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J. A. (Joel Asaph) Allen.

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ataxia and myelitis. Benedikt, of Vienna, another leader of neu-
rological thought, has had, in a number of severe cases of tabes,
apparently astonishing results. Patients who were quite power-
less to walk or stand were enabled to take long promenades with,
and sometimes without, a cane. Neuralgic attacks seemed to be



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218 KBAUSS: NBUB0L06Y.

m6re often influenced by this method than any other train of
symptoms.

Bonjoar, of Zurich, in treating eighteen cases, thirteen of
which were locomotor ataxia, obtained excellent results in the
alleviation of some of the symptoms in every case. Duncan, of
Glasgow, reported recently a case of locomotor ataxia with con-
siderable improvement. Bogroff, of Paris, likewise reports sue-
cess in his cases. Gray, in his recent work on nervous diseases,^
one of the best from a therapeutic standpoint, says :

SuspensioD, indeed* is a new fad that has certainly effected a tern-
porary improvement in all the symptoms of some cases* often to a won-
derful degree. Thus, in one case of my own* in the last stages of the-
disease, this remedy was tried as a last resort, and. incredible as it may
seem* the patient* after two suspensions* got out of bed* which he had
not left for weeks* and walked down several flights of stairs.

Other favorable results have been obtained by Rnmpf, of
Marburg ; Althaus, of London ; Mendel, of Berlin, and a host of
other men high in neurological circles. Hirt, in his admirable
text-book, recently translated into English, has had a somewhat
monotonous experience. He treated 114 cases of locomotor
ataxia (eighty-nine men and twenty-five women) by suspension^
"In no single instance," says he, "was I able to note any marked or
lasting improvement, and in no case was either the general con-
dition of the patient, or the course of the disease, influenced for
the better ; nay, even in the individual symptoms, no decided im-
provement could be perceived." This experience is rather surpris-
ing, because, coming from such a keen observer, he certainly
would have detected results had they been forthcoming.

My experience with suspension has been very satisfactory,
partly because I did not expect to see my cases cured in a few
days, and partly because I would advocate this mode of treatment
as a last resort, and was content with any relief, however slight it
might have been. I treated three cases of locomotor ataxia, two
of hemiplegia, three of railway spine, two of neurasthenia, and
one of multiple sclerosis of the cord. One case of locomotor
ataxia, a prominent business man in this city, came to me with all
the characteristic symptoms of this disease, such as Romberg's,
Westphal's, and Argyll Robertson's symptoms, ptosis, and strabis-
mus, lancinating pains, ataxic gait, vesical and sexual disorders,
stomach crises, etc. Surely a typical case of tabes. His treatment
consisted of suspension three times weekly and spinal galvanism.



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KRAUSS : NBUBOLOOT. 219

After ^ye months of such treatment, I found that the tabetic
symptoms had all disappeared, save the myosis. Even the tendon
reflexes had returned, though not to their normal intensity. Today
he is at his work, thoroughly convinced that he has been cured of
locomotor ataxia. Occasionally he comes to be suspended, and on
each occasion I find his condition improving. I would not dare
claim that he has been cured or permanently benefited, because I
cannot believe that a spinal cord once sclerosed can be cleared up,
any more than a hobnailed liver can be repaired to its former use-
f olness. The other two cases of locomotor ataxia were temporarily
benefited, especially the gait and pains. One case of hemiplegia
recovered splendidly, surprising even herself ; the other case died
before the results came ! The case of multiple sclerosis grew
worse, if anything, while the cases of railway spine and neuras-
thenia have done well, and, supplemented by other treatment, have
recovered.

From all these reports, with the exception of Hirt's, we are
jostified in saying that suspension has done all that was promised
for it — sometimes doing more, sometimes less. When we consider
how exasperating are some of the symptoms of locomotor ataxia,
the least palliation that this treatment affords should be gladly
embraced and thanks returned. I doubt whether it will ever dis-
appear entirely as a therapeutic procedure in the treatment of
■pinal cord diseases.

HYPNOTISM.

Hypnotism and suggestion, another method which has at differ-
ent times claimed the attention of experimenters, but not until
reoently has it been considered a therapeutic agent. Animal mag-
netism of Mesmer, Hypnotism of Braid, and Suggestion of Char-
cot is a brief history of the development of this strange phenome-
non. Each of these experimenters has done much to unravel the
mysteries surrounding this agent, but to Charcot must be credited
the honor of snatching it from chicanery and giving it a certain
respectability. Liebault, Li^gois, and Bernheim must be com-
mended for their zeal and interest, while Luys has plainly carried
it beyond the limit of science and truth. Time will not permit
to enter into a discussion of the various stages, the different
methods, or into the points of difference between the Charcot and
Nancy schools, but merely to indicate its applicability and the
results that may be expected. I need not recall to you the won-
derful results obtained by observers, the world over, during the



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220 KBAUSS : NEUBOLOGY.

years 1886-1890 ; how long-standing chronic diseases of the brain
and cord disappeared like the dew, and how in it was found the
panacea of human ills. These much desired qualities were, how-
ever, of very short duration, for the crucial tests were soon applied,
and hypnotism and suggestion quickly found their proper sphere.

Hypnotic suggestibility depends first upon the presence of
extreme instability of the cellular nervous elements, and secondly,
upon a weak power of inhibition or control of the activity of
these elements. Persons of a low order of intellect are not favor-
able subjects for hypnosis ; neither are persons of a strong indi-
viduality, nor the insane. The class of cases most favorable for
hypnotic treatment are the hysterical ; first, because they can be
easily hypnotized, and secondly, because the disease requires a
treatment which appeals directly to the perverted action of the
cerebral centers. It surely is not indicated for exhibition pur-
poses, or for the treatment of any nervous disease or state, unless
all other remedies have been exhausted. Even in hysteria this
holds equally true. Binswanger, of Jena, in reviewing the litera-
ture on the use of hypnotism in the treatment of the insane, finds
that the best results were obtained in hysterical insanity, but in a
number of cases of melancholia, and chronic alcoholism, hypnotic
suggestion had marked success. Berillon, in treating 800 cases,
one-third of which were hysterical, had good results in almost all
from the use of hypnotism. Collins, of New York, Dujardin-
Beaumetz, of Paris, and many others, have had good results in
hysterical conditions, and uphold the Charcot doctrine. Almost
every functional nervous disorder, and many of the organic
diseases of the nervous system, have been benefited by hypnotiflm.
My cases were all of hysteria, and generally of the dull phlegmatic
temperament. Neurasthenia, and the excited states, are rarely
ever benefited. I agree with Berillon that hypnotism is indicated
(1) in the spasmodic attacks of grave hysteria and the paralysis
following, (2) in mono-symptomatic hysteria, (3) in ordinary hys-
teria, and in (4) hysterical insanity.

This subject is of such recent discussion in medical literature,
and the diseases treated so various, that I will refrain from taking
any more of your valuable time. In conclusion, I may repeat that
hypnotism is of the greatest therapeutic importance in some cases
of hysteria, but that its use should be delayed until it is absolutely
demanded.

382 Virginia Street.



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CLINICAL LECrUKS.

(^finicaf Isecfure.



CLINICAL MEMORANDA FROM THE SURGICAL CLINIC
AT THE SISTERS' OF CHARITY HOSPITAL.

Bt HERMAN MYNTER, M. D.,
Professor of Surgery, Niagara University, and Surgeon to the Sisters* Hospital.

CASE OF ACUTE INTERMITTENT UTDBO-NBPBBOSIS, FBOM VALVULAR

8TBICTUBE OP THE UBETEB, WITH TWO ILLUSTBATI0N8.

Case I. — Benjamin 6., aged 25, tailor, entered the Sisters' Hospital on
August 12, 1893, with the following history : He had, for twelve years,
had periodical attacks of pain in the right lumbar region without any
known cause. The attacks have come on about every two or three
months, and then lasted for four or six days. The pain has usually
been very intense, extending downwards into the thighs, scrotum,
and head of penis, and could only be relieved by hypodermics of
morphia. They were ushered in by continual vomiting and general
malaise, with fever and restlessness. During the attacks he had
noticed that the urine was somewhat scanty (one pint in twenty-four
hours), and voided with sonle difficulty. When the attack was over,
he passed urine freely and in greater quantity. The urine had never
contained blood or pus to his knowledge. He had never paseed any
concrements. Of late the attacks had become more frequent. He had
been treated by different physicians with alkalies, mineral waters, etc.
His mother had died of phthisis ; the rest of the family were healthy.
By the objective examination nothing particular was discovered. He
was tender, upon pressure, in the right lumbar region, but no apprecia-
ble fullness was discovered. The examination of urine showed specific
gravity 1035, acid reaction, no albumen, sugar, or bile. The color was
slightly reddish. Microscopically it contained numerous crystals of
oxalate of lime and blood corpuscles ; no pus or casts. It is to be
deplored that no cystoscopic examination was made, as it probably
woiild have given important information in regard to the diagnosis.
The patient had suffered for so many years, that he was anxious to
have something done to relieve him of his continual misery. The
symptoms pointed to the right kidney as the seat of lesion, and to a
kidneiT-stone, or an occlusion of the ureter, as the probable cause, and
I, therefore, advised an explorative nephrotomy, and performed it on
August 14, 1893, by aid of the usual oblique incision. After the kid-
ney was exposed, a fluctuating swelling, as large as an orange, was
discovered below and inside the kidney. It contained a clear, watery
fluid and was a hydro-nephrosis. An incision, one inch long, was made
io its lower end, and about one-half pint of fluid evacuated. The
finger was introduced and the pelvis explored for stone, but none were



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CLINICAL LECrUBB.



through
valvular s trie fare
and sa,c.




J/ydro
nephrosis



■nee SI on



appearance
after operation



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CLINICAL LECTUBE. 223

found. By spreading the incision iateraily the opening of the ureter
•could be seen plainly. It appeared as a papilla, extending one-fourth
of an inch into the cavity. A flexible bougie, No. 14 French scale,
was introduced with ease into the bladder, showing the ureter to be
permeable through its whole length. I could find no other cause for
the recurrent hydro-nephrosis than this abnormal condition of the
ureter. The kidney was not more movable than normally. I, therefore,
•enlarged the incision downwards through the papilla and well into the
healthy ureter, pulled the margins of the wound outwards with fine
hooks, and united the wound with numerous fine silk sutures, taking in
the outer two coats of the ureter and the sac and avoiding the mucous
membrane. After the wound was sutured, the appearance was more
like that of a funnel. (See illustrations.) The wound in the ureter
and sac was protected with a mesh of iodoform gauze for possible drain-
age, and the rest of the wound closed. For three or four daysa fter
the operation he complained of considerable tenderness in the lumbar
region, and moderate fever. No discharge of urine occurred through
the wound. The urine contained considerable blood, and had to be
drawn by catheter. The amount was seventeen and eighteen ounces
the first and second days, twenty ounces the third day, twenty-six
•ounces the fourth, thirty-eight ounces the sixth, and thereafter about
iorty ounces daily. Under the use of

Tinct. chlor. iron gtt. 20

Fid. ext. ergot 38s.

Acid gallici gr. x.

Glycerine, q. s. ad §ss.

d. Every four hours.

the urine cleared up and became normal, all pain and tenderness dis-
appeared, the wound healed, and on August 29th, fifteen days after the
operation, he was discharged well. He has since been well, and had
no attacks. From a letter of October 11th, I quote : "I am still feel-
ing well, and hardly realize that there ever was an operation performed
on me.^* I have so far not made a cystosoopic examination, and
satisfied myself that the fimction of the kidney is restored.

This case is of interest in more than one way. It proves, what
otherwise is well known, that incised wounds of the ureter may
heal as any other wound if carefully sutured. Fenger, of Chicago,
has published a very similar case (Chicago Medical Recorder ^
March, 1893.) He remedied the defect by dividing the valve
transversely and uniting the ends of the incision by suture. In a
<)a8e of stricture lower down he made a longitudinal incision and
united it transversely, similar to the operation of Heinecke-
Jtfikalicz for stenosis of the pyloris. I united the incision by



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224 CLINICAL LECTURE.

longitadinal sutare in my case, as there seemed to be a redandance
of tissue after the tip of the valve had been palled outwards.

Fenger states that " valvular stricture at the pelvic orifice of
the ureter is usually caused by lateral insertion of the ureter in a
dilated pelvis." Kiister, in a similar case, but with another stricture
lower down, resected the stricture and united the ureter with the
pelvis of the kidney. The result was excellent, but, as Fenger
states, the plastic operation is easier of technique.

The spontaneous evacuation of the hydro-nephrosis was prob-
ably due to obliteration of the valve, or papilla, by pressure, when
the hydro-nephrosis reached a certain degree.

The usual cause of intermittent hydro-nephrosis (according to
Terrier and Baudonin, who publish eighty-three cases,) is a float-
ing kidney, causing a kink in the ureter, and thus arresting the
evacuation of urine.

Most of the cases become, eventually, permanent by inflamma-
tory changes, which form bands of adhesions and thus fasten the
kidney in its displaced position. They advise early nephroraphy,
or else nephrectomy. Judging from the successful result of
Fenger's and my own cases, nephrectomy can scarcely be indi-
cated. It is well enough to call the attention of surgeons to the
possibility that a valvular stricture may be the cause of the acute
hydro-nephrosis, whether there be a floating kidney or not, and
that it then may be remedied by nothing more serious than a
slight plastic operation.

In the January (1893) number of the Buffalo Medical and
Surgical Journal I reported eleven cases of operations on the
kidney for various lesions. Three of these cases were nephro-
raphies for floating kidneys. Although considerably benefited
by the operation, the result was not what had been desired.
Sutures of animal tissue had been used ; and what is there to pre-
vent prolapse of the kidney again after the sutures have been
absorbed ? If too tightly knotted they will cut out anyway.
Riedel tried to improve the results by producing adhesions between
the kidney and the diaphragm, and he was successful in five cases.
Having exposed the kidney, he strips off the fibrous capsule and
pushes the organ so far up behind the diaphragm that only its
lower half is exposed. The median portion of the fibrous capsule
is then fixed to the anterior portion of the quadratus lumborum
muscle by deep catgut sutures. A strip of iodoform gauze is
then thrust up between the kidney and the diaphragm, so that the



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CLINICAL REPORT. 226

entire posterior surface of the kidney is covered, a second piece of
iodoform gauze is introduced into the space formerly occupied by
the prolapsed kidney, and a third piece is placed upon the lower
portion of the kidney lying upon the anterior surface of the quad-
ratus lumborum muscle. The whole wound is thereafter sutured,
leaving the ends of the gauze projecting at its upper and lower
ends, and the gauze tampons kept in place for four weeks. When
then removed, the cavity between the kidney and the diaphragm
will be found surrounded with strong, healthy granulations,
which will be changed into fibrous tissue and firm, strong
adhesions between the kidney and diaphragm.

I carried this operation out in the following two cases :
Case II. — Nephroraphy for floating kidney, after Riedel's method.
Mrs. H., 32 years old, had been in perfect health till April, 1891, when
she commenced to complain of dragging pain in the right side of the
abdomen. She emaciated rapidly, her weight falling from 118 pounds
to ninety-five pounds, complained of loss of appetite, insomnia, head-
ache, and frequent attacks of renal colic. A tender and movable lump
was discovered in the lower part of the abdomen. Shortly after she
became pregnant, ^nd as the pregnancy advanced, the symptoms grad-
ually disappeared, so that she '*had never felt better in her life.*"
After confinement the symptoms returned with increased severity, the
oervous symptoms particularly being severe. Dr. Frederick, who had
delivered her, then discovered a floating kidney near the brim of the
pelvis, which could be moved about with great ease, but was very
tender on pressure. On January 17, 1893, I performed nephroraphy,
after RiedeFs method. With the exception of some surgical fever dur-
ing the first days, and considerable oozing of serum from the wound,
necessitating large dressings, the course was uneventful. On Febru-
ary 18th, the gauze tampons were removed, and the kidney and sur-
rounding tissues found studded with healthy granulations. Drainage
tubes were introduced. March 8th, the tubes were removed. March
12th, wound healed. March 17th, patient allowed to get up ; kidney
feels immovably fixed. September 23, 1893, the patient has since felt
well, eats and sleeps well, has no pain, and is able to do all her house-
work and take care of her two children. The kidney cannot be felt in
any position.

Case III. — ^Nephroraphy for floating kidney, after RiedePs method.
Mrs. R., 45 years of age, had for six months complained of severe
pain one and a half inches to the right of the ensiform cartilage. The
pain would come periodically, and be attended with yellow color of
skin and conjunctivae and clay-formed stools. Five weeks previous to
ber entrance in the hospital she had symptoms indicating peritonitis.



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226 CLINICAL REPORT.

followed by a very severe attack of pain and jaundice, lasting four days.
She felt then a lump in right hypochondriac region of the size of an
eggt and corresponding to the gall-bladder. She entered in order to
have a cholecystotomy performed, it being supposed, from the history
and symptoms, that she suffered from gall-stone colic. Over the region
of the gall-bladder a pear- formed, nodulated, apparently immovable
tumor was felt, which had all the appearances of an indurated gall-
bladder filled with gall-stones. An explorative incision was made in
September. 1892. along the right margin of the rectus muscle, but on
entering the abdominal cavity, much to our surprise, no tumor was
found, and even the gall-bladder was absent. A hard lump was felt
behind the colon transversum. An opening having been torn through
the mesentery of the colon transversum, it was found to be a floating
kidney. The wound was therefore closed, and the patient left the
hospital in two weeks. She felt well for three months, when the
attacks returned more severe than ever, and could only be controlled
by opiates in large doses. For the last two weeks she had noticed that
previous to, and during the attack, there was a decreased amount of
urine, and that just after the attack had passed away, the urine would
be discharged in large quantity, all indicating acute hydronephrosis
from a kink of the ureter. She entered the hospital again on June 26,
1893. The kidney was then felt freely movable over the brim of the
pelvis, moving over an area of about three or four inches. June 26th,
operation after Kieders method. The further course was favorable.
The tampons were removed on July 25th, and the patient left the hos-
pital on August 14th. October 3, 1893, the patient has had no attacks
since, and says she is feeling perfectly well. She has gained con-
siderably in flesh. There is no tenderness, even by deep pres-
sure, in the iliac region, and the kidney cannot be felt in any posi-
tion.



The Massachusetts Institute of Technology has published a
beautiful and handsomely illustrated brochure, giving a brief
account of its foundation, character, and equipment, that was pre-
pared in connection with the World's Columbian Exposition. It
is published by the institute, and printed by the University Press,
Cambridge. It contains much interesting information relating to
this remarkable educational institution, and well repays reading
by every friend of advanced education in this country. It can be
obtained on application to Dr. II. W. Tyler, Secretary Institute of
Technology, Boston, Mass.



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THE STATB EXAMINATION FOR LICENSE. 227

BUFFALO MEDICAL AND SURGICAL JOURNAL

A MONTHLY REVIEW OF MEDICINE AND SURGERY.

EDITORS:
THOMAS LOTHROP, M. D. - - WM. WARREN POTTER, M. D.

AH oommunioations, whether of a literary or business character, should be addressed
to the managing editor: 384 Fbanklik Street, Butpalo, N. Y.

Vol. XXXIII. NOVEMBER, 1893. No. 4.

STATE EXAMINATION FOR LICENSE.

We have before as a copy of the law passed by the Pennsylvania
legislature, regulating the practice of medicine in that State. The
act is largely modeled after our own State law, but contains some
features which we fear may prove a stumbling-block, because of
the non-existence of a board of educational control, such as is our
state board of regents. A medical council, composed largely of
state officers, will be the governing body, who are to supervise the
examinations, both academic and professional. And just here is
where the trouble is likely to arise. If the work of this council
is to be rendered effective, the standing of every educational
institution in this country, and the regulations governing foreign
schools of learning, must become a part of its office files. The
appropriation of moneys for all the purposes of the law is but one
thousand dollars per year, which sum includes the salary of the
secretary and treasurer. The law is to go into effect March 1 ,
1894, and if those interested are wise, they will ask the regents at
Albany to place at the disposal of the Pennsylvania Medical
Council the records, accumulated during the past 100 years, which
show the institutions whose certificates indicate the completion of
a " competent common school education,^' and also the rating of
the many medical colleges in as well as out of the country.

As in this state, there are to be three boards of examiners,
representing the three incorporated systems of medicine. In
almost every other particular the law follows closely the lines
adopted in our state, and many pitfalls will be avoided if 'the
newly-appointed examiners were to make a practical inspection of
the workings of the law in New York. If the same harmony
which marks the operation of the law in this state, obtains in



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228 EDITORIAL.

Pennsylvania, we predict great and lasting results as the outcome
of this latest step in the advancement of medical science.

Two years have rolled by since the law empowering the state
(done to grant license for medical practice, has been in operation
in New York, and the promises of the advocates of the measure
have been more than fulfilled. The situation, fumed at by charla-
tan, fretted over by frightened student, and fought against by
some college professors, has now become a matter of fact, and
we hear of no one other than the barnacle that fattens in the



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 23 of 78)