COMPLIMENTS OF TOE AUTHOR. THE GENU-PECTORAL POSTURE IN Uterine and Ovarian DISPLACEMENTS. READ BEFORE THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, FEBRUARY 7, 1882, AT ALBANY, N. Y. BY WILLIAM WARREN POTTER, MoP„ BUFFALO, N. Y- SYRACUSE, N. Y.: Truair, Smith & Bruce, Printers and Book Binders. 1882. THE GENU-PECTORAL POSTURE IN Uterine and Ovarian DISPLACEMENTS. READ BEFORE THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, FEBRUARY 7, 1882, AT ALBANY, N. Y. BY WILLIAM WARREN POTTER, M. D., BUFFALO. N. Y- SYRACUSE, X. Y.: Tkuair, Smith & Bruce, Printers and Book Binders. 1 882. THE GENU-PECTORAL POSTURE In the Treatment of Retro-Displacements of the Uterus and in Dislocations of the Ovaries. William Wabeen Pottee, M. D. Buffalo, N. Y. The influence of posture upon the health of woman is one of acknowledged potency; that many of her maladies are primarily induced through this influence cannot be denied. It must be so, since gravity plays such an important part in the economy ; the solids and fluids of the body, alike, are subject to its influ- ences, and obey its laws; and gravity, in turn, yields a large measure of submission to the mandates of posture. The reproductive organs of women are so generously supplied with blood-vessels, as to make them peculiarly susceptible to the influences of gravitation, while their extreme mobility ren- ders them especially liable to displacement under the action of gravitory law. If this be true in health, when all of the functions of the body are normally performed, then it must be admitted that the tendency is materially augmented when these organs are increased in bulk, or changed in structure, through the in- fluences of disease. That which is physiological under certain conditions, becomes pathological under others. It is but a step accross the health line. Since gravity, therefore, becomes a factor of so much im- portance, etiologically speaking, in the sexual disorders of women, it is fortunate that we are enabled to invoke the aid of this self-same law, in the treatment of many of the maladies which it has been instrumental in causing or augmenting. To accomplish the reversal of the normal gravitation of the blood and viscera, and thereby relieve the reproductive organs of the vascular distension, hypersemia, blood-stasis, and impaction, consequent upon uterine and ovarian dislocations, is to fulfill one of the most prominent and important indications of treat- ment which these cases present. Whenever it becomes advis- able to reverse the action of gravity upon the pelvic organs of the female, or to remove the pressure and impaction of the superincumbent viscera, the genu-pectoral posture furnishes a most precious method of accomplishing this result; moreover, through its systematic, intelligent, and persistent employment, we lay a broad foundation of relief, upon which to construct the ultimate superstructure of possible cure. Having accustomed myself during several years past, to em- ploy the knee-cliest position in the treatment of all backward displacements of the uterus, as well as in prolapse of the ovaries, I am prepared to affirm the superiority of this method over all others with which I am familiar, in the man- agement of this class of maladies. Under its timely and judi- cious use even the most complicated and obstinate kinds of retroversion and retroflexion, with fixation of the uterus in the hollow of the sacrum, may be made to yield. The methods generally recommended, and commonly em- ployed, in reducing the retro-displaced non-gravid uterus have, oftentimes, been disappointing and unsatisfactory in their re- sults ; while, in not a few instances, dangerous conditions have followed their use. The genu-pectoral method of replacement possesses the advantage of freedom from danger, besides being more effectual and infinitely less painful, than reduction by the sound, or redresser, or even by manipulation. It is a well-known fact, that when a woman is properly placed in the knee-chest posture, the pelvic and abdominal viscera gravitate toward the epigastric region, and that air, upon separation of the labia, rushes into the vagina, dilating it to its fullest capacity, and making its entire surface visible at a single glance. The accidental discovery, —perhaps I should say re-discovery,—of this fact by Sims, in 1845, marked a new era in the intra-pelvic surgery of women. New instruments were devised to meet the new order of things; and, soon, many of the accidents of parturition, hitherto entirely beyond the ken of the most skilful surgeon, were repaired with the greatest ease. While, therefore, the superior advantages of the genu-pec- toral posture, or some modification thereof, have been uni- 3 versally recognized by gynecologists in bloody operations upon the genital tract, I feel sure that I am entirely within the limits of truthfulness in asserting that, except by a few specialists, it is seldom brought into use for the commoner ailments, for which it seems equally well adapted. Authors of text books as a general rule, if, indeed, they refer to the position at all, recommend its trial in the replacement of such wombs as have resisted all other known means. They wrnuld try all other methods first and, finally, after failure and disappointment, reluctantly perhaps, resort to the knee-breast posture. Teachers of gynecology also, in so far as I am familiar with their methods, with a few notable exceptions, follow the same order, as do the text books, in recommending the method. It will be my purpose, in this article, to advo- cate the adoption of the genu-pectoral posture as a primitive measure, in the reduction of all retro-displacements of the uterus, as well as in prolapse of the ovaries. To obtain the full benefits of this position, in the treat- ment of the diseases under consideration, some conven- iences are essential, and they may as well be enumerated here: 1. A table. 2. A proper speculum. 3. A double-curved uterine dressing forceps. 4. Bits of cotton tied with thread. 5. An assortment of pessaries. 6. Jars containing (a) carbolated glycerine, (5)glycerate of tannin, (c) sedative mixture,* etc. So much depends upon minute attention to details in this, and for that matter, in all gynecological procedures, that I may with propriety make more specific and extended refer- ence to these working tools. Specialists will not, I am aware, feel much interest in this dull recital; but as most of my auditors are not of that category, a more minute de- scription of wdiatever may be necessary for the success of the method, will not, I feel sure, be considered out of place. First, Of the Table : Many elegant and useful ones are in the market, but as they are, in the main quite expensive, I recom- mend an ordinary four-legged table ; provided only, it be of proper height and dimensions. It should be mounted on casters, supplied with a thin mattress, and may be con- * Formula given on page 10, 4 veniently furnished with drawers on the right side. Exten- sion foot-rests can be added at one end, for use in the dorsal position. The table possesses many advantages over any form of examining couch or chair, for all gynecological work; it is necessary, alike, for the comfort of the patient, and the con- venience of the physician, while, for the business in hand, it is simply indispensable. Having once become accustomed to its use, I am sure no one would go back to the old way. Second, Of the Speculum : It is important, for knee-chest uses, that the speculum should be constructed with laterally expanding blades, and be more or less self-retaining. A perineal elevator with a convenient handle, and a flattened blade, goes to make up an essential part of the instrumental equipment. These requirements are admirably met in the in- struments devised by Dr. Bozeman, and which bear his name. While the Sims speculum is, undoubtedly, possessed ol a wider range of usefulness than any other speculum, and may be made vastly serviceable in the genu-pectoral posture, yet for purely knee-chest purposes, the Bozeman instruments are superior to any with which I am familiar. Third, Of the Forceps : The double-curved dressing forceps is superior to the straight instrument for the firm placing of the cotton pledgets in the posterior vaginal cul-de-sac. A thorough trial will furnish ample proof of this fact, which is by no means ,an unimportant one. Fourth, Of the Cotton Pledgets: I am in the habit of pro- curing the cotton which I use in columning the vagina, at a thread mill in New Jersey. It is wound upon spindles into large compact coils, and is readily broken up into short bits, which are secured in loops of strong sewing thread (Coats’ No 8); and each pledget when made up should be about the size of an English walnut (30 by 40 mm.) Any good, clean, raw cotton will answer the purpose excepting, however, absorbent cotton, which is too inelastic when wetted ; but the kind mentioned is much more quickly prepared than any other and, besides, is not expensive. The pledgets should be pre- pared in advance and kept on hand in sufficient quantity to meet the requirements of the practice. Made in this form they are, also, very useful in the tamponade of the vagina for hemorrhage. 5 Fifth, Of Pessaries: Much might be said in regard to the pessaries required ; but this is a question which must be left to the judgment of the physician, to be exercised in each case as presented, for there is as much difference in vaginas as in faces. For myself, I confess to a growing preference for the Albert Smith pessary which, in some size or other, seems adapted to the greater number of cases. For temporary use, it is well to have an assortment of sizes constructed of elastic steel spring, covered with soft rubber; but for more per- manent service the hard-rubber pessary is, for obvious reasons, the only proper one. These that I have mentioned, form an esential part of the armamentarium, necessary to the success of the measure in its initial stages. Many other conveniences can be supplied, from time to time, as conditions arise to suggest them. Having equipped ourselves with the requisite working tools, let us proceed to apply them practically in the treatment of a case of retroversion of the womb. A celebrated authority in culinary art when giving directions for hare soup says: “First catch the hare.” It is requisite that we should first ascertain the nature of the case with which we have to deal. Suspecting a case of backward dis- placement of the uterus, the patient is placed upon the table in the dorsal position, when the diagnosis can generally be made out by digital and bi-manual examination. The sound is rarely necessary in this form of displacement, but may be appealed to in doubtful cases. Having ascertained that the womb is retroverted, the next step is to effect its replacement. The patient is now directed to assume the knee-chest posture. She will need explicit instructions in regard to the position, and I generally explain to her the mechanism of the posture, and just what I expect to accomplish by it. This once done, I have yet to meet the first patient, with any sort of intelligence, who has objected to the attitude. The dress skirt should be slipped off, and the underskirt fastenings and corsets loosened. The patient should now be made to kneel upon the front of the table near its edge, and to cast the trunk forwards, until the upper portion of the chest touches the mattress. A thin pillow for the face, turned sidewise, to rest upon, adds to the comfort of the patient. The thighs should be at right angles to the table and perfectly vertical, thereby affording a greater inclina- 6 tion of the trunk. A triangle is thus formed with the aid of the table,—the thighs furnishing the upright, the trunk the hy- pothenuse, and the table the base. The phenomena which ensue when this posture is correctly taken, are: First: Reversal of normal visceral gravity. Second: Marked elongation and expansion of the vagina. The co-operation of these forces seems to accomplish the re- position of the retroverted womb, oftentimes, without other aid, instrumental or manual. The gravitation of the ab- dominal viscera towards the epigastrium, makes way for the pelvic viscera to follow, thus carrying the uterus to its proper level, and, upon separation of the labia, air rushes into the vagina, expanding it to its utmost capacity, and becoming a powerful supplementary aid to the gravitory law. If there are no adhesions, and if the fundus is not too firmly wedged into the sacral excavation, the joint action of these forces alone will, no doubt, effect replacement of the organ. In this position the weight of the superincumbent viscera is taken off the uterus and its appendages, the pelvic hypersemia and impaction which the erect and other postures may have caused, are either modified or disappear, in obedience to the law of gravitation, while the power of tenesmic resistance is wholly abolished. It is of no consequence to direct the patient to relax the muscles of the abdomen, for, in this position, the woman cannot possibly “ bear down.” There is complete suspension of intra-abdominal pressure in front, and a powerful intra- vaginal atmospheric pressure behind. The vagina becomes expanded to its greatest capacity, folds and wrinkles are smoothed out, and the cervix is seen at the most distant part of this shining, dome-like vault. In every case it is my custom to commence the treatment, by filling the post-cervical space of the vagina with the pledgets of cotton already described. The first two pieces are usually saturated with carbolated glycerine (1 per cent, carbolic acid), and placed well behind the cervix, covering the os uteri, to be quickly followed with other dry bits, until a column is built down to the pubic arch. This is done through the Bozeman speculum, and each pledget as it leaves the forceps is caught by the distal end of the perineal lever, and gently but firmly carried to its place. The lever is first withdrawn, then the speculum, and, finally, the right index finger is introduced to steady the cotton column, while the patient is resuming the erect posture. It is well, now, to make a little gentle pressure in the iliac regions with the left hand, to facilitate the impaction of the viscera behind the uterine body, the right index finger, meanwhile maintaining firm hold upon the cotton. This support should usually be allowed to remain from thirty-six to forty-eight hours, when it can be withdrawn by the patient, who is directed to make traction upon the threads which have been previously united by a single knot, and the superfluous ends cut away. After the removal of the support, the vagina should be thoroughly cleansed with a copious in- jection of hot water, administered in the dorsal position; im- mediately afterwards the knee-chest posture is assumed and the cotton column again built in the same manner as just de- scribed. This process should be repeated with regularity and precision, until the parts are sufficiently prepared for the recep- tion of a more permanent support, or until the cure is complete as the case may be. This method of treatment possesses a two-fold advantage. First: It furnishes a most complete, secure and painless splint to the replaced organ; and second: it is, in effect a poultice to the hyperemic and tender uterus, the inflamed ovary, or other intra-pelvic viscera and tissues which, by reason of exquisite tenderness, forbid the immediate use of harder and more permanent kinds of support. Thus far we have been dealing with a simple case of retro- version without impaction, or fixation of the fundus in the hollow of the sacrum—a case in fact, capable of automatic replacement. If, however, there should be impaction without adhesion, a little gentle pressure upon the fundus with the finger, or with the sponge-armed forceps will, speaking gene- rally, carry the uterus to its place. But, if there should be adhesions, the reduction becomes more difficult and, as a mat- ter of course, slower of accomplishment; nevertheless, under the method advocated, many cases formerly deemed incurable may be restored to normal positions. The most effectual way of managing such cases, appears to be as follows : The patient having assumed the knee chest posture, the dilating speculum with the perineal retractor are now intro- 8 duced, whereupon the outlines of the uterine body can readily be seen occupying the lower pelvic space, and stretching across it from bladder to rectum. The fundus will be found joined to the pelvic connective tissue with more or less firm- ness, according to the duration of the retroversion, and the extent of the cellulitis which has previously existed. We now proceed to pack the space posterior to the uterus, with the glycerated cotton pledgets in the same manner as before ; only fewer in number will be required. Sometimes, indeed, but two or three pledgets will be tolerated at first; and it may even be necessary to remove these in a few hours. This will assuredly be the case, if there is much uterine ten- derness, or hypersesthesia of the intra-pelvic tissues. After a little time, however, it will generally be found that the parts become more tolerant of the treatment; then the number of cottons should be gradually increased, until the adhesive bands give way or stretch out sufficiently to permit the com- plete reposition of the organ. The length of time required to accomplish this result must, necessarily, be variable ; but most likely, success will be at- tained within a few months, if the method is regularly and presistently carried out. There are, no doubt, some cases which appear to belong to the incurable class; but, happily, they are exceptionally few in number. It will usually happen during the progress of a case treated in this manner, that the uterine tenderness, induration, and enlargement diminish, or perhaps disappear altogether ; so, that, by the time the uterus can be replaced, the case is ready for a pessary. The use of this instrument should be commenced with more than usual caution. Now and then a hard-rubber support can be intro- duced at once, with the expectation that it will be well borne ; but generally it is well to begin with a more flexible instru- ment. I have found the Albert Smith pessary made of steel spring, covered with soft-rubber, to serve a good purpose, in a large number of cases, for use during the period intermediate between the suspension of the cotton treatment, and the final employment of the permanent support. The Noeggerath cradle pessary, made of the same materials, is also a valuable instrument in a goodly number of cases. Finally, when all obstacles thereto have been overcome, a liard-rubber pessary of appropriate form may be adj listed, the daily use of the hot 9 vaginal bath enjoined, and the patient instructed to return occasionally for examination, that the conduct of the pessary may be watched, and its use dispensed with as soon as its purposes have been served. For the proper adjustment of a pessary in any retrodis- placement of the uterus, the knee-chest posture is simply invalu- able. It is incomparably superior to any other position in the supervision of the pessary so necessary to its successful employment. The pessary, no matter how well fitted, nor how well it seems to keep its place, must be removed at intervals and the vagina thoroughly inspected, that any abrasions, erosions, or ulcerations which it may have produced, may be detected early. This inspection can be more thoroughly made in the knee-chest posture than in any other ; for here, at a single glance, the eye sweeps over the entire field, detecting abrasions or reddened spots upon the epithelium, which the finger is not competent to note. If any such should be found, the use of the pessary must be temporarily suspended, and the cotton tamponade again resorted to until the parts are healed. It is, moreover, a good plan when such complications arise, to introduce a tampon steeped in a saturated glycerate of tannin, renewing these tannin tampons at brief intervals until all irritation of the epithelium is removed. Suppose, in addition to the retroverted or retroflexed womb, we also have prolapse of an ovary ; for it is, by no means, an uncommon circumstance to find one of these little bodies dragged down to the bottom of Douglas’s pouch, and incarcerated between the fundus uteri andthe pelvic wall. If these abnormalities co-exist they will, speaking generally, have produced a chain of symptoms of a most distressing nature, ranging all the way along the hystero-neurotic series, from simple hysteria to absolute mania. To replace the dislocated ovary under these circumstances is, oftentimes, to afford in- stantaneous relief. The most effectual, safest, and best method of replacement, is through the medium of the genu-pectoral posture. The reversed gravitation of the abdominal viscera with a little assistance a tergo will, in many instances, carry uterus and ovary to their places. If, however, there are adhesions the replacement becomes a much more difficult problem. The moorings must be broken up, or stretched out, sufficiently to permit the ovary and womb 10 to return to their proper places, before any hard or perma- nent support can be made available. The persistent and re- peated tamponade of the vagina with the cotton pledgets, soaked in glycerated tannin, carbolated glycerine, or plain glycerine, as the case may be, will generally succeed in ac- complishing the end sought in a few weeks or months. If the ovary is tender and sensitive, with hyperaesthesia of the sub- jacent parts I have found it a good plan to moisten one or two bits of cotton with the following mixture : $ Chloral hydratis, 3 ij. 8 Acidi carbolici, gr.x. 65 Ext. opii fluidi, 3 ij. 60 Glycerinse, 1 ij. 60 Misce. One drachm of the mixture carried up against the ovary on the cotton and snugly held in place by dry pledgets, furnishes a good foundation for the cotton column. These medicated cotton supports can ordinarily be worn forty-eight hours, when they should be removed, and the vagina thoroughly cleansed with the hot douche, after which it should be repacked as be- fore ; and the treatment should be continued, until the hyper- esthetic tenderness is sufficiently overcome to permit the em- ployment of the permanent support, unless, perchance, the cure has already been accomplished; a circumstance by no means improbable. The adjustment of a proper pessary in these cases is, very frequently, a difficult task. It is not suf- ficient for the pessary to retain the womb well in place, but it must be of such a conformation as to support the ovary in proper position also, while, at the same time, it must not im- pinge upon the rectum in a manner to interfere with, or ren- der painful, the act of defecation. It has happened to me more than once, in earlier years, after careful and complete re- duction of a retroverted uterus, and, what was supposed to be, an equally careful adjustment of a pessary from which I confidently expected the most satisfactory results, to have the patient return in a few hours complaining of agonizing pain in the pelvis, which necessitated the removal of the pessary. The cause of this disappointment and chagrin, then so difficult to understand, but now so simple of explanation, was this: The ovary had slipped down behind the posterior segment of the pessary, becoming imprisoned between it and the sacrum, and the resulting compression of the already over-sensitive 11 and congested organ caused unendurable agony. It is not germane to the aims of this paper to discuss the whole sub- ject of pessaries, but this point is deemed of sufficient import- ance to warrant, in passing, a brief reference. Finally, it is highly probable that, in some cases, the whole list of pessaries will be searched over in vain, for one which will fulfill the in- dications of treatment and, at the same time, be painlessly worn. Such a case should be relegated to the tampon, which must be continued in use until the cure is complete, or the symptoms have sufficiently abated to warrant the discontinu- ance of further treatment. The following cases are subjoined, as illustrating some of the principles advocated in the preceeding remarks : Case I.—Miss A. B , aged thirty-two years, for several years had had retroversion of the womb. Treatment by sev- eral physicians who had adjusted pessaries on different occa- sions ; but their use had been as often discontinued, owing to the pain which they produced by reason of the extreme sensi- tiveness of the parts. She suffered from many of the hystero- neurotic symptoms pertaining to such cases, some of them extreme in character. Menstruation was usually preceeded by a most distressing attack of hysteria ; there was constipation, indigestion, meteorism, headache, backache, pain extending down the left thigh and leg ; she was moody, irascible and melancholic. Digital examination revealed retroversion in the second degree. The slightest pressure upon the body of the uterus caused insufferable pain. There was, also, dis- placement with imprisonment of the left ovary which was, likewise, extremely sensitive to the touch ; but there were no adhesions. In the genu-pectoral position the uterus and ovary went to their places with comparative freedom, and a thorough, regular, and persistent tamponade of the vagina was immedi- ately commenced. This treatment was kept up for five months, during which time there was scarcely a return of the hysteria. The method was supplemented with the hot vaginal douche, tonics and galvanism, under which plan the general health steadily improved, when a permanent support was adjusted and worn with comfort. Case II.—Miss C. D—, aged 35, consulted me in the autumn of 1878, having been, for ten years previously a sufferer from uterine diseases of one form and another, and for which, dur- 12 ing the greater part of the time, she had been under the care of a number of different physicians. The uterus was retro- verted, enlarged, somewhat indurated, tender to the touch, and moored to the pelvic wall by left lateral adhesions. Her physical condition was pitiable ; the hystero-neurotic phe- nomena were of the most exaggerated kind; there was con- fusion of thought, brain oppression, sleeplessness ; constipa- tion, disturbance of digestion, intolerance of even slight noises, such as the rustling of a newspaper, or the “ singing” of locusts ; amenorrhcea, anaemia, dread of society and melan- cholia. This patient complained that the knee-chest posture increased the discomfort in the head, therefore I commenced the treatment in the Sims position. At first but three cotton pledgets were placed in the post-cervical space, and even these were removed in the course of a few hours on account of the uncomfortable pressure which they produced. They were, however, renewed next day, moistened with one drachm of the sedative mixture mentioned in the text, when they were better tolerated. From this time the number of pledgets was gradually increased, and after a few weeks the genu-pectoral posture could be assumed without much discomfort. This course was pursued with tolerable regularity for nearly a year before a pessary was attempted. Finally, the moorings became sufficiently loosened to allow the uterus to float to its place, and a Noeggerath soft rubber pessary introduced. This form of support was worn, with an occasional rest, during the suc- ceeding four months, when an Albert Smith hard rubber pes- sary was adjusted which has been worn, for the most part of the time, down to the present. The treatment has been varied by occasionally laying aside the pessary for a short period, and the resumption of the tamponade during its suspension. The hot vaginal douche has played an important part in the management of this case from the first, and lias been self- administered in the dorsal position, the patient being provided with an apparatus for that purpose. Iron, arsenic, and gal- vanism have also, it is believed, been supplementary aids of considerable potency, in contributing to the favorable results; for, though the patient cannot be regarded as completely restored to health, she is so much improved as to be regarded comparatively well. The hystero-neurotic symptoms have nearly vanished ; the constipation is at an end ; digestion is good ; menstruation nearly normal; and the functions of the body so well performed, as to convert a heretofore burdensome existence into a life of comfort and happiness. Case III.—Miss E. F , aged 28 years, came under observation in September, 1879, with retroflexion of long standing. For eight years she had suffered with dysmenor- rhcea; there was partial acquired cervical stenosis; great tenderness of the uterine body ; cicatrices across posterior wall of the vagina ; and various neurotic disturbances not necessary to enumerate here. This patient had received ‘‘local treatment” at the hands of various physicians of both sexes, and had worn a pessary ; but she was now despondent, skeptical, and discouraged. In the genu-pectoral posture the uterus assumed its normal relations witlqbladder and rectum quite readily, and I, therefore, immediately began a system- atic tamponade with the medicated cotton pledgets, which was continued with great regularity for eight months. In the meantime the cervix was divided bi-laterally, and the patency of the os maintained by the use of Hanks’s dilators ; and this latter treatment had the further effect to partially straighten the flexion. A soft-rubber pessary of the Noegge- rath pattern was first adjusted, worn for a time, and after- wards an Albert Smith soft support for a few months longer. Finally, a hard-rubber pessary, also of the Albert Smith pat- tern, was introduced, which is still in use. This patient is a person of unusual intelligence in regard to her own case, un- derstanding its mechanism perfectly, and has been most faith- ful in carrying out all instructions. She uses the hot vaginal bath in the dorsal position, and frequently employs the genu-pectoral posture herself, whenever, indeed she feels the necessity therefor ; and this has, I cannot doubt, been of great supplementary aid in the management of the case. The result may be thus summarized: First, entire recovery from the dysmenorrhcea for, whereas, at the outset she was obliged to take the bed for three or four days during each menstrual epoch, and suffered agonizing pain notwithstanding, she is now enabled to go about her domestic and social duties during this time, and is entirely free from all extraordinary pain. Second, great improvement in the general health ; and, third, disappearance of all uterine and vaginal hypersesthesia. Case IV.—Miss Gr. H , 21 years old, consulted me in 14 July, 1878. She had a profuse catarrhal leucorrhoea for which I prescribed in a tentative way, postponing, for the time being, a physical examination. Finding no improvement after a few months, she submitted to the usual examination, which re- vealed retroversion with prolapse of the left ovary. The usual tamponade of the vagina in the knee-chest posture was instituted and, after a few months, a pessary fitted, which she wore until marriage and pregnancy, when I removed it. This case steadily improved from the beginning of treatment, neither the tampon nor the pessary having occasioned the slightest inconvenience or discomfort. Case V.—Miss J. K , aged 24 years, liad been four years an invalid when she consulted me, during which time she had employed thirteen different physicians. She was, at each menstrual epoch, subject to hysterical outbursts of an exag- gerated phenomenal character. She would shut herself in her room, permitting no one to enter, and abandon herself to the most maniacal actions and uterances imaginable. She would shout at the top of her voice, cry, laugh, break the furniture, and tear her clothing; again she would refuse to speak, de- clining all kindly offices and attentions on the part of physi- cian, nurse or kin, and commit herself generally to the “sulks.” During the intermenstrual period she was “every- thing by turns and nothing long irritable, petulant, moody and irascible, but not violent; while at other times she was cheerful, amiable, and comparatively happy. Recognizing the liystero-neurotic character of the symptoms, and their con- sequent relationship to sexual disturbance, I prevailed upon her to submit to a physical examination of the pelvic organs. The uterus was retroverted, somewhat under-size, and tender; there was cellulitis of the broad ligament, while the left ovary was prolapsed and incarcerated behind the fundus uteri. There was no leucorrhoea, and the vagina was narrow and short. This examination was made in the Sims position. Placing the patient in the knee-chest posture, moderate digital pressure in the post-uterine space carried the fundus and ovary, over the promontory of the sacrum to their proper places; whereupon I proceeded to occupy their former site with the cotton pledgets medicated with the sedative mixture heretofore mentioned. The cotton column was builded upon this foundation in the usual manner. This treatment was 15 regularly carried on for four months, with the effect to cause an abatement of the hysterical phenomena, and a general im- provement in her physical condition as well. This patient was exceedingly averse to ‘‘local treatment,” wherefore it was difficult to persuade her of its necessity, and still more difficult to maintain regularity in the treatment; nevertheless, she was held to entire faithfulness for four months. At the end of this time, having improved so much as to consider herself well, and, moreover, having obtained the opinion of another physician to the effect that she required no uterine treatment whatever, she passed from my observa- tion. Conclusions. In the narrow limits of time which it would seem proper for me to appropriate, it is impossible to compass the entire field of possibilities of the genu-pectoral posture, in its applicability to the treatment of uterine and ovarian displacements. I have, therefore, simply sought to draw attention to the subject, in the hope that some of the learned gentlemen here present will afford us the benefit of their more enlightened views and riper experience, in this interesting and important field of observa- tion. In concluding, permit me to offer the following abstract of some of the principles, which observation and experience would appear to teach, in regard to the utility of the genu- pectoral posture in the treatment of retro-displacements of the uterus, and in dislocations of the ovaries:— I. That, in a large number of cases of uncomplicated retro- version, or of ovarian prolapse, the combined action of gravi- tation and atmospheric expansion of the vagina, obtained through the medium of the knee-chest position, will effect replacement without instrumental aid, such as the sound or the various repositors. Some cases in this class may, however, require slight manual assistance. II. That, in cases where there is fixation of the fundus uteri in the hollow of the sacrum, without adhesions, the tamponade of the vagina with the cotton pledgets furnishes a most complete and simple way of overcoming the mal-position. III. That, in cases of retroflexion with fixation due to plastic exudation or adventitious deposits, the products 16 of cellulitis or other inflammations of the intra-pel vie viscera, and associated with prolapse and incarceration of one or both ovaries, the genu-pectoral posture affords the most rational way of treatment with reference to the removal of the condi- tions named, and thereby to ultimately obtain reduction ; for, in this position the vagina can be most completely packed with the medicated tampons, which, by their gentle pressure, reduce inflammation and promote absorption. IV. That retroflexions of the womb, after a course of treatment by the vaginal tamponade in the knee-chest posture, are more readily straightened and are rendered more tract- able. The influence of the tampon, by pressure and otherwise, seems to soften the indurated and gristly cervix, thus prepar- ing it for further treatment, and sometimes, even, rendering further interference unnecessary. V. That in prolapse of the ovaries, replacement can be more readily obtained in the genu-pectoral position. Gravita- tion alone is, oftentimes, sufficient to effect reduction of these organs ; moreover, they are frequently so tender and sensitive that any other method of replacement would be torture to the patient, while it is painlessly accomplished by this method. The support of the replaced ovary by the vaginal tamponade for a considerable period will, even in a large proportion of cases, be sufficient to accomplish a cure ; while in cases where uterine dislocations co-exist this method of treatment serves a double purpose in ministering to both conditions. VI. That the adjustment of pessaries is more accurately accomplished, and with less discomfort to the patient, if done in the genu-pectoral posture. The complete reduction of the displaced uterus, or ovary, or both, is a condition precedent to the successful employment of these instruments ; and, in this posture, such reduction is absolutely possible, while it is not the case, to the same degree of precision, in any other position which may be chosen for the introduction of the pessary. The replacement once accomplished, what more favorable condition could be desired for the introduction of a support, than while the forces of gravitation and air-pressure are conspiring to simplify this otherwise difficult proceeding ? The law of gravity on the one hand, operates in holding the heretofore displaced organs securely in their appointed places, while on the other, the vaginal inflation serves to bring the parts with- 17 in the range of vision so completely, that the size and shape of the pessary required can be most accurately estimated. A pessary carefully selected with reference to the peculiar- ities of a case and fitted in the knee-chest posture, will seldom require removal, except from causes other than such as per- tain to the manner of its adjustment. Here the pessary is not pushed up against a tender and irritable womb (and ovary, perhaps,) but is simply laid gently upon the parts, causing no pain and rarely any discomfort; for the instrument will move about loosely in the expanded vaginal vault. After the pessary is placed the patient is brought to the erect kneeling posture, the finger, meanwhile, maintaining its hold upon the anterior segment thereof, until the abdominal and pelvic viscera gravitate back to their proper level. A final digital inspection of the pessary, in situ, can now be made, that the accuracy of the adjustment may be proven. VII. That the self-assumption of the genu-pectoral posture by the 2)atient each night, or even at other times during the day if necessary, may be made a serviceable adjunct to the treatment, in relieving the pressure of the uterus upon the pessary, by taking off the weight of the superincumbent viscera. The patient should lie in the prone or semi-prone position for sometime afterwards, avoiding the erect posture, at all events, for a few hours. In this manner much may be accomplished in the way of relief from backache, intra-pel vie pains, cystic or rectal irritation, and other phenomena usually attendant upon these maladies, when it is convenient or impossible to consult the physician with regularity. The patient may, in- deed. be taught to remove the pessary, cleanse the vagina with a copious hot water injection, and to replace the instrument herself, assuring its proper adjustment by a resort to the genu- pectoral posture. Furthermore, the frequent self-assumption of this position establishes the “habit” of replacement of the intra-pelvic organs and, by unloading the vessels, relieves hyperaemia, con- gestion and pelvic blood stasis. Literature. Aveling.—“The Influence of Posture on Women in Gynecic and Obstetric Practice.” Philadelphia. Linsday and Blakeston, 1879. 18 Bozeman.—“The Mechanism of Retroversion and Prolapsus of the Uterus,” etc. Transactions of the American Gynecological Society. Vol. III., 1878. Burkall.—“On some of the uses of the Knees-and-Elbows- Posture.” American Journal, Medical Sciences, January 1874, p, 103. Campbell.—“ Resume of a Report on Position, Pneumatic Pressure and Mechanical Appliances in Uterine Displacements.” Augusta, Georgia, 1876. Campbell.—“Pneumatic Self-Replacement of the Gravid and Non-Gravid Uterus.” Transactions American Gynecological Society, Vol. I., 1876. Hart.—“The Clinical Features, Anatomy and uses of the Genu-Pectoral Posture.” American Journal of Obstetrics, October 1881, Vol. XIV., p. 820. Munde.—“The Reposition of Retro-Displacement of the Gravid Uterus by Posture and Atmospheric Pres- sure.” American Journal of Obstetrics, 1876, Vol. IX., p. 292. Munde.—“Treatise on Minor Surgical Gynecology.” New York, Wm. Wood & Co., 1880. Munde.—“The Curability of Uterine Displacements.” American Journal of Obstetrics.” October 1881, Vol. XIV., p. 789. Munde.—‘ ‘ Prolapse of the Ovaries. ’ ’ Transactions American Gynecological Society, 1879, Vol. IV., p. 164. Sims.—“Clinical Notes on Uterine Surgery.” New York, Wm. Wood & Co., 1871. Skene.—“The Relation of the Ovaries to the Brain and Nervous System.” American Journal of Obstetrics, January 1881, Vol. XIV., p. 54.