843

includitg the present, would have been found in them if obser- 1vation had been exact as to the value of remedies. Alw,vys akeep in mind the well-known aphorism of Hippocrates : J’Experience is deceptive.’ Mistrust your own observations observation

at first and do not on too slight grounds assume they are 1correct. Ccnfirin them by repetition. In much of your work 1

in your student career you will find good opportunities for for exercising yourself in exactness, and in none more so than 1when you are taking notes in the hospital wards. It is (

then that you have for the lirst time the opportunity of cmaking observations in practical medicine for yourselves.Make good use of it. It is carelessness in observation iin the wards which often leads to unsatisfactory results 1at a later period. I have told you to mistrust your 1

own observations--equally mistrust those of others. Above iall things beware of accepting hypotheses as facts. Many c

so-called laws are really only what are called workinghypotheses-that is, theories which are put forth as possible l

truths, to be used in a tentative manner as guides to further 1experiments. Reasoning based on them has no firm founda- found- tion, yet they are often used. ]

"Although observation is such an important matter inmedicine, yet for its progress much more is wanted. It is i

probable that the healing art had been cultivated, and with 1some care too, in Egypt for at least 3000 years before the 1

Papyrus Ebers was compiled. But although this book Jcontains much that is true and useful it indicates that but ia slight advance in real knowledge had been made. Thisarose partly from the imperfect observations, but partly partly from the fact that the art of healing cannot advance far by <simple observation of what does good in individual ailments- 1a knowledge of many collateral subjects is essential.You will not gain by devoting your attention as exclusively 1

as you can do to what may be called the practical details of essential.medicine, surgery, and midwifery. Physiology, chemistry, and spathology are not subjects merely to be slipped through withthe idea that they are of no active service. The harder you lwork at them, and the more full your knowledge of them, (

the easier will you find what are often called the more (

advanced subjects, and the better medical men will you 1make. Neither as students in after life try to limit your ]acquisition of knowledge simply to the methods of cure, for 1

if you do you will limit your knowledge of the methods of cure. 1

Physics, chemistry, anatomy, and physiology will all stand 1

you in good stead in the practical work of your profession. ]For the advancement of medicine they are absolutely essential. JDo not treat these subjects as if they were to be acquired for (

examination simply, and to be forgotten as soon as possible.In your medical work, gentlemen, remember the injunctions of 1

Hippocrates to watch the course of nature and bear in mindthe necessity of always trying to find out the natural courseof disease, that you may be the better able to treat it. How 1much misery would have been prevented if medical men of 1

old had known that many conditions which they thought 1required the most energetic treatment would get well if left ]alone. x

"Finally, gentlemen, remember the teaching of Hippo- acrates with regard to conduct : 400 years B.C. it was con- (

sidered essential that a medical man should pass his lifein purity and holiness ; that he should respect the confidence Jof his patients, and that he s’nould be careful of their J

feelings; that he should be ever on his guard lest what he 1

prescribed should do harm; and that he should avoid ill ikinds of charlatanism. These and many other injunctions 1should press on you, living in the nineteenth century, even 1

more strongly than on those who lived before our present era. lLet me strongly urge you never to forget the teaching in this 1respect of the great Father of Medicine." I

j

MASON COLLEGE, BIRMINGHAM. INTRODUCTORY ADDRESS BY PROFESSOR PERCY FRANKLAND.

AN address was delivered at the opening of the MedicalSession at Mason College, Birmingham, on Oct. lst, byProfessor Percy Frankland, F.R.S., on Pasteur and his Work:the Debt of Medicine to Chemistry-of which the followingis an abstract :-

It may be said without exaggeration that there is no

scientific name which is so universally known and in somany different connexions as is that of Pasteur. Thechemist, physicist, biologist, and medical man each viewLouis Pasteur as the author of some of the mostimportant, novel, and fruitful departures in their several

branches of knowledge, whilst in the worlds of industryand agriculture his influence has also been deeplyfelt and gratefully acknowledged. The first subject ofresearch taken up by Pasteur at the early age of twenty-fivewas of such an abstract character that if his career hadterminated with its completion the general world would havenever known his name, and yet the initiated few wouldhave been able to recognise one of the shrewdest scientificobservers of this or any age. His strict mathematical andchemical training led Pasteur to be fascinated with thewonderful geometrical forms which are assumed by solidsin what is generally callecl the crystalline state, and theparticular phenomenon which attracted his attention wasthe existence of two tartaric acids apparently identicalin chemical composition, in chemical properties, and in

crystalline form, and, in fact, in all respects exceptingalone that the solution of one had no effect on polarisedlight, whilst the solution of the other turned the plane ofpolarisation to the right. Submitting these crystals to themost searching scrutiny, Pasteur found that there were someminute faces on the crystals of the active tartrate whichwere absent from the crystals of the inactive tartrate, andsuch importance did he attribute to these little faces thathe recognised that their presence relegated the sub-stance possessing them to an entirely different classfrom that to which belonged the substance not possess-ing them. The crystals of the inactive tartaric acid whichwere destitute of these little surfaces he found were sym-metrical, whilst the crystals of the optically active tartaricacid he found were unsymmetrical, or "dissymmetric," ashe called it. His speculations, subsequently developed byWislicenus, Le Bel, and Van’t Hoff, led to the foundation ofthat most fascinating and fertile field of chemical sciencenow known as stereo-chemistry, and prepared the way forsome of the greatest achievements of modern chemistry,such as the artificial production of the natural sugars.Pasteur’s genius was, however, not long to be retained in theexclusive service of abstract science. In the course of his

experiments on the different kinds of tartaric acid he wasled to try the effect of submitting them to fermentationprocesses, and he found that the two oppositely activetartaric acids are physiologically utterly distinct, one of thembeing capable of undergoing fermentation by means ofbacteria, whilst the other remained untouched. This strikingphenomenon has been largely utilised by later investigatorsfor the preparation of new optically active chemicalcompounds. Pasteur was thus drawn by accident, as itwere, from the inanimate world of pure chemistry intothe vortex of the world of life, and it was to the study ofvital phenomena that practically the whole of his geniusand energies was subsequently devoted. The frontier linewhich Pasteur crossed from the domain of chemistry intothat of biology was at the time very ill defined. The

phenomena of fermentation which he had attacked werenot generally regarded as vital phenomena at all, and itrequired years of patient labour before Pasteur was

able to convince the scientific world of the truthof his statement that fermentation processes were thework of living microscopic organisms, and that eachfermentation process was the work of distinct organisms.Knowledge and appreciation of these classical researcheshave meant wealth to the brewer, the distiller, and the wine-grower ; and it is hardly an exaggeration to say that thebrewer of to-day is able to stand the relentless taxation ofthe late Chancellor of the Exchequer as much through thelabours of Pasteur, and those who have succeeded him, asthrough the unquenchable thirst of the British proletariat.Extensive as were Pasteur’s researches in the domain offermentation, there were processes which time did not permithim to investigate before he was hurried on into otherfields of scientific interest and practical utility. His intuition,however, led him to recognise as a fermentation process thetransformation known as nitrification, consisting in the con-version of ammonia into salts of nitric acid, which takesplace on such an extensive scale in all the fertile soils of theearth. This process, from being regarded as a case of simplechemical oxidation, is now recognised as dependent uponthe action of bacterial life, and the particular bacteriaresponsible for this action, after long eluding the search of theinvestigator, have during the last few years been isolatedand described. In the course of these researches the astounding fact has been brought to light that in these nitrifyingbacteria we have living cells which are capable of flourishingand multiplying in the entire absence of organic matter

844

Even still more important revelations in vegetable physiology thave resulted from the careful study of bacteria in recent v

years, for it has been shown that certain green plants c

obtain the nitrogen which they require for their nutrition ’]from atmospheric nitrogen by means of certain bacteria a

which infest their roots. These bacteria produce nodular c

excrescences on the roots, but when they are carefully ex- a

eluded these root nodules do not make their appearance a

and the assimilation of free nitrogen ceases also. The r

lecturer then referred to the recent important researches c

of Winogradsky of St. Petersburg on this subject, which fhave shown that under suitable conditions certain bacteria r

can take up this free nitrogen without the presence of the c

green plant at all. The intimate contact in which Pasteur c

had lived with the microscopic forms of life during his s

researches on fermentation-the great importance of which iwas recognised by the French Academy already in 1859, when i

they awarded him the prize for experimental physiology- i

naturally led him to take a deep interest in the contro- Iversy which was then raging on the spontaneous generation 1of life. Into this contest he plunged, despite the urgent 1

protestations of many of his scientific friends, who feared ithat nothing would come of his venture but the loss of ivaluable time. It is now, however, admitted on all sides ithat the settlement of this question of such transcendent 1

importance was finally accomplished by Pasteur through (

experiments as remarkable for their extreme simplicity as for i

their clinching force. (

Professor Percy Frankland then reviewed Pasteur’s con- !:nexion with the foundation and development of the infant iscience of bacteriology and his contributions to our 1

knowledge of infectious diseases. Soon after he hadcommenced to study the bacteria of particular diseases he iwas impressed by the fact that often in the course of cultiva- i

tion in artificial media outside the body their virulence becamediminished to such an extent that they ceased to be fatal on (inoculation into susceptible animals; but the most important idiscovery in this connexion was that the animals inoculated iwith such enfeebled or attenuated cultures were found to havebecome protected from the disease, even when subsequently 1inoculated with most virulent cultures of the same organism. iThis discovery at once enlarged the scope of Pasteur’s

investigations, which now included not merely the study ofinfectious diseases and their exciting causes, but embraced Jalso the artificial protection of the individual against 1

their attack. The most varied methods were devised and I

elaborated for attenuating viruses of different kinds, and Imultitudes of domestic animals were protected from someof the most destructive plagues with which they axeafflicted. Pasteur next proceeded to grapple with a diseaseaffecting both man and animals-viz., hydrophobia. This

problem was surrounded with special difficulties, over

which, however, the genius of Pasteur triumphed, and theattenuated virus of hydrophobia was successfully prepared andby several different methods. As a testimony to the faithwhich experience has built up in the efficacy of the treat-ment, we find centres for carrying it on in almost everycivilised country in the world, whilst at the Institut Pasteurin Paris it is carried out on an enormous scale.The great problem of securing immunity from disease,

which thus occupied the later years of Pasteur’s activity,has, however, now entered upon an entirely new phase.For, whilst Pasteur’s methods depended essentially uponsubmitting the individual to be protected to the attackof the disease-producing organism itself in a weakenedcondition, the new methods of conferring immunity do notnvolve any contact whatever between the individual andthe virus in any shape or form. The initial step in thisnew method of treatment was the discovery that the artificialcultures of pathogenic bacteria may be entirely freed fromthe micro-organisms and yet produce their characteristicpoisonous effects ; the symptoms of a particular in-fectious disease can be obtained through the injection ofthe toxic or poisonous products elaborated outside the

body by the particular micro-organism associated withthat disease. By this discovery the toxines of diphtheriaand of several other diseases have been rendered as

specific poisons as are laudanum or the extract ofnux vomica. It was further found that animals can be

gradually accustomed to these specific toxines, and the ques-tion then arose as to how such animals which had undergonethis gradual habituation to a particular toxine would behaveon being subsequently inoculated with the disease-producingorganism itself. It was found that such animals were able

o withstand or were protected from the attacks a suchirulent bacteria. This important step we owe to the labours,f Salmon, Roux, Chamberland, and other investigators.she next step was the discovery that the blocd of an

,nimal thus artificially protected from a particular diseasecontained materials which can be transferred to otrer animals,nd which protect them also from the same disease. This,stounding property of the blood serum of artificially im-aunised animals was first discovered by Richet and Heri-;ourt, but to Behring and Kitasato is due the credit of havingirst shown in the case of diphtheria and tetanus that byneans of such serum animals may be cured even after thelisease has been actually contracted, provided the injection)f the antitoxic serum is not postponed until too advanced a:tage of the malady has been reached. Again, to Behrings due the merit of having extended these benefits in con-iexion with diphtheria to man himself. The lecturer then’eferred to a diagram showing the diphtheria death-rates)er million living in the principal cities of the United

kingdom during the years 1883-92 and 1893 respectively.n commenting upon these statistics it was pointed out hown London the figures had risen from 300 in 1883-92 to 760n 1893, whilst in West Ham, virtually a part of London, anncrease from 250 to 420 deaths from diphtheria had alsoJeen recorded. As indicating the value, so far ascertained,)f the serum treatment of diphtheria he quoted Kossel’s"ecent figures giving the mortality from diphtheria injermany before the introduction of the new treatment as347 per cent. and since its application as 11’1 per cent. A’act of great importance to be observed in this new treat-nent of diphtheria is the circumstance that its efficiency isgreatly dependent upon the time which elapses between theirst manifestation of the disease and the application ofhe curative serum. The shorter the period which inter-venes the better are the results obtained, and this con-

lition applies equally to the treatment of other diseases,such as tetanus, by means of antitoxic serum, whilst.t has also been established as a cardinal principle byPasteur in his treatment of hydrophobia. So great isjhe demand for the therapeutic serum for diphtheria thatLts production is already a commercial undertaking ofsome magnitude in Germany, where coal-tar colour manu-facturers with their numerous staffs of skilled chemists havestill further enlarged their works by undertaking the elabora-tion of diphtheria antitoxic serum on a most extensive scale.The possibilities of securing protection by means of the serumof immunised animals extend even beyond the boundariesof infectious disease, for Calmette in France and Fraser inEdinburgh have been able to gradually accustom animals tolarger and larger doses of snake venom, and have found theblood serum of such animals endowed with the power of

protecting other animals into which the venom is injected.When we remember, said the lecturer, that 20,000 ofour Indian fellow-subjects perish annually from snake-bites, and that the new method of treatment extendsthe prospect of saving many if not all of these, it isobvious that we are here again face to face with a

subject of stupendous importance, and which affects usabove all the other nations of Europe. In conclusion, Pro-fessor Percy Frankland pointed out the widespread influencewhich Pasteur had exercised upon the progress of science

during the latter half of the present century, and that thisextraordinary influence, wrought in so many different depart-ments of science, must be attributed in the first instance tothe possession of a singularly active, clear, and originalmind, matured under the strict discipline of an arlytraining in mathematics and the exact sciences, whichenabled him to submit biological phenomena to a rigid,logical, and uncompromising criticism such as they had neverpreviously received. But even this rare combination ofnatural and educational endowments would have availed butlittle had there not been united to them an almost super-human industry, an almost limitless capacity for work. Itwould be difficult also to find a better illustration of *.hemanner in which one science can benefit from contact withanother than that which is furnished by the results whichhave attended the digression of the specially trainedchemist into the fields of biology and medicine. To LouisPasteur belongs the glory of having set in motion thatgreat medical ievolution which has been well sketched bya modern French writer. " When man learnt how to protecthimself from the wild beasts he made the first step in civilisa-tion. To-day man is learning how to defend himself frommicrobes ; it is a step of equal importance. A day will come

845

when in Berlin, in London, in Paris, man will not die of in

diphtheria, of typhoid fever, of scarlet fever, of cholera, or fyof tuberculosis any more than he dies in these cities to-day foof the venom of snakes or of the tooth of wolves." (1

_____________ (4

- Tl

SPASMUS NUTANS, OR THE NODDINGSPASM.

BY GEORGE DICKSON, M.D. EDIN.,FORMERLY RESIDENT MEDICAL OFFICER, EDINBURGH CITY POORHOUSE

HOSPITAL, CRAIGLOCKHART.

THE following is a typical case of a somewhat rare

disease - viz., spasmus nutans. The name "spasmusnutans" is somewhat misleading. Probably spasmusoscillans " would be at once more descriptive and less

confusing.The patient, a boy aged one year, came under my care at

Craiglockhart Poorhouse Hospital on Dec. llth, 1893. No

history was obtainable. On examination the child was foundto be pale, but well nourished. There was only a slightappearance of rickets. There were two upper and two lowerincisor teeth. The head was noticed to be constantly heldinclined to the right side when the child was sitting up. Inaddition it shook from side to side in a way such as expressesdissent. The greatest excursion of the lateral movementswas to the left, and there was a slight downward inclination,also to the left. The movements were not constant, but wereinduced or increased by excitement of any kind or by engag-ing the child’s attention. Restraint of the movements causedmarked discomfort. They entirely ceased during sleepand when the child was laid on his back. A day or twoafter admission horizontal nystagmus of the left eye wasnoticed. It also was only occasional, and was increased orinduced by attempts at fixation, and markedly so by restrain-ing the head movements. There was no impairment of visionor ocular movement, and the fundus oculi was healthy. The

right pupil, however, was somewhat larger than the left.When looking at objects the child threw back his head, and,still keeping it inclined to one side, of necessity squinted atthe object looked at instead of directing his gaze straighttowards it. On Dec. 23rd the patient remained in statu yco.On Jan. 26th, 1894, the movements returned more markedly,and two teeth were observed to be cutting through the gums.On Jan. 29th there was slight return of nystagmus in the lefteye, and slight nystagmus also of the right eye. About themiddle of February another tooth cut through the gums andthe nystagmus disappeared, the movements at the sametime becoming less marked. On April 3rd the child to allappearance was quite well. In this case no treatment was

adopted but the administration of cod-liver oil and attentionto diet.

Since the above case came under my notice I have, throughthe kindness of Dr. John Thomson of Edinburgh, seen

three others, and have been able from the books to collectfull notes of twenty-three more, making twenty-seven in all.The literature on the subject is somewhat scanty. ToHenoch of Berlin belongs the credit of having first drawnattention to the subject. In his text-book on Diseases ofChildren he gives in the first edition two cases and inthe second edition four cases. In THE LANCET 1 Dr.Stephen Mackenzie gives two cases (Harveian SocietyReports). In St. Bartholomew’s Hospital Reports 2 two casesare recorded by Dr. Gee. In the Ophthalmic SocietyReports 3 Mr. Nettleship records what appears to be an

example of spasmus nutans. In THE LANCET 4 Dr.Hughlings Jackson mentions the affection in his addresson the Relation of Ophthalmology to General Medicine,and suggests that it is akin to canine chorea. In theOphthalmic Ptevie7v5 a case is quoted from Dr. GordonNorrie of Copenhagen. The fullest account of thedisease, however, will be found in THE LANCET,* inwhich the late Dr. Hadden gave full notes of five cases andan analysis of twelve. In St. Thomas’s Hospital Reports for1892 Dr. Hadden recorded nine other cases. Kassowitz,

1 THE LANCET, May 1st, 1886.2 St. Bartholomew’s Hospital Reports, vol. xxii., 1886, p. 96.

3 Ophthalmic Society’s Reports, 1887, p. 76.4 THE LANCET, Oct. 26th, 1889.

5 The Ophthalmic Review 1888, p. 355.6 THE LANCET, June 14th, 21st, and 28th, 1890.

in an untranslated paper,7 mentions spasmus nutans, classi-fying it among the nervous symptoms of rickets. The

following five symptoms of the disease may be noticed:

(1) head movements ; (2) nystagmus ; (3) petit mal;(4) strabismus ; and (5) a peculiar way of looking at objects.The first two are by far the most constant. Both movements’and nystagmus are present in about 90 per cent. of the cases,but at certain stages, or even throughout its entire course, theaffection may be represented by only one of these. Duringincidence one-most frequently nystagmus-appears beforethe other, and during subsidence the nystagmus generallypersists longest. The head movements are most commonlya combination of shaking and nodding. Pure lateral move-ment is very uncommon, and pure nodding extremely rare.In frequency the movements are about 20 per minute.They cease during sleep and when the child is placed on hisback. They are increased or, if absent, excited by engaging-the child’s attention. They are not increased or induced bycovering the eyes. Whether moving or not, the head is

generally held inclined to one side, and there is gene-rally greater excursion of the movement to one or otherside. Restraint of the movements causes marked un-

easiness. The nystagmus may be monocular or binocular,most commonly the latter. The nystagmic movements.are very rapid, about 200 per minute. They are increasedor induced by engaging the attention, and markedlyso by laying the child on his back or by fixing the head.The nystagmus is only occasional, like the head movements.In direction it is most frequently horizontal, and onlyoccasionally rotatory or vertical. Nystagmus of the eyelidssometimes occurs, and hippus has been noticed. Withregard to petit mal, Dr. Hadden first drew attention to thisfairly constant symptom. The child is simply observed tolook vacant for a few seconds, and occasionally the head orthe eyes, or both, deviate to one or other side. Strabismusis not nearly so common as the other symptoms. It may be

constantly present or only occasionally. In some cases itis only noticed during an attack of petit mal. A peculiarway of looking at objects is nearly always observable.Dr. Hadden has happily described it as "looking out ofthe corners of the eyes." It is probably due to thehead being held, when looking at objects, in that positionin which its movements can best be restrained.The pupils are generally normal, but hippus has been noticed,and occasionally temporary inequality of the pupils has beenobserved. The fundus oculi is always normal and the visionperfect. The general health is nearly always good. The

diagnosis is comparatively easy. Eclampsia nutans-thesalaam convulsion-is only confusing in name. In this thewhole upper part of the body participates in a forward move-ment which is distinctly paroxysmal. The movements ofspasmodic torticollis resemble slightly those of spasmusnutans. Cases represented by nystagmus alone might be mis-taken for other forms of nystagmus until the eyes were examinedand no ocular defect discovered. , The prognosis is alwaysfavourable. In any given case it would be safe to say thatrecovery will take place before the child is two years of age,and that in all probability it will take place very much earlier.It is not the forerunner of epilepsy, and the after intelligenceof the child is in no way impaired. As to treatment, theaffection has a natural tendency to recover without drugs.Bromides are recommended by Dr. Hadden, Dr. Thomson hasfound benefit from antipyrin, and Kassowitz recommendsanti-rachitic treatment (phosphorus).

- ReMs.&mdash;In considering the etiology of spasmus nutansit is evident that, while sex has probably no influence, age is afactor of the first importance. A comparison of the cases shows.that 50 per cent. occurred between six and twelve months ;15 per cent. were under six and 15 per cent. over twelvemonths of age. The youngest was that recorded by Norrie,where the disease was noticed shortly after birth. AlthoughKassowitz looks upon the affection as due to rickets, this.occurs in such a small proportion of the cases that it cannotbe looked upon as more than an occasional predisposing cause.Convulsions, either as a personal or family tendency, aresomewhat uncommon. Falls on the head are recorded in sixor seven of the cases, the affection being noticed imme-diately afterwards. Dr. Hadden suggests that they may bemore the result than the cause, being actually attacks ofpetit mal. It is possible also that anxious mothers, lookingout after a fall for consequent mischief, have their attentionfirst drawn to symptoms already existent. Dentition is,

7 Wiener Medicinische Wochenschrift, 1893, U. 321.O 3