No. 3194.

NOVEMBER 15, 1884.

An Inaugural AddressON THE

REVIVAL OF OVARIOTOMY,AND ITS

INFLUENCE ON MODERN SURGERY.

Delivered at the Midland Medical Society, Birmirigham,November 5th, 1884,

BY SIR SPENCER WELLS, BART.,LATE PRESIDENT OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.

(Concluded from p. 813.)

By careful consideration of all the sources of danger, andby successive improvements in practical details, the mortalityof ovariotomy became less excessive ; and it was soon feltthat the mortality, after other surgical operations, both inLondon and provincial hospitals, as well as in privatepractice, was excessive, and ought to be diminished. It wassome years after Southwood Smith, Edwin Chadwick, andWilliam Farr had begun their attempt to impress the

mportance of a knowledge of sanitary science upon thepeople of England that its influence was much felt either inhospital practice or in domestic life ; and I doubt whetherthe attention of surgeons was ever fully awakened to thepossibility of reducing the mortality of great operationsbefore Sir JAmes Paget, at the meeting of the British MedicalAssociation in London in 1862, delivered his memorableaddress upon the study of the large group of diseases con-founded under the name of "pyaemia." "

Two years afterwards, at Cambridge, I addressed theAssociation upon the same 8U ..ject; and, after alluding tomany sanitary measures, called attention to the bearing ofthe then recent researches of Davaine and Pasteur, and tothe value of Polli’s experiments upon the use of sulphurousacid and the alkaline and earthy sulphites in the preventionand treatment of many of the infectious and contagiouscauses of excessive mortality after operation?. We were onthe dawn of that phase of modern surgery when the so-calledlaws of sanitary science were tested in the laboratory byphysiological chemistry and experimental pathology, andwere afterwards acted on by Lister and his followers.Daring this. time of reaction and activity in abdominal

surgery there wa9 a corresponding development of theliterature of the subject. It appeared in all shapes and camefrom all quarters. The names of men who have sincebecome cetebrated were ushered in with their first contribu-tions. Essays and records of cases abounded in periodicals.Pamphlets fell thick upon the public and books were

published which, though more or less incomplete, showedhow fast nutfrtal was accumulating for the future comp)si-tion of elaborate treatises.A review of all this matter poured out by the press, both

English and foreign, on the question of ovariotomy, a fewyears before and after the date of 1865, enables us in ameasure to gauge the extent of the interest the operationhad excited, the change of opinion in reference to it, thesuccess that had attended it, and to trace the indicationswhich the reports contained of the spreading eagerness of theprofession to scizs every opportunity of giving to humanitythe benefits which the practice was capable of conferring.But that which most forcibly strikes the attention in readingthis literature is the contrast furnished by its tone andtendency with that which preceded and made way for therevival. Previously all that had been written was sceptical,doubting, speculative, or even prohibitory. Wavering expec-tation WdS modest in its demands, timid in its forecastings.There was more of fear than hope for the future. Toatfuture came, and with it the revival. Then, instead of thevague prophetic inspirations of the Huntera, the movingexhortations of Bd], the qualified and cautious encourage-ments of Blundell, the passive admissions of Astley Cooperthat ovariotomy might be done, the conscientious shrinking,in an exalted reverence for the sanctity of human life, fromthe realisation of what seemed so desirable and within thecompass of daring power, the pathetic wailings over suffer-ings unrelieved and deaths unresisted, and the despondency i

’-T- ."...

of professional iuaction, we had reports of accomplishmentwhich proved, by the wideness of their sources, theirnumerical importance, and the character of their authors,that the revival was assured. The quetion now changedfrom one of possibility to one of improvement, and reportsof cases merged into discussions of practical details ofoperative and therapeutical interest. These, from theirprecautionary or conservative bearing, gave good auguryof the vast ameliorations which we have seen within thelast twenty years, and have brought us at the present timeto nearly certain success when a careful surgeon operates ina favourable case. One may truly affirm that in all theseoutpourings of the revival period there was nothing vain.glorious, boasting, presumptuous. As contributions toscience they were serious, candid, plain, aiding furtherprogress, informing to the profession, and useful to man-kind. They bore upon them the signs of a wise resolutionto advance circumspectly upon the path now open ; and iftinged with a glow of the personal satisfaction which flowsfrom a sense ot duty in part fulfilled, and brightened with agleam of the complacency reflected from the visible evidence,now so constantly before the public in the living, healthysurvivors of the operation, that the profession as a corporatefraternity was equalliog in its philanthropic energy thatwhich had made the reputation and bad been the pride andsolace of its older "men of renown"-I can only say, notthat it was excusable or admissible, but that this gratula-tion was no more than the circumstances prompted, or thanmay justly be felt by all who join in working, with a rightmind and to a good issue, for the welfare of their kind.And here with 1865 I may end this retrospect d the

revival of ovariotomy, of a rapid revolution in opinion andpractice in less than ten years. Before 1858 the operation,like all good things, had been of slow growth. One hundredyears ago it was but a germ that might be described in alecture by John Hunter. Ten y ears later it was seed thatfell from the hand of Bell. In little more than anotherdecade it germinated as a living vitalising reality inKentucky. Sixty years ago it was transplanted to the landof its philosophical conception. In twenty years more wefind it a sapling on English soil, growing slowly at first, andup to 1858 looking as if it might prove no more than awithering gourd. But by 1865 its root had struck firm, itsstem istood erect, its branches were wide and strong, knownand sought as a refuge by the sick and dying. That it wasno withering gourd nas been proved by all that the worldhas since seen. Thousands of perishing women have beenrescued from death ; many more thousands of years ofhuman life, health, enjoyment and usefulness have beengiven to the race; and to all future victims of a maladybefore inevitable in its fatality, it gives consolation, hope,and almost certainty of cure.And passing over another twenty years-advancing from

1865 to 1884-we can rejoice that in all our metropolitanand most of our provincial hospitals, and from the bestteachers on both sides of the Atlantic, medical students ofto-day may hear of the good already done-may see forthemselves how success is attained, and possibly, by theestablishment of some new fact, or the discovery of somenew device, they may increase our power over disease, andcarry on the work to our successors.

I must leave it to others to speak of our great hospitalsand important schools. But I cannot close this part of myaddress without one word of hearty congratulation to mysuccessors at the small hospital where, with seldom morethan six or eight beds at my disposal, in twenty years Icompleted 408 cases of ovariotomy, the deaths havingdiminished in successive periods of five years from one inthree to one in four or five, and in the last two years to onein ten. In seven years, 1878-83, my three successors amongthem had 496 cases-some ninety more than I did alone intwenty years,-the deaths falling from one in five in 1878 toone in eighteen in 1883. And the recent publication of mycolleague Doran adds to the satisfaction I feel in seeing myoperative work so efficiently continued, the pleasure ofnoting how happily he is supplementing the opening of hiscareer as an operator by the intellectually higher distinctioaof being ackuowledged as a penetrating investigator andclear expositor of the obscure subject of ovarian pathology,to which he is devoting his philosophical earnestness. Onthis centenary of Hunter’s lecture we may truly claim thathis example is followed, his foresight verified, and ourexertions rewarded.In asking you to consider the influence which the revival

U

858 SIR SPENCER WELLS ON THE REVIVAL OF OVARIOTOMY.

of ovariotomy has had upon modern surgery, I think wemay not only assume the revival as complete by the year1865, but that, in the words of Paget, "the influence for goodwas not limited by the increased success of ovariotomy, butextended to every department of operative surgery, and willalways continue to be felt in the whole practice of surgery." "And the rapidity with which the success of ovariotomy led,again using Paget’s words, to " an extension of the wholedomain of peritoneal surgery," is not less remarkable thanthe rapidity with which ovariotomy had advanced in pro-fessional opinion between 1858 and 1865. The first extensionnaturally enough was to the removal of uterine tumours.

. At first this was only done after a mistaken diagnosis;but before many years had passed it was done designedly.At first only in cases of pedunculated subperitoneal out-growths ; but latterly, under conditions most unfavourable,success has been obtained in a proportion of cases very sur-prising even to those who in their long experience havemany times been astonished at their own success. Nothingin the whole history of surgery can be at the same time sogratifying and so astounding as the records of Keith’s latercases of the removal of uterine tumours, collected and pub-lished by his son. Taken alone, they would almost justifya general law to the effect that no woman should be allowedto die of any innocent uterine growth without attempting tosave her life by operation being made. When the earliercases of Koeberle were criticised in the French Academy byBoinet, Richet cautioned the audience against summarycondemnation of an operation not dreaded more thanovariotomy was not long before. The question since thatday has been decided by experience, and if a word ofcaution is now needed, it is oaly to warn surgeons of thefuture that they cannot hope for success unless they preparethemselves for operation upon the living body, by takingevery available opportunity of practising upon the deadbody, and by a conscientious determination to study ratherthe true welfare of the patient than, on the one hand, howto avoid responsibility, or, on the other hand, how to advancetheir own renown.

It is fortunate that in some of these cases of uterinetumour an alternative proposal ought to be considered.Both ovaries may be removed with the knowledge that thisproceeding has been followed by atrophy of the uterinegrowth. This, on the part of Hegar, was the legitimateapplication of a principle, and the practice has often provedsuccessful. In cases where removal of the tumour wouldhave been impossible or exceedingly dangerous, removal ofthe ovaries and FaUopian tubes has led, with far less risk,to cessation of bleeding and more or less diminution of themorbid growth. But we must have further experience beforewe can arrive at a hir estimate of the relative value of thetwo courses of action. We have learned, however, that ifthe ovaries are not completely cleared away, if, having beenadherent, they have been twisted or scraped away from theirconnexions, and some small portions left, menstruation mayafterwards recur quite regularly, even though both Fallopiantubes have been totally removed. I have more than oncewarned the profession against the capricious extirpation ofthe ovaries, becanse they are supposed to be the source ofall womanly ills, and I repeat my caution, seeing to whatwide-spreading evils its neglect may lead. I think it acharity to lay a checking hand on an erring judgment beforeit has gone too far, and I would fain save our profession fromthe public odium which must sooner or later be the penaltysuffered by all, if a few indiscreet members of our body actwithout general sanction, or disregard general disapproval.

I have not time to enter upon the very important questionof the excision of the entire uterus, either by the vagina orby abdominal section. nor of that substitute for the CsMareansection known as Porro’s operation, nor on the operativetreatment of extra-uterine fcetation ; and can only say a veryfew words about the next kind of abdominal tumour, theremoval of which followed the ovarian and uterine-theenlarged spleen. I did not meet with a case which I thoughtjustified the operation until 1865, although I had long beforethat been determined to do it in any suitable cae. My secondcase was performed in this town, and I have only met withone since. I need not tell you that the example has been fre-quently followed by other surgeons, and there is everyreason to hope that increased experience may be followedby diminished mortality.And so with renal and peri-renal tumours. Nephrotomy,

nephro lithotomy, pyelo-lithotomy, and nephrectomy, termshardly entering into surgical literature twenty years ago,

define operations which are now performed in increasingnumbers, and, (,specially to the physiologist, with a wonder-ful success. My colleague, Knowsley Thornton, can boastof ten nephrectomies, all by abdominal section, as well asfour nephrotomies, and three nephro-lithotomief, the wholeseventeen cases successful. These cases, and aeven success.ful cases of pyelo-lithotomy out of eight, as lately recordedby Anderson, can only be the effect of rigidly abiding bythe observance of what we now know to be the rule andcriterion of good work. So also with a variety of solid andsemi-solid abdominal tumours, originating in the pelviccellular tissue, or in the peri-renal fat, or in the mesentery,the appendices epipioicse, the omentum, or the abdominalwall, extirpation is effected with a loss of life so small aswould have been almost incredible a few years ago.Already in several cases tumours formed by peritoneal

hydatids have been successfully rt-moved. I have not timeto do more than barelv allude to opening of the 5all-bJadderand the removal of gall-stone8, the OtCning and draining ofhepatic abscesses, of hydatid cysts of the liver, of pelvicabscesses, and of haematocele, to removal of the pylorus, gas-trostomy, and opening of the stomach and removing a largemass of hair. In one remarkable case Mr. Thornton removeda mass of hair weighing two pounds, which was mouldedinto the shape of the stomach. The incision across thegreater curvature was five inches long, and fifteen deep andfifteen peritoneal sutures were required to close it. Theabdomen was closed, and the patient is perfectly well. Tenyears ago such an account would hardly have been believed.With the exception of this and one successful case by Schon-born, in all other reported cases such masses of hair in thehuman stomach have only been found after death. But noone who has watched the progress of these operations, hasconsidered the causes of death in fatal cases, and the detailsof the operative proceedings in successful cases, can come toany other conclusion than that one important element in theattainment of success is the scrupulous observance of theprinciples laid down as necessary to success in ovariotomy;not only as regards the hygienic precautions never omittedinmodern surgery, but especially as to the importance of a veryaccurate and exact union, not only of the edges, but of thesurfaces of the peritoneal surface of the viscera and of the ab.dominal wall. In gastrostomy, for instance, it is found thatwhen the stomach is attached to the abdominal wall by asinglering of sutures, the weak attachment may give way, andrifk of extravasation into the peritoneal cavity may be great.But when, after dividing the abdominal wall, the parietalperitoneum is sewn to the skin all round the opening, abroad surface of visceral and parietal peritoneum may after-wards be maintained in contact by a circle of sutures, form.ing loops, passed through the peritoneal coat of the pro.truding portion of stomach, and through the whole thicknessof the abdominal wall, about half an inch from the edge ofthe iucision. Smaller fine sutures being inserted betweenthe larger ones, a very close and secure attachment of thestomach to the peritoneal lined opening in the abdominalwall, and complete occlusion of the peritoneal cavity, areguaranteed. This done, we have an example of the carryingout in its integrity of one of the fundamental rules of practicein the operation of ovariotomy as regards the peritoneum-surface to surface, not edge to edge merely,-and it is a factnot to be overlooked that in gastrostomy the result of theoperation seems to depend upon it; the rule being that thecases in which it has been neglected fail, while those inwhich it is observed end satistactorily. Thus the lessonslearnt at an early stage of our experience in one operationhave been the means of leading directly to the successfulperformance of the other.

This tracking of Paget’s extension of the " domain of peri-toneal surgery" has carried us a long way, and perhaps thosewho have entered upon their career at a late stage of thesuccessive annexations may find it not easy to understandthe fascination which the subject has for their precursors,who remember its dawning, who were pioneers in realisingpossibitity, and who now live and are still pressing forwardto the ever-receding horizon before us. Far as we have comeon the way, and much as we have done, there is more to doand more to gain. If formerly we plumed ourselves on ourtriumphs over the peritoneum-or rather, as it really was,over our fears of the peritoneum-upon our ovarian, uterine,renal, and splenic victories, and put up trophies of all thoseorgans in our museums, we now see our way to new conquests.In proof of this, it is a satisfaction to refer to a seriesof cases and papers in some of the very latest English and

859SIR SPENCER WELLS ON THE REVIVAL OF OVARIOTOMY.

foreign medical journals, showing how much more fre-

quently than heretofore obstruction of the intestines is nowsuccessfully treated by operation, and that excision of thepylorus, and of parts of the intestines, is already a subjectof careful experiment. This is directly traceable to ovario-tomy, for one of the very earliest cases was my ownunion of the upper and lower ends after removing aboutthree inches of small intestine invaded by cancer from anovarian tumour. In Treves’s paper on Excision of Intestine,you will see how firmly an operator of to-day is taking hisstand on the true principles of abdominal surgery which wehave watched emerging from their obscurity. He does notignore the teachings from experiments ,upon animals. Hesupports himself by the nine successful resections of lengthsof the intestines of animals made by Madelung. He traces thefailures in many operations of the same kind on the humansubject to faults in the details, such as want of perfectadaptation and insufficiency of sutures. And he lays down Ias rules for his own action that he must separate the peri-toneum from the other tissues, introduce abundance ofsutures after Lembert’s method, bringing the two seroussurfaces together, and avoiding the mucous membrane withthe needle. A recent paper by Reichel informs us thatalready 121 cases of resection of intestine have been col-lected, the conclusion being that the two ends of the bowelshould not be united at the time of the resection, butthat an artificial anus should be established. This can beclosed by a subsequent operation. You will probably soonsee a report of a case, not yet published, where Mr. Jessopof Leeds cured a faecal fistula by separating the injuredintestine from the abdominal wall, and uniting the upperand lower parts of the gut by suture. What I said withregard to practice on the dead body before operating onliving women afflicted by uterine tumours is equallyapplicable to the resection of intestine. But here practiceon the dead is not sufficient, and if we are not allowed toexperiment on living animals in this country, we must eithergo abroad or practise on men and women. At my requesta young surgeon, Mr. Jennings, from whom I hope andexpect great things in the future, has recently cut awayportions of the intestines of dogs, uniting the upper andlower parts so as to maintain the continuity of the canal.Some of the preparations may be seen in our CollegeMuseum, and they strongly confirm the conclusion thatsuccess depends upon complete union of the apposed seroussurfaces.

If I were reviewing modern surgery in general, and notlimiting myself to the influence upon it of the revival ofovariotomy, I should speak hopefully of pulmonary surgery,of the draining of cavities in the lung, of incising gangrenouslung, of resection of portions of ribs to obtain contractionand closure of the pleural cavity, and of excision of parts ofthe lungs, or of an entire lung, even of the surgical treat-ment of puralent pericarditis. But these are subjects towhich I can barely allude as proofs that we do not yet knowhow far we may go with rational surgery, or what may bein store hereafter for surgical enterprise.But while we modern surgeons congratulate our science

on its liberation from the trammels of tradition, upon itsworking in an atmosphere cleared of the mist of super-stition, upon the changing of its mode of action from ablind grappling with the phantom entities of disease to astudy and manipulation of over-nourished or degeneratingtissues, upon its having laws which can be understood, andrules of practice which can be followed, we ought not tooverlook one fact, which perhaps is more evident to out-siders than to ourselves, standing as we do in the dust andturmoil of the arena of our work. I mean that that work,good and useful as it is, has too much the character of whatis technically called ‘° salvaging," is too much in correlationwith what is done by the lifeboat service. Is it there thatwe ought to stop ? I know that we are gradually drawingon beyond that point, and that our investigations are turn-ing in the direction of sources, causes, means of prevention,and outlets for avoidance. But before we can reach thesame level of achievement in preventive medicine that wehave arrived at in operative surgery, before we can arrestthe formation of ovarian cysts instead of excising them, wemust know and understand what we have to deal with; wemust master the problems presented to us by the erraticdevelopments and mortal decadences of the tissues andorgans which we are now content to clear away. And weought to have the means of accomplishing this task on ascale commensurate with the importance of the subject of t

pathology, the professional desire for original research, andthe dignity of the College of which we are members.Most of the University cities on the Continent have made

provision for this necessity, with a liberality and such a pro-fusion of accommodation that the prosecutors of these studiesare there at a great advantage. I have visited some of theseestablishments, and have been able to make comparisonswhich cause me to regret that so little of the like kind hasbeen done here, and that we have been content to leave amatter which really touches the honour of the profession,and is of national concern, to almost unaided personal zealand efforts. In England the jesting phrase that 11 sciencedoes not pay" is so common that we scarcely feel thereproach. The history of medical science gives us manyinstances of unfairlyremunerated men (W. Farr, for example),and of the appropriation of the profits of their applied work,and it would be well if the authorities of our profession tookthe lead in forming an organisation which should aid themodest labourers of its foundations, protect their interests,and reward their industry. I have long desired to see this doneby our College, and the munificent bequest of Erasmus Wilson,a man who estimated the’value of money by the good that itcould be made to do, now puts it in the power of the Collegeof Surgeons to outrival all other corporations, by setting upround the nucleus which Hunter left the most elaboratecombination of all the means and appliances for physiologicaland pathological research, by concentrating the intellectualpower which now runs to waste or is diverted t,o personalinterests, and by guiding and directing all that ca.n be doneto the advancement of the purely scientific progress ofmedicine and science.Last winter I was away from London for about six weeks. "

While staying at Wiirzburg and Munich, I could note inthe most recently erected pathological laboratories how farour German brethren are in advance of anything which I,at least, have seen in this country. At R0me again, and atNaples, I was both pleased and surprised to find how muchour Italian brethren were doirg. And during the meetingof the Medical Congress at Copenhagen, I was shownarrangements for the study and cultivation of micro-organisms quite as complete as those which many of youmay have inspected at the temporary rooms at the HealthExhibition in London, under the able and instructiveguidance of Mr. Watson Cheyne. Now, one may fairly askwhy provision cannot be made to ensure the continuance ofthis work, and its extension, in a better and permanent abode ?Something of the kind I hope to see in Lincoln’s-inn-fields.I concur completely in the project to make such additions toour noble building as our Council have long felt to be anabsolute necessity, and for which they have already con-sidered plans prepared by the eminent architect Mr.Waterhouse. These constructions are intended to furnishbetter and more convenient arrangements for the examina-tions for our diplomas, to guarantee the uninterrupted useof the library, and to give us further facilities for thepromulgation of the higher truths of surgical science. Un-

questionably this will be in some degree a credit to ourCollege and to British surgery. But I hope I shall not bemisunderstood. I have no wish whatever to add to theduties of our College as a teaching institution. We are anexamining body, acting for the protection of the public bytesting the success of the teaching in the schools andhospitals, and vouching for the competence of our candidatesfor their calling, after proving to us that they have gonethrough the course of study we prescribe and possessthe average skill and knowledge necessary to meet all theusual demands of practice. Perhaps, hereafter, we maytake the higher position of sitting simply as a court ofjudgment upon the qualifications of those who present them-selves for our diploma, irrespective of the mode and timeand place in which their knowledge has been acquired,putting aside all interference with the routine and details ofthe course of study.But I aspire to something more than success in securing

the requisite skill in practical surgery in those who dispersethemselves among the people as practitioners under ourwarrant and authority. I trust that we may go further,and, no longer trammelled by State interference and sensa-tional clamour, that we may accomplish that which suchmen as are on our Council would probably have done longago, had it not been for the restrictions placed upon them byfinancial considerations. Now the funds at their commandgive ample means for the carrying out of any schemes whichthe most enthusiastic devotee of original research could, in

860 SPASTIC CONDITIONS OF THE VOLUNTARY MUSCLES.

his most sanguine dreams, imagine. My ambition is thatwe should not merely be the source of honour to students,and the directors and approvers of schools and teachers, butthat we should become the centre of medical research, themainspring of all the developments of medical science. Andnow that we can do it, why should we not do it? Whyshould we not have buildings and accessories, imposing intheir grandeur and adequate in their accommodation ; labo-ratories, complete in their fittings, instruments, andmaterials, rooms for conferences, and proper places for thestoring of records and results ? Wny should not our Fellowsand Members who are moved with the desire to advancemedicine and surgery by inquiry and experiment be pre-sented with as great tacilities as are to be found in any con-tinental city or university, such as are so profitably enjoyedby Pasteur, Ranvier, Brown-Séquard, and their colleaguesand assistants, advantages hitherto unapproached on thisside of the Channel, but which our Transatlantic brethren arenot slow to emulate ? I feel that to support the honour ofour profession, to fulfil our duties as the representatives ofsurgical science, justly to carry out the intentions of our latepresident and benefactor, we ought to be magnificent inarchitectural and constructive outlay, active in personalwork, and liberal in the encouragement and help we profferto those who come to make use of the opportunities whichour College will give, and promote the object for which weare all so deeply concerned and so heavily responsible.

I am encouraged to augur the completion of such a schemeas this for rendering original investigation in the futureinfinitely more easy, precise, and valuable than the surgeonsof the past ever hoped for, and to believe in the accomplish-ment of its designs, when I think that the will of suchmeetings as this must be obeyed, and feel the convictionthat the men of Birmingham will be among the first to availthemselves of it.I have spoken to you of the past and the present. The

future is in your hands ; and I appeal to you as men typicalof the thought and action of the profession, actuated by thehighest moral sentiments, seekiug and mutually guardingyour honour as a body-chasing out, with instinctive repug-nance, that which, ignominious in principle or practice, hasaccidentally intruded itself among you, and conscious that-by assuming the highest functions of your calling, in theinvestigation of national interests, in the promotion of publicgood by giving counsel to princes and legislators, by such adevotion of your energies, by such a sacrifice of personalconsideration as is involved in bettering the condition of thepeople, in shielding them from disease, and in the prolongagation of their healthy lives-you will add lustre and dignityto the private confidence, gratitude, and sympathy whichthe profession has already gained by its power over actualsuffering and sickness, and by the skill, conscientious vigi-lance, and humane tenderness with which you make thatpower manifest. "I speak as unto wise men, judge ye whatI say." z)

_____________

ON THE

NERVOUS OR MUSCULAR ORIGIN OFCERTAIN SPASTIC CONDITIONS OF

THE VOLUNTARY MUSCLES.BY SYDNEY RINGER, M.D.,

PROFESSOR OF MEDICINE AT UNIVERSITY COLLEGE, LONDON,AND

HARRINGTON SAINSBURY, M.D., M.R.C.P.,ASSISTANT PHYSICIAN TO THE ROYAL FREE HOSPITAL.

(Concluded from p. 816.)

THIS peculiar form of rigidity, then, we have observed asone effect of sodium phosphate ; as another effect we haverecorded fibrillary contractions. What is the nature of theseeffects? Are they peripheral or central? To answer this

question, the hind limb of a frog, which, by hypodermic in-jections, had been first brought under the influence ofsodium phosphate, was severed from the body, and then thesciatic nerve was faradised m mentarily. The result was

rigid extension, which extension persisted some seconds orsometimes some minutes after the discontinuance of thestimulus.’ This extension was demonstrable by holding the

1 Loc. cit.

leg vertically with -the foot uppermost, the extension beingmaintained against the force of gravity for the period men-tioned, after which the leg would slowly subside. On per.forming this same experiment with the muscles of an un-poisoned frog, the contrast was very marked in the suddencollapse of the limb after cessation of the stimulus. In addi.tion to this spastic condition, marked fibrillary action wasobserved in the poisoned muscles of the severed limb on fara.dising the sciatic nerve. Clearly, then, the effect is peri.pheral, not central.

Before analysing further this peripheral effect we may ask,Are we dealing with manifestations purely toxic, or may weobserve in unpoisoned muscle anything of a similar charac.ter? The answer is that in unpoisoned muscle we mayobserve both the spastic state and the fibrillation. Butobserve the requisites : to bring out the spastic state the fara-disation must be both powerful and prolonged-i.e., rela-tively,-and even then it will be not nearly so persistent asthat induced in the poisoned muscles. In like manner, toproduce the fibrillary twitchings in unooisoned muscle, theinduction shock must be powerful. We observe, therefore,that the effects brought out by the sodium phosphate are notnew in kind, but only very much exaggerated in degree.These several points are very strikingly illustrated by meansof myographic tracings, but for these reference must be madeto the before-mentioned paper in the British MedicalJournal.During these investigations certain other facts came out.

Thus, it was found that cold favoured the production of thespastic state; further, that repetition of the excitation causedboth the spastic contractions and the fibrillary contractionsto diminish; they would, so to speak, wear off.To proceed with the analysis. The effect we have seen is

peripheral. But this includes both nervous and muscularelements; which are the ones concerned here ? To answerthis, hypodermic injections of sodium phosphate were prac.tised as usual; but, in addition, curare was also injected.The limb was then severed and the sciatic faradised; thisyielding no contraction, it was concluded that the motornerve fibres were paralysed. With such curarised limb amyograpbic tracing from the gastrocnemius muscle wastaken, and it was found that, though fibrillation could stillbe brought out by the strongest induction shocks, it wasgreatly diminished, but not so for the prolongation of relaxa.tion; this was even more marked for the curmsed thanfor the non-curarised muscle. This result is extremelywell seen in Fig. 4 of the tracings. 3 Observe, then, thatwith the elimination of the nerve element fibrillary con-tractions have been much lessened, but the tonic spasm has,if anything, been augmented.Admitting the efficiency of curare to eliminate the nervous

element, the conclusion is inevitable that the tonic spasm isof muscular origin. Nor is this conclusion surprising, for tomuscular tissue we unhesitatingly attribute the quality ofcontractility, but to nervous tissue the quality of conveyingthe necessary stimulus to call this contractility into action.If now we survey the animal kingdom we note great varia-tion in the mode in which contractility is manifested-i.e.,as to rapidity of contraction ; and it is most probable that acontinuous scale could be established which, according toMarey’s statements, would place at the beginning the cross-striped muscles of insects with extreme rapidity of contrac-tion ; on this would follow in order the striped skeletal,muscles of birds, fishes, mammals, frogs, lowest amongstriped muscles being those of the tortoise and of the hiber.nating marmot; then the muscles of the heart wouldfollow, these occupying a mid-way position between stripedand unstriped muscular fibre; finally would come plainmuscular fibre, whose contraction curve is, so to speak,macroscopic. 4 In addition to this scale we meet with somecurious instances of two kinds of striped muscles in thesame animal. Thus, in the rabbit we have, as before men-tioned, slow and rapidly contracting muscles, these corre-sponding to the red and the white muscles respectively.But this very slow contraction which we here record may beotherwise described as of the nature of tonic spasm, andaccordingly we witness tonic spasm as a normal manifesta.tion in the scale of animal life, and this manifestation weadmit to be of muscular origin. Hence analogy comes tothe aid of direct experiment, and favours the view that thetonic spasm of drug action is muscular in its nature. But

2 Or sodium carbonate; this salt appears, if anything, more activethan the sodium phosphate. 3 Loc. cit.

4 Hermann : Lehrb. de Physiologie, Bd. i., p. 38, quotation nearlyverbatim.