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J. A. (Joel Asaph) Allen.

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714 Daggett: bladd&b gymnastics and auto-irrigation.
BLADDER GYMNASTICS AND AUTO-IRRIGATION.

Bt BYRON H. DAGGETT, M. D., Baffalo, N. Y.

At the regular meeting of the Lake Erie Medical AssociatioD^
July 15, 1892, 1 read an article describing a method of irrigation
of the deep urethra and. bladder without the use of a catheter,
which was published in the Buffalo Medical and Surgical
Journal, March, 1893. After the lapse of nearly two years' time,
and the additional experience of continual tests, I feel warranted
in asserting that nineteen out of twenty patients may be taught to
irrigate in this way. The failures will be due to a very small
stricture or a very large prostate.

I will briefly refer to a few notes taken since the publication of
that paper, and preface these memoranda by repeating the technique
of bladder irrigation without catheterization. The materials are a
four-quart bag, a tube six feet long with a shut-off within easy reach.
The tube is attached to the inlet of the double canula (Fig. 1),
its bore being twenty per cent, larger than that of the outlet. The




Fig. 1. — The Daggett canula.

nozzle of the canula is introduced from one to two inches, accord-
ing to the size of the meatus, and is made wedge-shaped, in order
to All the varying calibers of urethral meati. It is sufficiently long
to be conveniently held in place by grasping the penis behind the
glans, at the same time drawing the pendulous portion in line with
the fixed urethra. The bag is filled with water, at a temperature
of 1 15 degrees, to insure more than blood warmth as it flows, and



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DAGGETT : BLADDBB GYMNASTICS AND AUTO-IRRIGATION. 715

is made bland by the addition of a little glycerine, mucilage, a
few grains of salt or soda carb., and elevated two or three feet
above the plane of the pelvis.

The patient mast assume a reclining position — a reversed
squatting posture — since flexure and gravity are essential factors.
He may do this in an ordinary bath tub by resting his back along
the incline at its head, so that the trunk is at an angle of forty-five
degrees from the horizontal line, flexing the thighs at right angles
with the body and supporting the legs at right angles with the
thighs. If there is no bath tub at hand, a hip bath may be
arranged for this purpose, or the patient may posture himself in a
low rocking chair, tilted and blocked (Fig. 2), so that his body
assumes the position described, his legs resting upon another chair
or upon a stand.



Fig. 2. — Posture for auto-irrigation of the bladder.

The nozzle of the irrigator is then introduced, the penis grasped
and drawn in line with the fixed urethra, the stop opened and the
water allowed to run if necessary until the bag is empty ; if it has
not passed into the bladder, try again. A peculiar feeling gives
warning of the passing of the water through the posterior urethra,
the return flow diminishes and escapes in a pulsating stream, when
a finger of the right hand is placed over the exit, to divert the
entire flow into the bladder, which at first resents the intrusion



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716 DAGGETT : BLADDER GTHNASTICS AND AUTO-IRBIGATION.

and ejects after reoeiving two to three ounces. Repeat this and the
bladder becomes more tolerant each time. Three to four flushings
are sufficient at each stance and the stances may be repeated three
times daily if necessary. The novelty and comfort afforded by
irrigation sometimes induce patients to overdo, at the beginning,
before tolerance is established. The diminished, pulsating outflow
would seem to indicate an anti- or retro-peristaltic action of the
accelerator muscle. This process is a coaxing one, in which the
gentle pressure of the continuous flow of the hot, non-irritating
current and the posture described are essential conditions. The
patient acquires a knack at the first success, which he realizes and
which I can scarcely describe, that gives him an abiding faith in his
ability to flush his bladder at will.

MEMORANDA.

Case I. — R., 63 years of a^e, gives me the following history of hia
sufferings : In a mining camp, twenty-three years ago, he had a very
severe attack of cystitis, caused by drinking alkaline water. He came
home on this account, was ill several months, and never fully recovered.
He had been confined to his room four weeks ; drugs falling to bring
relief, irrigation by double catheter was employed ; still his condition
grew steadily worse. His attending physician, realizing that a crisis
was at hand, proposed to call in a surgeon to do cystotomy. R. declined
this service, and called me to take charge of his case. At this time, he
presented all the phenomena of septic infection. His urine was
stroDgly alkaline, offensive, depositing one quarter part, by volume,
solid matter, consisting of pus and inflammatory debris. R. readily
learned self-irrigation without the catheter, and cleared his urine in
five days, and was able to attend 'his office. There still remained a
tendency to relapse, which was controlled by irrigation.

It was noted that irrigations not only warded off this tendency, but
they also relieved soreness and pain, as he expressed himself, were
luxurious, and enjoyed three times each day. R. would completely
empty his bladder, as he supposed, placing himself as described. The
first washing would show straw or amber color, the third would be
clear. He passed into his bladder half a pint of hot milk, and main-
tained that, as hot milk was good for sore eyes, therefore it ought to
be good for sore bladders. After micturating, he irrigated, and the
first washing was very milky, the third showed up clear. These tests
indicated residuum, which, becoming disturbed, caused cystitis. The
prostate is not perceptibly enlarged, and he has never had retention.
He firmly refused permission to pass the catheter to test the question of
residual urine, alleging that he had already suffered sufficiently from
the use of that instrument for irrigation.



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DAGGETI : BLADDER GYMNASTICS AND AUTO-IBBIGATION. 717

After doing bladder gymDastios by three daily Irrigations for six
weeks, it is evident that this visous is completely evacuated by normal
urination, and, more than this, the rising stream is ejected with suffi-
cient force to menace facial autonomy . Gymnastics of the lower urinary
apparatus had relieved urinary stasis and its ever-attending threat.

Cask II. — B., 20 years old, a railroad fireman, had been confined
to his bed five days, suffering from prostatocystitis, caused by gonor-
rhea, passing thick decomposing urine every ten to fifteen minutes.
He succeeded, in the second trial, in fiushing the bladder. The swell-
ing of a prostatic abscess interrupted or blocked deep irrigation for
eighteen hours. Immediately following the rupture of the abscess,
irrigation was successful and uninterrupted to the end. Pain practi-
cally ceased in three days, and within a week he could hold his water,
for six hours. For three days following the rupture, he passed masses
of macerated blood coagula, which was made possible by fiooding the
bladder and evacuating its contents by normal urination. Recovery
was speedy and complete.

Two oases of recurring attacks of orchitis due to chronic irri-
table posterior urethritis have been promptly relieved and relapses
forestalled by irrigation pending other measures.

Dr. T. S. Stuart, of Buffalo, kindly permits me to include in this
paper a synopsis of a report of one of bis cases of prostatic hyper-
trophy, which caused stillicidium and retention of urine :

W., a house painter, 61 years old, states that for five years his urine
has passed away by dribbling, constantly necessitating the use of pro-
tectives. April 20, 1894, he had a severe attack of strangury, and his
physician being unable, after repeated efforts, to pass a catheter, pal-
liated the symptoms by the admini^ration of drugs. W. continued to
suffer from distension and tenesmus. Dr. Stuart was called April 28th,
and, after making diligent efforts, failed to pass a catheter. The case
becoming urgent. Dr. Stuart says : ' * I determined to test the method
proposed by Dr. Daggett — namely, relaxation by posture and hot water
irrigation. My patient was seated in a low rocking chair, tilted as
described in this method, and his legs placed on the tops of two other
chairs. The canula was introduced, and within a short time he
expressed a desire to urinate ; the canula was then removed, and he
passed nearly a pint of fiuid. Irrigation was used twice daily for a
week, then once daily since that time. Convalescence has been unin-
terupted. and his power to void urine has steadily improved. At present
W. has no difficulty in urinating, dribbling has ceased, and he feeU
better than for several years past."

Another interesting phenomenon is developed by this process,,
and that is the restoration of impaired procreative functions.



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718 CLINICAL REPORTS.

After several years experience and two score cases as they occur
in the roands of a general practice, I feel warranted in asserting
that more than ninety per cent, of these patients may be taught to
irrigate the bladder without a catheter.

Success is attained by technique, posture and perseverance.

258 Franklin Street.



(©PinicaP S^eporfA,



. CLINICAL MEMORANDA FROM THE SISTERS' OF
CHARITY HOSPITAL.'

Bt HERMAN MYNTER, M. D.,
Professor of Surgery, Niagara University, Buffalo, N. Y.

CHOLECY8T-DUODEN08TOMY AND GASTRO-ENTEROSTOUIES BY AID OP
murphy's BUTTON.

While operations on the gall-bladder have been performed as long
ago as in the middle of last century, it is first during the last ten
or fifteen years that improved methods have been devised, by aid
of which a moderately favorable prognosis could be obtained.
And yet the progress has been so rapid, that operations, which but
a few years ago were universally employed, are obsolete now or
will soon be considered so.

We owe this progress, as so many other advances in surgery, to
American surgeons ; in this case to Dr. John B. Murphy, of Chi-
cago, whose anastomosis button, by its simplicity and mechanical
perfection, and the ease and celerity with which it may be applied,
seems to fulfil all indications for a safe and reliable removal of
gallstones from the gall-bladder itself.

The question arises, When ought we to operate in cases of
jaundice ? It is impossible to give a distinct diagnosis in each
case. Jaundice may be the result of gallstone impaction in the
common duct, or of cancer of the pancreas or liver, involving the
duct, or simply of a gastro-duodenal catarrh. In many cases, of
course, the symptoms will be sufficiently prominent to give a dif-
ferential diagnosis ; in others the diagnosis will be obscure, unless
we open the abdomen.



1. Read before the Surgical Section of the Buffalo Academy of Medicine, Tuesday
evening, June 5, 19M.



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CHOLKCY8T-DUODKN08TOMY AND GA8TBO-ENTSR08TOMISS. 719

I need scarcely mention that an impacted gallstone, if suffi-
ciently large, in the common dact gives jaundice, and, secondarily,
swelling of the gall-bladder, while an impaction in the cystic duct
is not followed by jaundice, and may not be followed by swelling
of the gall-bladder, unless cholecystitis superrenes. On the other
hand, swelling of the gall-bladder, with or without jaundice, may
be the result of a carcinoma of the gall-bladder itself, or neoplasms
in the pancreas and liver, involving the common duct, or of an
empyema, the result of a cholecystitis with or without gallstones.

When ought we, therefore, to discard medical treatment, and
have recourse to the only means which can clear up the diagnosis
— laparotomy ?

I believe that jaundice ought to be treated by laparotomy after
a course of medical treatment of several weeks has demonstrated
the improbability of relieving the trouble by this means.

The abdomen having been opened by a vertical incision at
the outer edge of the rectus muscle, we may examine the gall-
bladder for stones in the common, cystic or hepatic ducts,
and if found, particular)^ in the gall-bladder, remove them with
scarcely any danger to the patient. If carcinoma of the gall-
bladder should be found, it is entirely feasible to remove the gall-
bladder by cholecystectomy. If the common duct should be found
obstructed by a neoplasm, we may, at least, relieve the jaundice by
a cholecystenterostomy, without any more danger to the patient
than accompanies an ezplorotive antiseptic laparatomy, and that is
nihiL

The older operations for gallstones consisted in: (1) suture
of the gall-bladder to the parietal peritoneum with secondary
incision, t. e., cholecystotomy in two sittings ; (2) suture with
immediate incision, i.e., cholecystotomy in one sitting ; (3) incision
of gall-bladder followed by immediate suture and reposition in
abdominal cavity, t. «., ideal cholecystotomy. Of these three
operotions, the first has given the most favorable results, the mor-
tality being ten per cent., six deaths in fifty-nine cases.

The second operation has given a mortality of 19 per cent, in
201 cases, but both the first and second operations have the great
disadvantage that a biliary fistula is left in a large number of cases,
estimated at 81 per cent., so that perfect recovery has only been
obtained by these operations in about 50 per cent. The third
operotion, ideal cholecystotomy, has given a mortality of 23 per
cent. Compare the results of these operations with the most



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720 CLINICAL BEPOBTS.

modern operation, soaroely as yet known to physicians, the
cholecyst-enterostomy, or cholecyst-duodenostomy, by aid of Mur-
phy's button, with a mortality of nihil and a complete recovery
of 100 per cent, in seventeen cases, or if I add one of my own,
eighteen cases, and you will probably agree with me, that the pro-
blem of removing gallstones by operation has been most ably and
brilliantly solved by this new device.

The operation is performed in the following way : after the
abdomen has been opened and the gall-bladder isolated and drawn
out of the wound, a running thread is inserted around a line one-
third longer than the incision to be made, and going through all
the layers of the organ. The incision is thereafter made and the
gallstones removed. It is not necessary to remove all the gall-
stones, as they will pass away after the button has been passed. One-
half of the button is now inserted with a forceps and the running
thread tied around the cup. A similar thread and incision is made
in the duodenum, opposite the mesentery and below the head of the
pancreas, the button inserted and the two halves firmly pressed
together. The spring in one of the pups maintains pressure
till the button sloughs off, and it is voided by rectum in from
seven to twenty or twenty-five days. The gall-bladder shrinks
thereafter, forming a canal of the size of the common duct. This
operation is, according to Murphy, indicated : (1) in all cases
in which it is desired to drain the gall-bladder ; (2) in all cases of
cholelithiasis with obstruction of the common duct ; (3) in all
cases of cholecystitis, with or without gallstones ; (4) in all pro-
fusely discharging biliary fistulas. It is contra-indicated : (1)
when the gall-bladder is too small for insertion of the button ; (2)
where adhesions are so extensive that the bladder and duodenum
cannot be approximated ; (3) where the ductus cysticus is obliter-
ated, in which cases cholecystectomy is indicated.

When a stone is impacted in the common duct, attempts have
occasionally been made of removing it either by crushing it through
the walls with instruments protected by a rubber covering, or by
dividing it by a needle introduced through the wall, or, lastly, by
incising the duct, removing the stone and closing the wound by
suture. This last operation is very difficult, on account of the deep
position of the duct, and the mortality is about forty per cent.

The Murphy button may be used to advantage on other organs
than the gall-bladder. In a recent case, operated seven weeks ago,
I made an anastomosis between the stomach and the duodenum, on



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CHOLECYST-DUODKN06TOMY AND G ASTRO-EN TSROSTOMISS. 721

aoconnt of cancerous striotare of the py loras. The case was entirely
successful, all vomiting stopped, and the patient left the hospital
in three weeks greatly improved, able to eat and retain his food.
His life will, probably, be lengthened a good many months by
this operation. In another case of cancer of the pylorus, in which
the patient was extremely exhausted from starvation from vomit-
ing, death occurred twelve hours after the operation. The Opera-
tion was performed in less than fifteen minutes, and she died
simply from exhaustion. In a third case of cancer of pylorus, in
which the patient was in a state of extreme inanition, I made a
gastro-daodenostomy a few weeks ago, using the smallest of Mur-
phy's buttons, as the others of my set were all in use. For seven
days everything went well, vomiting had ceased, and the patient
was improving and feeling well, when she suddenly complained of
severe burning pain in the abdomen, as if ** melted lead was being
poured down among the bowels." She collapsed and died in two
hours. The post-mortem showed thskt the button had slipped out
of the stomach, leaving a large opening, through which the con-
tents had entered the abdominal cavity. The small diameter of
the button necessarily allowed only a small brim of the hypertro-
phied wall of the stomach to be compressed between the cups, and
the accident occurred partly on this account, partly from muscular
contractions of the stomach. I consider it of the utmost import-
ance to publish this case, and shall, in all future gastro-enterosto-
mies, use a running suture around the button as a means of safety.
I do not believe it could have occurred in a cholecyst- enterostomy,
where the muscular force, probably, is lacking.

I question whether a gastro-duodeuostomy may not be the
proper thing to do in recurrent ulcers of the duodenum. We do
not, of course, know in a given case whether the ulcer is duo-
denal or gastric, but both result in stenosis with consecutive dila-
tation of the stomach, hypertrophy and, later, atrophy of the wall.

Dr. Carle, of Turin, in the last international congress, at Rome,
reported fourteen operations on the stomach for non-malignant
affections, of which only one died. Eleven were pyloro-plastio
operations, one a gastro-enterostomy for stenosis with hemorrhages,
one a divulsion and one a resection of the pylorus. His conclusions
are : (1) In rebellioas chronic gastric catarrh it is permissible to
resort to exploratory laparatomy. (2) When a condition is found
to exist rendering evacuation of the stomach difficult or impossible,
it is necessary to perform some operation <o remedy the defect.



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722 CLINICAL REPORTS.

(3) It is absolutely essential to provide for free evacuation of the
stomach, for it is better that the organs should be incontinent than
that stagnation of the gastric contents should exist. (4) The suc-
cessful result in the case of gastro-enterostomy proved to his satis-
faction that ulcer with hemorrhage can be treated in this way more
satisfactorily than by resection.

Mikulicz's pyloro-plastic operation is difficult, and takes a
long time, probably several hours, to perform. Loreta's opera-
tion of divulsion has the same disadvantage as divulsion in stric-
tures, — that there is nothing to prevent a return of the con-
striction. With Murphy's button, on the other hand, we can
establish a new communication in a very short time (about ten
minutes), without danger of shock from long exposure of the
abdominal organs, and I should, therefore, consider this method
preferable. In cases of ulcer with hematemesis and stenosis we
may expect, it seems to me, the ulcer to heal and form a firm
cicatrix, as it will not be continually irritated by the passage of
food and fermentation.

Lastly, I wish to report two cases of oholecyst-enterostomy :

Case XVII. — Mr. M., aged 24, entered the Sisters' hospital in
March, 1894, with the following history : He had been taken sick
fourteen months previously with a deep-seated, heavy, dull pain in the
epigastrium, followed, at irregular intervals, by sharp, crampy pains,
beginning in the same region and extending all over the abdomen.
Jaundice occurred shortly after, and had continued since in increasing
degree, so that he was now of a deep yellow, or rather greenish, color.
He had continually had clay-colored stools, dark urine, intense itching,
nose-bleeding. He had complained of increasing emaciation and weak-
ness, and I do not remember to have seen a more utterly prostrated
and cadaverous-looking patient. The liver was enlarged, extending
three inches below the lower border of the ribs. A rounded tender
swelling was felt to the right of the median line in the epigastrium.

That we here had a case of stenosis of the' common duct admitted
of lio doubt, but the cause was unknown, although the probable cause,
judging from the history, might seem to be gallstones. Laparatomy
was, therefore, performed along the right border of the rectus muscle.
An enormously dilated gall-bladder, as large as the head of a child,
was seen, strongly adherent to transverse colon. The adhesions were
loosened and the gall-bladder drawn out through the wound and punc-
tured. * It contained about a pint of thin, yellow-greenish fluid mixed
with mucus. No stones could be felt, but a deep hard tumor was felt
behind, probably in the pancreas. A cholecyst-duodenostomy was
thereafter made with MuV*phy^s button. No. 2, and the wound closed.



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PUBRPERAL CONVULSIONS WITH ALBUMINURIA. 723

He lived six days after the operation, and died of prostration without
peritonitis. On the second day the stools commenced to become brown-
ish in color, the urine cleared up tsonsiderably, . and he complained
only of extreme weakness.

Post-mortem showed cancer of pancreas infiltrating and closing the
<;ommon duct, and disseminated cancerous foci in the liver.

Case XVIII. — Mrs. K., sixty years of age, had for* nine years
suffered from periodical pain in the region of the liver, followed by
severe vomiting, and treated for neuralgia of the stomach. She had
never suffered from icterus. In February, 1894, she was taken sick
with what was supposed to be an attack of appendicitis, had pain, vom-
iting, fever and a tender painful swelling in the right ileo-cecal region.
She recovered, but had another attack in the beginning of April, 1894,
which also was treated for appendicitis.

I was called to see her on April 14th, as she continued to have pain
in the ileo-cecal region. There was felt here a deep-seated, oblong,
movable and painful tumor, extending from McBurney^s line downward
and inward. The tumor was about three inches in length and, appar-
ently, a couple of inches broad, and could be indistinctly followed
upward toward the liver. An exploratory inoision was made, on
April 17th, by the usual oblique incision for appendicitis, and the
tumor proved to be an enlarged, thickened and elongated gall-bladder,
full of pus and gallstones, and adherent to colon ascendens and trans-
versum. The usual suture was applied and the gall-bladder opened,
«nd 126 gallstones removed, of different sizes, the largest as large as
a hickory nut. Duodenum was found with difficulty and only by follow-
ing the ileum upwards from the ileo-cecal valve. The button was
thereafter inserted and the abdomen closed. The further course was
favorable, and she left the hospital on the fourteenth day, stating that
she had not felt so well for many years. The button could then still
be felt beneath the scar. On the twenty-second day the button could
not be felt any more, and she passed it on the twenty-third day. She
has since felt in perfect health.



PUERPERAL CONVULSIONS WITH ALBUMINURIA.^

By BENJ. G. long, M. D., Buffalo.

Mrs. T., American, aged 30, married; seen first Jane 15, 1892.
Pale and waxy in appearance ; face paffy ; feet and limbs very
edematous ; coughing almost persistently, headache, sleeplessness^
and some impairment of vision ; reports that she is about eight
months pregnant ; second pregnancy ; first child born dead, labor

1. Reported to the Section in Obstetric»< and Gynecology, Buffalo Academy of Medi-



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 72 of 78)