she died of 
recurrence of the original disease. A gentleman 
I frequently meet in the City is one of six sons, 
all living and healthy, whose ages range between 
fifty-three and sevent}^. His father died at the 
age of fifty-seven from cancer of the rectum, his 
mother at sixty-one of cancer of the breast. He 
had one sister, who lived with her parents, and 
attended them in their last illnesses. She died 
of cancer of the breast, and what makes the 
probability of contagion stronger is the fact 
that the nurse also developed cancer, and died 
from it. 

I operated on a lady in 1898 with so extensive 



THE BRAD SHAW LECTURE 



15 



a recurrence in the axilla that I removed both 
axillary artery and vein in dissecting out the 
growth. The wound healed primarily and she 
had no recurrence ; but five years later she died 
of acute ptomaine poisoning from eating potted 
meat at a ball supper. A post-mortem examina- 
tion showed no evidence of cancer anywhere, but 
there was extensive ulcerative colitis. Her 
husband subsequently died of cancer of the 
rectum. 

The tendency of modern workers is to regard 
the cancer-cell, produced by irritation, as the fons 
et origo mali, and this has recently been very 
forcibly put by Sir Henry Butlin, but I am loth 
to accept such a hopeless hypothesis, as there is 
nothing analogous to it in the whole field of 
medicine. The forces of Nature are always 
directed to safeguarding the individual against 
attacks from without which may weaken health or 
endanger life. To produce a cell which wars 
against its parent and brings about self-destruc- 
tion is contrary to every law of Nature. 

If chronic irritation were alone sufficient to 
produce cancer millions of people who wear boots 
ought to have cancer of the little toe, which is 
practically unknown. It is chronic irritation, 
plus abrasion, that is required — in other words a 



16 



THE BKADSHAW LECTURE 



surface through which a pathogenetic organism 
may find its entrance. Then the abrasion of the 
middle-aged woman's plump breast by the upper 
edge of her corset, the eczema of the nipple, the 
clay pipe sore of the lower lip, the tooth ulcer of 
cheek or tongue, the syphilitic and smoker's sores 
of the tongue, the chimney-sweep's sores of the 
scrotum, the burns caused on the Kashmiri's 
abdomin'a by the wearing of charcoal ovens, the 
chronic ulcers which become malignant, the X-ray 
eczema leading to epithelioma, are only means of 
entry for an organism yet to be discovered. 

A Question in Eugenics. 

I pass now from my destructive criticism of what 
were formerly believed to be diathetic diseases, 
but have been proved to be due to organisms 
penetrating from without, to make a few remarks 
on diseases of the nervous system with the object 
of alluding to a question in eugenics. Those who 
study mental diseases would have us believe that 
nothing is more certain than the hereditary 
tendency to the reproduction of nervous diseases, 
nor anything more disastrous than the results of 
in-breeding of tainted stocks. When criminals 
repeat their kind, and recurrent forms of lunacy 



THE BEADSHAW LECTURE 



17 



occur, with lucid intervals, in which children are 
conceived only to be a burden on the rates, the 
State may perhaps determine to interfere to pro- 
tect itself in the future. 

By the kindness of Dr. Mott I show two 
pedigrees indicating the classes among which 
State interference might be considered justifiable. 

Admitted to Cane Hill for 
attempted suicide by poison ; 
Patient IV 



An epileptic ; attempted 
suicide in 1874 by cutting 
her left arm ; was taken 
to Colney Hatch, where 
she still remains 



Mother III 



Father sane 



Committed sui- 
cide by cutting Father II 
his left arm 
and dying from 
haemorrhage. 



Mother died insane 




Four children (three males 
and one female) • all con- Mother died 
fined in lunatic asylums insane 



Father I Mother committed suicide ; cut her 
left arm and died from haemorrhage 

One of these shows suicide in four generations 

2 



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BEADS HAW LUCTUKE 



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THti BRADS HAW LECTURE 



19 



and all the offspring were lunatics. The other is 
the pedigree of a man subject to recurrent lunacy, 
who when out of the asylum continued to increase 
his family. Altogether he had eight children, five 
of whom were confined in asylums (see pedigrees, 
pp. 17 and 18). 

I do not suppose for a moment that in a 
country such as this, where emotion plays so 
prominent a part in politics, that any opera- 
tive measures such as have been adopted in one 
of the States of America would find favour. But 
political ideas gradually change. The " liberty 
of the individual " which was for a generation a 
great party cry has passed into oblivion, and we 
have in its place the political maxim that the 
minority must yield in everything to the wall of 
the majority. This would therefore seem to be a 
favourable time for medical men to press on the 
Government measures for the protection of the 
State against the gradual increase of lunacy, and 
especially of criminal lunacy. 

In this relation I would remark that the 
germinal organs (testes and ovaries) do not 
actually belong to the individual, but to the next 
generation. As soon as they have determined 
his adult form they cease to be of service in his 
economy; and at times prove of great incon- 



20 THE BEADSHAW LECTUIIF, 

*■ 

venience, being not infrequently a cause of disease 
and of death. They are given him on trust for 
his descendants, and so badly does he often per- 
form the duties of trustee that the blackest of 
bubble company promoters may appear innocent 
by comparison. If this view be accepted, and I 
maintain it is true in every respect, there should be 
less hesitation in employing humane and reason- 
able means for protecting the race. Within the 
last few years, and quite by accident, it has been 
discovered that exposure to the X rays destroys 
the reproductive function of the generative organs 
without injury to the individual. We have, there- 
fore, a humane method at our command, which is 
not only painless, but so insidious that it might, if 
necessary, be applied without the knowledge of 
the individual. It probably would also be of 
service to him in assisting him to maintain his 
mental stability in after years. 

I now leave this somewhat uninviting subject 
to say a few words on twins, on whom I have a 
few observations to record. 

Twins. 

The liability to the production of twins can, I 
think, be shown to be hereditary. It may be due 
to an excessive fecundity on the part of the 



THE BEADSHAW LECTURE 



21 



female, or it may be caused by a tendency to the 
division of a fertilised ovum, which tendency may 
be transmitted either by the male or female 
parent. Mr. Rooth, in describing his case of 
.Brighton united twins, gives the following family 
history : 

The grandmother of the children had four separate births 
of twins as well as other children, and was herself a twin. 
The mother of these children was one of these twins* 

That is, be records four generations of twins on 
the female side. 

The following case, as indicating the influence 
of the male parent, I give on the authority of 
Dr. Wormell, formerly headmaster of the Cowper 
Street Schools : An intimate friend and neighbour 
married, and his wife on two occasions gave birth 
to twins. After the second birth the wife died. 
Subsequently the gentleman married again, and 
his second wife gave birth to twins. In all these 
cases each pair of twins was of the same sex. 

Among domesticated animals twins are encour- 
aged in sheep, because the greater the number of 
lambs the greater the profit as mutton, so ewes 
which throw habitually only one lamb are weeded 
out of a flock. On the other hand, among cows 
the profit is from the milk, and a cow that gives 

* ' Brit. Med. Journ.,' September 23rd, 1911, p. 654. 



22 



THIS JBEADSHAW LECTURE 



birth to twins falls into disgrace and is fatted and 
killed for beef, because the farmer sells the milk 
which is in excess of what is required for the 
calf. Twin calves are therefore very rare. 
Breeders also recognise the male influence, and 
if many ewes throw single lambs as the result 
of conception to a particular ram, that ram is 
discarded. 

Dissimilar and. Identical Twins. 

There are two forms of twins generally recog- 
nised. In one there has been a simultaneous, or 
nearly simultaneous, fertilisation of two ova, an 
ovum descending probably from each ovary at 
the' same menstrual period. Such twins may 
differ in sex, in height, in appearance and in dis- 
position, presenting only the general resemblance 
of brothers and sisters. The other form is 
believed to result from the division of an ovum 
after all the elements for development are complel e. 
These are invariably of the same sex and are 
enclosed in the same membranes. In height, 
appearance, and character they so closely resemble 
each other as to be often spoken of as " identical " 
twins. Shakespeare in "Twelfth Night" was 
guilty of confusing the first form with the second, 
when he founded the plot of his play on the 



THE BRAD SHAW LECTURE 



23 



resemblance betwen Sebastian and Viola as if they 
were identical twins. 

Identical Twins. 
I am able to give some remarkable facts con- 
cerning identical twins who entered as medical 
students at the same elate and passed the examina- 
tions of the Royal Colleges and those of the M.B. 
and B.S.(Lond.) at the same time. After the 
Intermediate M.B. list was published, I was able 
to find out their numbers, and by what some 
might consider a curious coincidence, the totals of 
a large number of marks in anatomy given for 
two papers, dissections, and two tables of viva 
voce examination proved to be identical. 

Identical Twins. 



Intermediate M.B. Examination in Anatomy. 





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Soft parts, 
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Total, 
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Passed. 


Xa 


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85 


65 


35 


75 


405 


2nd D. 


Xb 


140 


110 


45 


35 


75 


405 


2nd D. 



Taken alone, too much stress must not be laid 
upon the fact that their marks totalled the same, 



THE BR AD SHAW LECTURE 



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THB BBADSHAW LEOTDRE 



25 



as anions 1 a large number of candidates this is. sure 
to happen occasionally. But the. table on p. 24 
signed • bv seventeen different teachers, signing 
altogether thirty-three' times for each student, 
shows a uniformity which could not be the result 
of accident. Out of all these sixty-six signatures, 
there is but one variation. One teacher put 
" excellent " instead of " very good indeed," terms 
regarded at the hospital as equivalent. In the 
opinion, therefore, of seventeen teachers, the 
abilities of these twins were indistinguishable or 
identical.* 

Dissimilar Twins. 

The difference between twins developed from 
fertilisation of separate ova may be emphasised 
by disease occurring in one whilst the other 
escapes. Dr. R. Hutchison exhibited at the 
Children's Section of the Royal Society of Medicine 
twin brother and sister, aged a year and a half, the 
girl being the subject of well-marked achondro- 
plasia whilst the boy was healthy. 

A photograph of these he has kindly allowed 
me to reproduce (see Fig. 1, p. 26). 

By the kindness of Dr. Shuttleworth I am also 
able to show a photograph of twin patients of Dr. 

* For another case of identical twins see Appendix. 



THE BRADSHAW LECTUKE 



27 



A. JefErys Wood, of Melbourne, by which it will be 
seen that the boy is normal and intelligent while 
the girl is a Mongoloid idiot (see Fig 2, p. 26). 
A third case, lent me by Dr. Hutchison, makes 



Fig. 3. 




Twins — one a cretin. 



the contrast still more evident, the boy being 
bright and intelligent, whilst the girl is a cretin 
showing a Mongoloid fold (see Fig. 3). 

It is interesting to note that in all these three 



28 



THE BRADSHAW LECTURE 



cases, the girl is the one that shows the defect, 
whilst the boy escapes. 

From these cases it will be seen that neither in 
sex }> mental development, nor tendency to disease 
need there be any resemblance. These are known 
as dissimilar twins. 

Modkbx Views on Heredity. 

It is almost impossible to allude to the various 
defects and deformities, known to be hereditary, 
without referring to the two modern schools of 
research, the Menclelian and Galtonian or bio- 
metrical school, each of which is doing excellent 
work in its own sphere, but can see no virtue 
whatever in the work of the other. To those 
trained in biology, the Mendelian researches offer 
a fascinating inducement to further study, and 
appear to give a rational explanation of the 
occurrence of variations which breed true. But 
the precision that Mendel was able to give to his 
researches by crossing peas, so that lie was able 
accurately to predict numerical results, can never 
occur among human beings, since such close in- 
breeding and back-breeding never occur in any 
human community. It is, nevertheless, much to 
anticipate approximate results. 

The study of Mendelism is essentially a study 



THE BRADSHAW LECTURE. 



29 



of cross-breeding : yet when in the human race 
a negro unites with a white, the result is a half- 
caste or mulatto. So also when a European 
unites with an Indian, the result is a Eurasian. 
Mulattoes united in marriage should, according to 
Mendelian law, segregate out into pure blacks, 
pure whites, and intermediates, but they do not ; 
they continue to produce mulattoes, and Eurasians 
continue to produce Eurasians. 

The G-altonian or biometrical school rely upon 
a statistical method of investigation. By collec- 
ting a large number of measurements or observa- 
tions they gain material from which to deduce 
laws of heredity. G-alton began by taking height, 
and maintained that what was true of one quality 
would probably prove true of all. His statement 
that half the heritage of a child is derived from 
his two parents, one quarter from the four grand- 
parents, and one sixteenth from the great-grand- 
parents, is so well known that I only mention it 
in passing. Professor Karl Pearson, repeating 
these observations, did not find the progression so 
regular, but the main results were not very dis- 
similar. Much has been done in this school since 
those early days, and the probabilities of many 
qualities have been worked out. 

It will be gathered from my critical remarks 



dU THE BLiADSHAW LECTURE 

on the old diatheses that I greatly dread the 
effect of a predominant theory; for if we arc 
impressed by its truth, we are too liable uncon- 
sciously to accept what tallies with it,, and reject 
that with which it does not agree. How other- 
wise could such giants in observation have made 
such extraordinary and obvious mistakes in the 
past ? 

A Pedigree oe Thirty Years Ago. 

It may be interesting now to show a pedigree 
that I buried in the c Guy's Hospital Reports ' just 
thirty years ago, because its publication was long- 
before the modern schools of heredity came into 
existence. I will leave it to you to judge whether 
it does or does not agree with the views of modern 
investigators. It is a pedigree of supernumerary 
digits associated with two other deformities, 
webbing of fingers and toes, and an occasional 
development of cleft palate. I can vouch that 
every possible care was taken to make it accurate, 
and where there was any doubt as to sex a 
neutral cross was used throughout the family. 
The man who furnished it was also of exceptional 
intelligence and he traced the deformity for us 
through five generations. It illustrates further 



THE BHADSHAW LTSCTUKR 



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o 
UJ 

o 
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Q: 

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rO-K5 



ft 
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*4 



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c 

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4+ 0+ 



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32 



THE BRADSHAW LECTURE 



three points to which I wish to draw particular 
attention : first, the extraordinary tenacity with 
which a deformity once developed clings to the 
stock in spite of admixture of new blood in each 
generation : secondly, the frequent association of 
altogether different deformities in the same 
individual ; and thirdly, the gradual increase of a 
deformity in succeeding generations, which I 
intend more fully to enter into presently. 

These deformities were transmitted without 
regard to sex, and it will be noted that in two 
instances, where the deformity in the mother was 
an extra finger on each hand, the children that 
were deformed had extra toes on each foot and no 
deformity of the hands. Altogether, the great- 
great-grandmother had eighty descendants, of 
whom twenty-four, or 30 per cent., were deformed 
(see pedigree, p. 31). Supernumerary digits are 
said to have been reproduced after amputation. 
Darwin gives three instances in which this oc- 
curred, and explained the recurrence as due to 
" reversion to an enormously remote, lowly organ- 
ised, and multidigitate progenitor." The associa- 
tion of webbing of the fingers and toes with 
supernumerary digits appears to support the cor- 
rectness of this view, and to suggest reversion to 
some highly remote amphibious ancestor. 



THE BRAD SHAW LECTURE 



Tenacity op Development op Defoempit. 

With regard to tlie first point, the tenacity 
with which a defect or deformity once developed 
persistently clings to a stock, and is repeated 
generation after generation, in spite of new blood 
being infused, there are pedigrees innumerable 
now to prove. Cannot a defect ever be washed 
out in its early beginnings by normal blood ? My 
own small studies in search of hidden deformities 
appear to show their tendency is rather to increase 
than decline. The normal appears powerless to 
overcome the abnormal, or, as the Mendelians 
say, the deformity is dominant, and the normal 
recessive. The pedigrees of spade hands or 
brachydactyly recorded by Farabee and Drink- 
water are claimed as clearly illustrating these 
features, the abnormal only giving origin to ab- 
normals and the recessive normals yielding only 
normals. Nettleship's pedigree of congenital 
cataract is also claimed as following this law, but 
in some cases the defect was apparently trans- 
mitted through a normal. In future the closest 
attention should be applied to those exceptions, 
as from them new facts will probably be gathered. 
The best illustration we have of tenacity of descent 
of an abnormal condition is Cunier's ten genera- 
tions of night-blindness. The descent appears to 

3 



0 * THE BRADSHAW LECTURE 

have been always carried on by an abnormal ; but 
the numbers of normal and abnormal, which should 
be about equal, according to Mendel's law, when 
an abnormal unites with a normal, shows a great 
excess of normals above the Menclelian anticipa- 
tion. 

Multiple Abnormalities. 

The frequent association of different abnormal- 
ities, apparently quite unconnected, in the same 
individual, is another point deserving close atten- 
tion and careful study. It would seem that the 
developmental process having once started in an 
abnormal direction may fail in its complex details 
at many points. Mr. Jackson Clarke published 
a case of clubbed hand due to absence of the 
radius associated with macrostoma in the first 
volume of the ' Reports of the Society for the 
Study of Disease in Children.' In the same 
volume the late Dr. Greorge Carpenter published 
an account of two sisters, each of whom had a 
keel-shaped skull, congenital heart disease, ventral 
ruptures, webbed fingers, and six toes on each 
foot, and was also mentally weak. The mother 
was strong and healthy, and showed no deformity ; 
but a cousin, the child of a maternal uncle, had 
deformed hands. In the second volume Dr. 



THE BEADSHAW LECTURE 



35 



Hutchison and Dr. Sutherland published the 
cases of two unrelated boys presenting exactly 
the same deformities in association, viz. : (1) 
Congenital heart disease, (2) a rudimentary hare- 
lip, (3) six digits on each hand, (4) shortening 
of the long bones of the extremities, and (5) 
defective development of the gums. Many other 
similar cases of multiple deformities might easily 
be added; but I have mentioned sufficient, I 
hope, to stimulate research into the origin of this 
failure of control of the developmental process in 
so many directions. 



grradual increase of deformities in succeeding 

Generations.. 

The last point to which I desire to draw 
particular attention is the origin of deformities 
from small, easily overlooked, beginnings. I feel 
sure a search for these will add much to our 
knowledge, and it maybe possible, by recognising 
the forerunners, to prevent the development of 
the graver deformities. Among minor deformities 
the crooked little finger, which can easily be 
shown to be tenaciously hereditary, has been 
treated almost with scorn by Mendelians. Pro- 
fessor Bateson writes : 



36 



THE BRADSIIAW LECTDBE 



This peculiarity may descend both through the affected 
and through the unaffected, but the affection, I believe, is 
like that seen in chickens, whose feet may be deformed 
through weakness. . . . Pedigrees of such peculiarities 
cannot be expected to give results of much positive value. 

I take a diametrically opposite view and regard 
these minor deformities as those from which most 
will be gathered in the future, regardless of 
whether they conform to theory or not. 

Weismann's Theory. 
Several families in which this defect dwells I 
have kept in view for years, and finding it prac- 
tically confined to the middle and upper classes 
I used to teach, before Weismann's theory swept 
the field of Lamarckism, that it was probably 
brought about by generations of cramping of the 
little finger in writing and by gloving. The 
adhesion between the little and ring finger I 
thought might have been brought about in the 
same way. But "Weismann has come and gone 
with his theory of the complete independence of 
germ-plasm and body-plasm, so that the effect of 
environment, use or disuse, upon any part of the 
body is not reflected, according to his theory, in 
the germ-plasm, and consequently not hereditary. 
His theory failed to account for the reproduction 
of lost parts, such as the salamander's tail, which 



THE BEADSHAW LECTUBB 



37 



is said to have been reproduced as many as ten 
times after amputation, and he was obliged to 
admit that certain influences, such as lack of 
nourishment, might influence and modify the 
germ-plasm which he regarded as continuous. 
His theory led to a discovery of inestimable value 
— the finding of the chromosomes of the nucleus, 
their reduction to half their normal number, and 
the restoration to the normal number on fertilisa- 
tion, half being supplied by the germ- and half by 
the sperm-cell. But his theory has probably 
swung the pendulum of thought too much in one 
direction, and though it may be true that body- 
influences of a few generations are not evident in 
the offspring, when we are dealing with hundreds, 
thousands, or millions of generations the effects 
of use and disuse seem to me scarcely to be 
denied. Perhaps no better illustration can be 
given than the gradual changes that are taking 
place in the human foot. It is twenty-three years 
ago that in a lecture on anatomy I pointed out 
that the gradual disappearance of the little toe 
was getting ahead of the text-books, for whilst it 
had already lost one of its extensor tendons, in 
quite an appreciable percentage of cases one of 
its flexor tendons was absent also. These at best, 
like its bones, are diminutive and useless, and its 



38 



THE BRAD SHAW LECTURE 



joints are commonly ankylosed. On the other 
hand, the great toe has undergone extraordinary 
development, because the inner side of the foot is 
the first to catch the centre of gravity in trans- 
ferring the weight of the body from one foot to 
the other in walking ; and I ventured to predict 
that if the world went on long enough, in perhaps 
half a million of years, as the useless outer toes 
being less and less employed gradually dis- 
appeared, man might become a one-toed race. 

Pig. 4. 




Da u.gh ter 



From this digression into which allusion to 
Wiesmann's theory has tempted me, I return to 



THE BRADSHAW LEOTCRE 



39 



the crooked little fingers and I throw on the screen 
a sketch showing the gradual increase of this 
defect in three generations. It is highly probable 
that Nature throws out warning signals of clanger 
in the early stages of many hereditary deformities 
which maybe discovered if a careful search be made 
for minor defects among the immediate ancestors. 

Relation of the Absence of, or a Defective, Lateral 
Incisor Tooth to Hare-lip and Cleft Palate in 
Later Generation. 
I have only worked this out in the relation 
of the lateral incisor tooth to hare-lip and cleft 
palate, but I refer to it in order to stimulate 
younger observers to turn their attention to this 
important study, and I have one further observa- 
tion as yet unpublished. My attention was first 
drawn to it by observing that a gentleman who, 
as a boy, was noticed to have an absence of the 
left lateral incisor tooth,, had an only daughter 
who presented precisely the same defect on the 
same side. As this only child has never married 
there was no chance of proving the relation to 
hare-lip and cleft palate in that family. It proved, 
however, that the defect could be transmitted, 
and that the transmission might be through, the 
opposite sex. Next, an infant Avas brought 
among my out-patients suffering from hare-lip on 



40 



THE BRADSHAW LECTURE 



the right side. This was the fifth child of a 
mother aged twenty-five years. The mother's lip 
was perfect but she had an absence of the lateral 
incisor tooth of the right side which had never 
been extracted and was known never to have 
developed. The third case was the first child of 
a delicate woman, aged twenty-three years. The 
mother had absence of the left lateral incisor, which 
she was certain had never been extracted; her 
infant had left-sided hare-lip and completely 
cleft palate.* 

Further observations led to the discoverv that 

t/ 

Fig. 5. 




Mcmth of mother showing- small right upper lateral incisor 
tooth and scar of hare-lip. Her child had right side hare-lip 
and completely cleft palate. 

an ill-developed lateral incisor tooih might fore- 
tell hare-lip and cleft palate in the offspring. A 

* ' Clin. Soc. Trans.,' 1888, p. U. 



THE UK ADS H AAV LEOI'UIIE 41 



mother who showed the scar of a hare-lip on the 

Fig. 0. 




Mother with a defective lateral incisor on left side. First child had 
left side hare-lip extending into the nostril. 



right side but no defect of alveolus or palate was 



42 



THE BRADSHAW LECTURE 



found to have an ill-developed lateral incisor on 
the right side. Her first child had an extreme 
deformity of hare-lip and cleft palate extending 
from the right side (see Fig. 5, p. 40). The next 
case was the first child of young parents who was 
brought for operation on a hare-lip on the left 
side extending into the nostril. The mother was 
a nice-looking woman and showed no defect in her 
lip, but on the left side her lateral incisor tooth 
presented a remarkably defective development. 
It will be noted that the defect in the child is 
invariably on the same side as the defect in the 
mother (see Fig. 6, p. 41).* 

My last observation is on a young man who was 
operated on for hare-lip on the right side in infancy. 
On examining his teeth I found that the prospec- 
tive division of the palate which did not proceed, 
or perhaps I ought to say lack of union, had 
divided his lateral incisor opposite the cleft into 
two separate small teeth (see Fig. 7, p. 43). 

* 'Reports of the Society for the Study of Disease in Children/ 
L903, p. 31. 



THE BRAD SHAW LECTURE 



43 



Fig. 7. 




outh, aged seventeen years, with right side hare-lip united 
by operation, showing- lateral incisor split into two peo-o-ed 
teeth opposite the scar. The palate was normal. 



44 



THE BUADSHAW LECTUEE 



ADDENDUM. 

The Results of the Assumption of the Beect 

Position. 

The necessity of curtailing much that I had 
intended to allude to in order to bring- the material 
within the limits of the allotted hour, prevented 
me from dwelling on those changes dependent on 
evolution and the assumption by man of the erect 
position which have long been a favourite study. 
I referred to the alterations that have taken place, 
and are still going on, in the human foot, merely 
to show that Lamarckism, which recognises the 
effects of prolonged use or disuse through many 
generations, offers yet the best explanation 
of such gradual changes ; for it could scarcely 
be contended that natural selection and the 
survival of the fittest would alone or together 
account for these alterations in structure. The 
quadruminuous hind-hand when placed on its 
palmar surface for walking would find the ab- 
ducted thumb (ad ducted in this position) too near 
the line of body gravity for safety against over- 
weight and consequent dislocation. It there- 
fore approached the forefinger for support, audits 
enormous metacarpal (becoming metatarsal) bone, 
in its growth, pushed up the web to the level of 



THE BIIADSHAW LECTURE 



45 



the other toes. The race for length has but 
recently been decided in favour of the great toe, 
for old sculptures show the second and third toes 
to be longer ; and the great toe has been handi- 
capped by having only two phalanges instead of 
three to grow from. Concurrently the carpal 
bones became changed and enormously strength- 
ened to bear weight, the heel being thrust back 
and the metatarsal bones lengthened for better 
leverage, but the four outer toes, no longer of 
service in prehension and of little use as weight- 
carriers, diminish relatively to the rest of the foot 
and the little toe falls away relatively to the others. 
Only the base of its metatarsal bone is retained 
and specially developed for the attachment of two 
of the peronei muscles which serve to help balance 
the body on the foot. The fibula or ulna, pushed 
aside by the radius or tibia and allowed no share 
in weight carrying, is retained only for muscular 
attachments and to prevent outward dislocation 
at the ankle. With the growth of the heel and 
the forward displacement of the weight-carrying 
astragalus the leg becomes extended on the thigh 
and the thigh on the pelvis. The head becomes 
more evenly balanced on the top of the spine, and 
the spine becomes more firmly fixed by its wedge 
to the sides of the pelvis. The viscera grouped 



46 



THE HE A DSIT AW LECTEEE 



around the spine and supported by the pelvis 
retain, or should retain, much of their old posi- 
tions. Such is a brief outline of the main changes 
brought about by the assumption of the. erect 
position. 

The Adaptation of the Human Frame to the 

Erect Position. 

After the thousands of centuries that the erect 
position has been assumed, can it be said that the 
human frame has completely adapted itself to the 
changed attitude ? I think it must be admitted 
that it has not, and that there are many defects 
and liabilities that can be directly ascribed to the 
change of posture. I have been trying to think 
if there are to be found any common defects, fre- 
quent in quadrupeds and in man, that the erect 
posture has been beneficial in relieving, and I can 
only think of umbilical hernia. This defect is 
common in domesticated animals — cows, sheep, 
dogs, and to a less extent I think in cats. I have 
never noticed the defect in a horse, because, pro- 
bably, a horse with such a condition is useless, 
and is destroyed and never used for breeding 
purposes. Umbilical hernia has in the lower 
animals, I believe, no tendency to cure itself. In 
man it is exceedingly common in infants, but 



TIIK BBAPSHAW . LEC'JL'lTE'l!] 



47 



.tends, more than any other form of rupture, to 
disappear with increasing age. The recession of 
the liver from the level of the umbilicus to a 
position beneath the ribs and the pull of the 
round ligament upon the umbilicus have, no 
doubt, much to do with the cure ; but I think it 
must be admitted that the relief from direct down- 
ward pressure which the erect posture assures 
has a potent influence in assisting the natural cure. 

When we consider the various displacements 
and defects directly favoured by, and in many 
instances definitely clue to, the erect position, Ave 
shall find that there is a long list to be enumer- 
ated. Among the solid viscera : (1) The dropping 
of the kidneys from their beds, at one time thought 
to be rare, but now known to be very common, is 
a condition largely due to the erect position. 
(2) The spleen, too, occasionally drags away from 
its anchors, and I have myself seen it occupy 
Douglas's pouch. (3) The uterus suffers in many 
ways : before impregnation from flexions and 
versions, and after childbirth from prolapse in 
addition to the other displacements. 

The hollow viscera also tend to be displaced 
by the erect position. The transverse colon, over- 
loaded with faecal matter, is liable to drop down 
from its position along the margin of the ribs and 



48 



THE BRABSHAW LECTURE 



to form a loop below the umbilicus with, the con- 
cavity upwards, thus bringing about kinking at the 
lateral flexions. The various weak points at the 
lower part of the abdomen are subjected to greater 
strain, and inguinal, crural, obturator, vaginal, and 
sciatic hernias are rendered more frequent. The 
bladder and ovary may also occasionally be found 
in a hernia. 

Outside the abdomen we notice varicocele 
caused by the weight of a loaded sigmoid upon 
the spermatic vein, where it is exposed to pres- 
sure on the brim of the pelvis; haemorrhoids 
associated with rectal accumulations and varicose 
veins in the legs are common in those whose 
occupations require that they should stand for 
many hours in succession. These defects are very 
definitely associated with the assumption of the 
erect posture. 

Knock-knee and flat-foot, bow-legs and weak 
ankles are the result of the assumption of the 
erect position before the supporting tissues have 
gained sufficient strength to bear the body- 
weight, or, perhaps, more often result from defec- 
tive feeding and hygiene, by which the bones, 
ligaments and muscles are weakened relatively to 
the strain put upon them when carrying the body 
in the erect position. 



THE BEADS HAW LECTURE 



49 



APPENDIX. 

Since delivering my lecture at the Royal 
College of Surgeons ray attention lias been drawn 
to the "identical twins," Myrtle and Violet Smith, 
daughters of Mr. George Smith, of Waltham 
Cross, who has kindly forwarded to me their 
photographs and a record of their school life. 
In answer to the question as to heredity, Mr. 
Smith writes: "I am a twin myself, the other 
died, and one of my sisters had twins but they 
both died." 

Each of these twins put in seven years' perfect 
attendance at school, being never absent and never 
late, which indicates unusual health, as well as 
unusual regularity. In this way each obtained 
three medals, a silver watch, and a certificate for 
Scripture. They also obtained forty-three prizes 
at day and Sunday schools. Their resemblance, 
as indicated in the photograph (see Fig. 8, p. 50), 
is so great that among persons who know them 
well, one is frequently mistaken for the other. 



4 



50 



THE BRADSHAW LECTURE