CORRESPONDENCE.

DÜHRSSEN'S METHOD FOR THE OPERATIVE CURE OF RETROFLEXION BY VAGINAL FIXATION.

"A CORRECTION."

TO THE EDITOR OF THE AMERICAN JOURNAL OF OBSTETRICS. ETC.

DEAR SIR. In the September number of this JOURNAL a description of Dührssen's operation for retroflexion is given by me which I fear does not describe the new method correctly. As followed in the way then described there would be constant injuries to the bladder, and it was to guard against this that Dr. Dührssen devised his method. I herefore append the following correct description:

The operation is performed under narcosis and with the aid of two assistants. A speculum is inserted and the cervix seized by three volsellæ, two placed in the anterior, one in the posterior lip. A male catheter is introduced into the bladder for the purpose of defining its boundary as it lies between the reflected anterior vaginal wall and the uterus (as the instrument is in the bladder until the operation is completed, a rubber cap is fitted over its tip to prevent the entrance of air). The assistant on the right side, by means of traction on the volsellæ, brings the cervix forward to the vulvar orifice; pressure with the catheter in the bladder showing its lower limit. A transverse superficial incision is made one-half inch below in the reflected anterior vaginal wall, a volsella seizes the upper incised lip, and steady traction is employed so that by means of scissors the wound is enlarged in its depth, and by the use of the finger the bladder is dissected up from the uterus.

A sound (whose beak has the curve of a prostatic catheter) is placed in the uterus, and the assistant on the left, by means of downward pressure on the same, forces the fundus against the left forefinger of the operator; under guidance of this finger a needle armed with a long silk thread is thrust through

the anterior wall of the uterus transverse to its axis and as high up as can be reached, the ends of the suture being given to the assistant on the right, who performs outward traction. In like manner two more such threads are passed, placed one above the other, and as high up toward the fundus as possible. With the aid of these three sutures the uterus is strongly anteflexed; where the uterus is of large size four such threads are used.

The fixation of the uterus is accomplished by means of permanent silk sutures. A needle armed with silk is passed through the serous vaginal tissue of the lip of the original incision into the body of the fundus and out again, and tied; in all, three are used. It is important that the prostatic sound hold the uterus in the median line, otherwise it will be sutured more or less to one side.

The provisional traction threads are removed and the original incision closed by means of a continuous catgut suture, thus burying the three threads that fix the uterus. The catheter and sound, as well as the volsellæ, are withdrawn, the parts irrigated, and the operation is done.

JACOB ROSENTHAL, M.D.

DRESDEN, Oct. 14th, 1892.

TRANSACTIONS OF THE WASHINGTON OBSTETRICAL AND GYNECOLOGICAL

SOCIETY.

Stated Meeting, December 4th, 1891.

H. L. E. JOHNSON, M.D., Vice-President, in the Chair. DR. W. SINCLAIR BOWEN presented an interesting

PLACENTA AND CORD

and gave the following history:

November 23d, 1891, he was called to a case of confinement. Primipara. Vertex presentation. Left position, anterior variety. Labor normal except artificial rupture of membranes. No accident to mother or infant. The point of interest in the case was the presence of a loose sac of amnion around the funis. The amnion was not applied to the umbilical cord in the usual manner, but was reflected from the fetal surface of

the placenta about three inches from the insertion of the cord, thus forming the peculiar cylindrical bag shown in the illus

tration.

DR. THOMAS C. SMITH read a paper on

THE USE OF ERGOT IN THE SECOND STAGE OF LABOR.2

DR. JOSEPH TABER JOHNSON, in opening the discussion, said that Dr. Smith had given in his paper reasons enough against

The

the use of ergot to convince any man that he should not use it. On the other hand, he had brought forward no argument to prove that the position he had taken in the paper read by him before the American Gynecological Society was wrong. paper referred to above was a protest against the abuse of ergot. He had not attempted to formulate rules for its adminis tration. He sought to induce that society to stamp the general use of the drug as dangerous. He did not doubt that in the

'See original article, p. 895.

hands of the discriminating physician the drug was a reliable therapeutic resource. He referred to a number of cases of stillbirth in which the reporters attributed the death of the fetus to the administration of ergot; and he gleaned from Health Office reports that the majority of still-births were caused by giving ergot. He had no doubt that ergot might be used advantageously, but he had no hesitation in saying that humanity would be a thousand times better off without it. It exerts a brutal force and is an extremely dangerous drug. It is a cause of rupture of the uterus, lacerations of the cervix and perineum, and the death of the child. He did not believe that Dr. Smith was correct in saying that the pains produced by ergot were natural. They are constant and not intermittent. Barnes said it was a brutal and murderous drug and should be banished from the lying-in room. The harm done by ergot was when it was used by the less informed. He had no hesitancy in saying that it had its uses. Perhaps ten-drop doses might be a good way in which to use it. But when the parts were in the condition described as suitable for the administration of the drug, why not use the forceps? He had no doubt that the drachm doses of ergot caused the death of the fetus referred to in his case, hence he wrote his paper against its use. was proud of his paper and thought it the best he had ever written. He had received more than a hundred letters commending the position he had taken.

He

DR. H. D. FRY said that he had been informed that at his own birth ergot had been administered faithfully, and he was born asphyxiated and was with difficulty resuscitated. He said he thought that Drs. Smith and Johnson held about the same views. The latter inveighed against the abuse of the drug, while the former advocated only small doses. He had regarded ergot as a dangerous drug in labor, but, thinking that his views might be extreme, had employed it recently in a case in which the labor had progressed normally until the head rested upon the perineum, where it lingered. He administered three doses of ergot, of fifteen drops each, at half-hour intervals, with satisfactory results. In another case, that of a primipara, in which the labor lasted about fifteen hours, he used the drug in the same way as in the former case. The child was born asphyxiated and was with difficulty resuscitated. The asphyxia was attributable to the ergot, as he could account for it in no other way. This last experience had scared him off from the use of the drug. Pajot's rule, quoted by Dr. Smith from Charpentier, was the correct one. The alteratives, as chloral and chloroform, hot douches, quinine, and the forceps, are preferable to the use of ergot. For you cannot limit the effect of ergot to the corpus and fundus of the uterus; it will also act on the circular fibres of the internal

os, which may lock up the placenta and clots within the

uterus.

DR. S. C. BUSEY said he had had no experience with ergot in the second stage of labor. He remembered to have had some trouble once with retained placenta where ergot had been given after the child was born. He thought it most remarkable that ten-drop doses of ergot would produce intermittent pains in twenty minutes after its administration by the mouth. There are few drugs administered in that way that will produce any effect so soon. He thought that Dr. Smith was treating his own impatience when he was administering ten drops of ergot in repeated doses. He thought that the lesson taught was to hold up in the administration of so dangerous a drug; but he would not banish it from the lying-in room. It was most valuable in post-partum hemorrhage. He related a case that occurred to him in the country, in which he could check the hemorrhage as long as he held ice within the womb or compressed it with his hand upon it. He gave a drachm of ergot and had to wait three-quarters of an hour to get any effect. It takes from three-quarters to one hour for it to produce contractions. In these cases of hemorrhage it is invaluable to keep up contraction after the uterus is empty. Referring to Dr. Fry's second case, he said it was not so much duration of labor as long continuation of impaction in the pelvis that produced asphyxia.

DR. H. L. E. JOHNSON said that when the pains were flagging he preferred to use forceps. He did not use ergot at all. He thought it should only be used after the uterus was emptied. Its action is slow and uncertain, and in post-partum hemorrhage other means must be employed until at least half an hour has elapsed after its administration. He related a case in which ergot had been given by a midwife; he was called in and delivered the woman of a dead fetus. He had no doubt that the dystocia was produced by the ergot, as the woman had a capacious pelvis.

DR. T. C. SMITH, in closing the discussion, said that the reason he had taken Dr. Taber Johnson's case was to use it as a text. He admitted having had a similar one himself in his early practice. Recently his experience with the use of ergot had been most agreeable. He had met with cases in which small doses relieved the patient. He gave ergot with the same judgment he did other drugs, and, when given in the manner he had indicated, it gently stimulated the womb and did not tetanize the uterine muscles, but, on the contrary, produced intermittent contractions such as we expect to have in a typical labor.