THE VALUE 
OF 
GRADUATED PRESSURE 
IN 
THE TREATMENT OF DISEASES OF THE 
VAGINA, UTERUS, OVARIES AND 
OTHER APPENDAGES. 
BY 
NATHAN BOZEMAN, M.D., 
I ROE ON TO THE WOMAN’S HOSPITAL OP THE STATE OF NEWYORK. 
NEWYORK, 
Reprint from the Atlanta Medical Register, January, 1883. THE VALUE OF GRADUATED PRESSURE IN THE 
TREATMENT OF DISEASES OF THE VA- 
GINA, UTERUS, OVARIES AND 1 
OTHER APPENDAGES. 
Bt NATHAN BOZEMAN, M.D., New York, 
Surgeon to the Woman’s Hospital of the State of New Yorlc. 
In The Atlanta Medical Register for September, 
1882, there appeared an article entitled “The Application 
of Pressure in Diseases of the Uterus, Ovaries and Peri- 
uterine Structures, by V. H. Taliaferro, M.D., Atlanta, 
Ga., Professor of Obstetrics and Diseases of; Women and 
Children in the Atlanta Medical College,” in .which I ana 
taken to task by the learned Professor in not over-choice 
language because I did not credit him with the merit he 
thought he deserved, in a paper which I submitted to the 
American Gynaecological Society at its annual meeting in 
Philadelphia, September, 1878. 
I am sorry the Professor deemed it necessary to resort 
to so questionable a mode of enforcing his views or prac- 
tice upon the notice of the profession, since it deprives 
me of the pleasure of treating his complaints, with that 
high degree of consideration which I always try to accord 
to my colleagues who may chance to differ from me on 
topics of common interest. 
1 In order to make myself fully understood, and to give 
some idea of the successive steps by which I was led, in 
1878, to set forth my views in the paper referred to, en- 
titled “The Mechanism of Retroversion and Prolapsus of 
the Uterus Considered in Relation to the Simple Lacera- 
tions of the Cervix Uteri and their Treatment by Bloody 
Operations,” it will be necessary for me to speak some- 
what in detail of my inventions and improvements in in- 
struments, and the various modes of using them, before I 
enter upon my subject. 
As far back as 1855 I had learned from experience that 
the cicatricial bands of the vagina, found as complications 
of vesico-vaginal fistule, could be divided with the knife 
and the expansion of the organ, through graduated press- 
ure with bits of sponge packed in oil-silk bags as dilators, 
could be carried to a degree often far beyond the normal 
caliber of the organ with corresponding loosening and ele- 
vation of the uterus and its appendages when fixed as re- 
sults of pelvic inflammation. These sponge dilators were 
of two kinds: first, vuivo-vaginal; and second, intra- 
vagi nal, the length and size being determined always by 
the depth of the vagina, and degree of contraction and 
resistance to be overcome. 
This principle of dilatation of the vagina by graduated 
sponge pressure, associated with my button suture princi- 
ple and the old knee-elbow position, marks the era (May, 
1855,) of the first consecutive successes in a series of seven 
operations for vesico-vaginal fistule to be found upon rec. 
ord. As a point of historical interest I will here quote 
from the first published report of the successful employ- 
ment of my sponge dilators as a means of making|direct 
pressure upon the walls of the vagina and upon the uterus, 
in a case of two vesico-vaginal fistules and almost com- 
plete obliteration of the vagina just below the cervix 
uteri: “A fistulous opening, three-quarters of an inch in 
length, occupied the vesico-vaginal septum and extended 
from near the beginning of the urethra obliquely upwards 
and to the left, terminating abruptly at the point of co- 
arctation. Here a careful examination revealed a small 
opening, which allowed a probe to pass into the vaginal 3 
■cut de sac above, and from thence into the bladder, showing 
clearly that another fistule existed in this situation. Hav- 
ing thus ascertained the true condition of things, I became 
satisfied that two operations would be required. 
“In a few weeks (after my first fistulous closure, June 
12th, 1855,) I made preparation for the other (the second) 
operation by first breaking up the morbid adhesions between 
the two walls of the vagina, so as to expose the fistulous opening 
above. To prevent reunion of the parts, a bag made of oil-silk 
and stuffed with bits of sponge was introduced into the vagina. 
This was removed daily, and injections of cold water used, 
by which means the upper extremity of the vagina was, 
in a few weeks, dilated to its normal size, and the fistule 
exposed.” 
August 23d, this second fistule was closed at a single 
operation with my button suture, and the cure thus com- 
pleted. 
(See Case 11., Louisville Review, May, 1856.) 
Next I associated with these two new principles of 
practice a third, the drawing down of the uterus when 
fixed and immovable (hystercephelcosis) after incisions 
and dilatation (kolpostenotomy and kolpoecpetasis), in 
order to make it subservient to the closure of large fistules, 
and thus was inaugurated a method which superseded the 
necessity of the dangerous plastic procedure of Jobert de 
Lamballe—autoplastic par glissement. Fourthly, with these 
three principles combined, I next undertook to overcome 
retroflexion of the uterus, with fixation and displaced 
ovaries superinduced by incarceration of the cervix uteri 
in the bladder, as a preparatory measure. The result was 
a complete restoration of the uterus and its appendages to 
their proper positions, and the final closure of the asso- 
ciated fistulous orifice. 
(See Case XXXVIII., New Orleans MedicalTand Surgical 
Journal, May, 1860.) 
By this latter combination of principles I cured five 
cases out of six; no other operator, as far as I amjaware, 
having ever recorded, even at the present time, a case on 
this basis of maintaining the normal outlet of the cata- 
menia. 4 
In 1858, or about this time, Dr. Sims modified my prin- 
ciple of intra-vaginal dilatation through graduated sponge 
pressure in oil-silk bags, by using a glass plug instead, in- 
tended simply for vulvo-vaginal dilatation, but this was far 
inferior to my sponge dilator, on account of its more limited 
application in the graver complications of vesico-vaginal 
fistule. 
In 1867, in a class of inaccessible vesico-vaginal fistules 
occurring in vaginas of very large size and quite relaxed, 
I discovered the total -worthlessness of even the larges 
size of my the univalve speculum, even 
the same size of Dr. Sims’ modification of it, for operative 
purposes in the position. And in order to 
meet the emergencies then presented, I devised a new 
self-retaining spring speculum for dilating such vaginas 
to any desired extent, and at the same time a supporting 
and confining apparatus for securing the patient in the 
fixed knee-chest position, that gave me absolute control over 
patient and fistule without the aid of assistants. These 
two additional inventions and the anatomical considera- 
tions suggesting their adaptation to use, will be better 
appreciated by reading the following extract from a pub- 
lication of mine upon these points, entitled “A Spring 
and Self-Retaining Speculum,” to be found in the New 
York Medical Record, January Ist, 1868 : 
‘ The vagina, as a membranous canal, in the distended 
state may properly be said to represent a truncated cone 
with the base turned upward and the apex downward, cor- 
responding with its mouth. 
“The general outline of the organ, as viewed in its 
natural condition, is such as would result from bringing 
the two opposing walls of the cone together, the cervix 
uteri being encircled by it at the center of its base, and its 
mouth closed by the falling together of the labia majora- 
“The line, therefore, formed by the anterior and pos- 
terior walls of the organ coming together is transverse, 
while that formed by the opposing surfaces of the labia is 
antero-posterior, being at right angles. 
“Now the most natural indications for the dilatation of 
this canal with the peculiarities named, would appear to 5 
be, first, separation of the labia, and second the two oppos- 
ing walls of the collapsed cone, so to speak. This, scarcely 
need I say, is the view generally taken of the relation- 
ship of these parts, and the usual practice is based upon it 
of bringing within the field of observation the cervix uteri 
and the two vaginal walls. 
“This plan of antero-posterior dilatation of the vagina, 
it matters not what form of speculum is used, I conceive to 
be a popular error, and it is wholly at variance with the 
true anatomical relationship of the parts. I shall presently 
attempt to explain more fully my meaning in my descrip- 
tion of a new form of speculum, which I have the pleasure 
of presenting now to the notice of the profession. The 
principle of construction, as well as principle of action of 
this new instrument, will be found to differ from all others 
heretofore in use in several respects, which I shall explain 
farther on. Suffice it to say, one of the essential differences 
is in what might be termed the working point of the in- 
strument, that portion which is applied to the resistance. 
The blades of my instrument are introduced between the 
opposing walls of the vagina edgewise instead of flat, as 
formerly; and the dilatation is effected transversely or 
horizontally, as will be better understood when I come to 
explain the principle of action. The same instrument 
applies to the dilatation of the vulva as the vaginal canal; 
thus giving at one glance a view of the parts from the 
mons veneris to the cervix uteri in front; and behind, of 
nearly the whole posterior wall of the vagina—every point 
within this extensive range being made accessible for 
operative purposes. 
“The dilatation thus effected is so regulated that the 
labia and the two extremities of the vagina are put upon 
the stretch only to the extent desired, which is in strict 
accordance with the anatomical conformation of the parts, 
this being of such a nature as to make the instrument 
self-sustaining, one of its peculiarties ; another being elas- 
ticity of flexure. This principle of elasticity has never be- 
fore been embodied in any form of speculum as far as I am 
aware, and its utility and importance in my judgment, 
cannot be too highly estimated. Instead of the hard in- 6 
flexible blades (of the bivalve, trivalve and quadrivalve 
instruments) formerly used, touching only at one or two 
points the soft and delicate structures, we have now the 
soft, elastic spring adapting itself to all the points of resist- 
ance with a uniformity to be attained in no other way. 
“The indications for complete dilatation of the vagina 
and vulva, I conceive to be four: 
1. Elevation of the perineum. 
2. Elevation and support of the upper part of the pos- 
terior wall of the vagina. 
B. Transverse {dilatation of the labia majora and the 
mouth of the vagina. 
4. Distention and steadiness of the upper part of the 
anterior wall of the vagina, the vesico-vaginal septum. 
“These are the indications to be fulfilled, according to 
my judgment, independent of any and all efforts of the 
patient to the contrary ; and any instrument, whether self- 
retaining or not, that does not meet these ends must be re- 
garded as incomplete. With my instrument I claim the 
accomplishment of all, the fulfillment of the third and fourth 
indications being an advance beyond other methods, to say 
nothing of the self-retaining quality of the instrument 
which is based upon more correct principles than any plan 
heretofore presented to the notice of the profession. 
“As regards the position, support and confinement of 
the patient, I propose a few remarks before entering upon 
the description of my instrument, as I consider these points 
of no little consequence in certain operations, especially 
those upon the anterior wall of the vagina. 
“While my speculum is equally well-adapted to all po- 
sitions, I prefer in the description and application of it, 
to consider the patient resting upon her knees and breast, 
the bocly forming a right angle with the thighs, and the 
thighs a right angle with the legs. This position I now 
prefer to all others and with propriety it may be termed 
the right-angle position upon the knees. 
“In no other position, according to my judgment, wheth- 
er chloroform be used or not, can the patient be made so 
comfortable and secure without the aid of assistants. My 
supporting apparatus for this position, when folded up, is 7 
compact, light and portable, weighing only eleven pounds. 
It exceeds twelve inches in height only on one side, the 
depth and width being twelve by eighteen inches. I hope 
before long to publish a description of this thoracic rest or 
support 
In the New York Medical Journal for February 1859, in 
an article entitled : “Remarks on the Advantages of a 
Supporting and Confining Apparatus, and a Self-retaining 
Speculum in the Operation of Vesico-Vaginal Fistule; 
Modes of Certain Forms of Suture; Their Results Practi- 
cally Contrasted in the Same Cases and upon the Same 
Fistulous Openings,” I introduced a cut to show the knee- 
chest position of the patient upon my Supporting and 
Confining Apparatus and the principal objects sought to 
he attained by it, to wit: 
Fig. 1. 
1. “Extension of the vertebral column and relaxation 
of the abdominal muscles essential to free gravitation for- 
ward of the pelvic and abdominal viscera. 
2. “Support and mechanical confinement of the patient 
by controlling muscular action at certain points without 
encumbering the abdomen, or interfering with the func- 
tions of respiration and circulation. 
3. “The safe administration of anaesthetics.” 
Fig. 1, shows the apparatus at work in the knee chest 
position. 8 
Fig. 2. 
Fig. 2; shows the exaggerated knee-elbow position. 
In regard to the latter position I would say as viewed 
from an historical standpoint, it came into use cotempor- 
aneously with that of the knee-elbow position, since it is 
well known by all who have had any experience with the 
knee-elbow position that a patient when placed in it for 
examination or operation almost always sinks from fatigue 
and exhaustion into the exaggerated knee elbow position 
as above shown and therefore the advantages and disad- 
vantages of it must have been long and well understood 
in practice. 
From the beginning of my experience with the knee- 
elbow position (1853) my object always was to prevent the 
patient from getting into this exaggerated knee-elbow po- 
sition, which I effected by placing a support under the 
chest so as to bring the body up to a horizontal plane as 
shown in Fig 1. In this way I avoided one of the disad- 
vantages of the position, perhaps the most important, 
namely, the cutting oif of the light from the vesico-vaginal 
septum and cervix uteri. My supporting and confining 
apparatus, as here illustrated, was simply an improvement 
upon my simple bench support usually extemporized for 
the occasion of converting an exaggerated into a knee- 
chest position. 
Dr. Henry F. Campbell, from whose article I have 
copied this cut, which was published in the Transactions of 
the American Gynxcoioyical Society for 1876, seven years later, 9 
and entitled “Pneumatic Self-replacement in Dislocations 
of the Gravid and Non-gravid Uterus,” must also have 
known the fact here stated, and yet he claimed it as some- 
thing which had scarcely been known, up to the time of 
his writing, for practical use in the treatment of prolapsus 
and retroversion of the uterus. Not only this, he named 
it the Genu-pectoral Position, the English designation of 
my position, the knee-chest, published nine years before; 
and what is still stranger, without making any acknowl- 
edgement or explanation for so doing. In all of my refer- 
ences, therefore, to thekneechest position in these remarks, 
I mean the one with the body of the patient resting on a 
horizontal plane upon my supporting and confining ap- 
paratus or any improvised support, and the exaggerated 
knee-elbow 'position with the breast of the patient on the 
same plane with the knee, as here illustrated by Dr. 
'Campbell. 
I also described in the same number of this journal, in 
■connection with my knee-chest position, further improve- 
ments and the completion of my self-retaining speculum 
setting forth again its “principal peculiarities” in these 
words: 
1. “The system of leverage employed, which gives us 
increased power over increased resistance. 
2. “Transverse dilatation with uniformly varying 
movement of the blades, which gives us a thin and favora- 
ble form of its points for introduction, and a reversal of 
the size of the two extremities of the instrument when 
expanded within the vagina. By virtue of this flaring 
expansion of the blades within the ascending rami of the ischia, 
the instrument is made self-retaining, which distinguishes 
it from all others of this class previously constructed. 
8. “The elasticity of flexure belonging to the working- 
part of the instrument, which gives it an easy adaptation 
to the soft structures, both of the vagina and vulva. This 
is also a feature of the instrument that particularly dis- 
tinguishes it from other valved specula, heretofore in use. 
4. “The applicability of it in all positions, and the ad- 
vantages secured to the physician or surgeon, of making 
all examinations, or of doing all operations required upon 10 
the vaginal walls and cervix uteri without the aid of as- 
sistants.” 
Fig. 3. 
Fig. 3 represents the instrument as expanded in the 
vagina with third blade attachment, supposed to be in the 
knee-elbow or knee-chest position. This drawing was 
made from my third size, there being four of them, but 
this view is not very well chosen to show the instrument 
to advantage. The second size speculum is the one suit- 
able for the ordinary treatment of uterine diseases in the 
recumbent, knee-elbow and knee-chest positions without 
an assistant. 
Although my speculum at this stage of its completion 
answered all purposes for which it was intended and even 
more, as I shall presently show, I found the scope of its 
usefulness, especially in the knee-elbow and knee chest 
positions could be greatly increased by the addition of an 
independent perineo-rectal elevator in the place of the 
third blade attachment, now found better suited as a rectal 
depressor in the recumbent posture. With this perineal 
elevator or retractor set upon a curved handle at different 
angles with sufficient size to allow the proper grasp of the 
surgeon’s hand, it was possible not only to raise the peri- 
neum and the already expanded speculum to the highest 
point and to throw the greatest amount of light upon the 
anterior wall of the vagina and cervix uteri, but to expose 
at the same time for operative purposes the posterior wall 
as well. The blade was narrow, thin, almost fiat and 
slightly curved on its convex side, independent of the 
blades of the speculum and free in its backward and for- 
ward movements between the latter for introduction or 
removal. Fig. 4. 
Fig. 4 shows the instrument at two set angles. For 
the posterior wall of the vagina:, as a depressor, it admits 
of two other set angles making in all, four. 
Accompanying the speculum and perineal elevator, for 
use in all positions without an assistant, there are : a. a 
narrow smooth spatula with straight handlej b. a narrow 
double-hook spatula also with straight handle, and c. a 
pair of curved uterine forceps. These five instruments 
constitute the set as now in general use. 
The instrument set at all four angles with my speculum 
and supporting apparatus is figured in the second edition 
of Dr. Frank H. Hamilton’s work on the “Principles and 
Practice cf Surgery,” 1873. On page 919 he shows the 
supporting and confining apparatus with patient in posi- 
tion as “Bozeman’s Knee-Chest Position.” 
It was with these instruments above described, and my 
knee-chest position that I met the late Prof. Gustav Simon 
of Heidelberg, in the autumn of 1874, and entered with 
him, in the hospital of the University, a competitive trial 
as to the relative advantages of our respective procedures 
for the cure of vesico-vaginal fistule and its complications. 
With what result, is to be seen in the medical literature 
of Europe. The same trials of my procedure with other 12 
methods and other surgeons, I made also in the hospitals 
of Vienna and Paris. 
In returning now to the consideration of the uses of 
these improvements in 1869, as means of treating vesico- 
vaginal fistule and its complications, and, second, the dis- 
eases of the uterus, ovaries and other appendages, I shall 
have to pass over the former for want of space. Suffice it 
to say that the association of these two principles with 
sponge and hard rubber dilators in the management of 
of cicatrical contractions of the vagina as complications 
of urinary and fsecal fistules (kolpostenosis) gave my 
operations of incisions (kolpostenotomy) and of intra- 
vaginal dilatation (kolpoecpetasis) such a preponderance 
over all other methods in this country and Europe, in 
point of effectiveness to overcome the then recognized 
necessity of shutting up the vagina and unsexing the 
individual (kolpokleisis), as might well be called a revolu- 
tion in vaginal surgery. 
The proof of this is to be found in the statistics of the 
late Prof. Simon, of Heidelberg, the originator of kolpo- 
kleisis, who subjected 34 per cent, of his cases at that time 
to this method of treatment, and that now, only eight years 
after I introduced my method into the hospitals of Heidel- 
berg, Vienna and Paris, there is scarcely to be found, in 
Austria and Germany, a surgeon who openly advocates 
kolpokleisis. Of the physicians of New York who fre- 
quently witnessed my operations about this date (1869), I 
will mention Drs. Frank H. Hamilton, I. E. Taylor, S. T. 
Hubbard, G. Sabine, T. C. Finnell, J. F. Chauveau and 
M. J. Moses. 
My Speculum and the Knee-Elbow and Knee-Chest Positions 
as Means of Treating the Diseases of the Uterus, Ovaries and 
Other Appendages.— Scarcely need I say that ten or twelve 
years’ experience in the treatment, especially of retro- 
flexion of the uterus with fixation as a complication of 
vesico-utero-vaginal fistule, previous to 1869, was quite 
enough to convince me of the superiority of my speculum 
over the univalve in all positions of the patient for treat, 
ment of the diseases in question, and as for the usual 
working positions the decubitus and knee-elbow, ivithout an 13 
assistant—my speculum, I felt, admitted of no comparison 
with the univalve. In cases of this class I had found it 
always necessary not only to maintain a full lateral dila- 
tation of the vagina through sponge pressure, but to 
gradually increase the latter in the linear or perpendicu- 
lar direction according to the commencing movement and 
elevation of the uterus from its fixed position against the 
rectum. This insured gradual stretching or elongation of 
the posterior wall of the vagina, and favored direct pressure 
upon the uterus and other resisting points in and about 
the broad ligaments and ovaries. In this way I found it 
to be possible, after making the necessary incisions for 
the disengagement of the cervix uteri from the bladder, 
to stretch the posterior wall of the vagina in extreme 
cases, elongating it from two and a half to five and a half 
inches. 
It was not, therefore, difficult to modify this form of 
graduated lateral and linear pressure to suit retroflexions 
of the uterus with fixation, unattended by lesions of the 
vesico-vaginal septum. 
The modification simply consisted in making the oil- 
silk bags narrower and not stuffing them so firmly, the 
object being here to lessen lateral and increase linear 
pressure. Made in this way, the cylinders admitted of 
easier introduction and removal, and could, when it was 
desirable, be flattened, so as to give them a form even 
more conducive to the avoidance of pressure upon the 
bladder and rectum. The point d’appui within the pubic 
arch and perineum, of course, remained the same. The 
rule, likewise, of using the warm douche twice a day, and 
of cleansing the sponges once a day, or sometimes every 
other day, was strictly observed. When it was not possi- 
ble to elevate the uterus to its normal position by this 
procedure, supplemented by the use of the uterine sound, 
as very often happened in my early experience, and a 
Hodge’s pessary could not be worn, I would continue the 
cylinder in its stead, which, after the active treatment, 
could be easily managed by the patient herself. In the 
active treatment I found my thin-bladed perineal elevator 
used alone to be of the greatest service, since it greatly 14 
facilitated the introduction of the cylinders in the knee- 
elbow position, because I found it more convenient and 
suitable than my knee-chest or the exaggerated knee- 
elbow position, which was always more disagreeable and 
uncomfortable to the patient. I would very often use my 
knee-chest position, however, when it was an object to 
save the patient from the disagreeableness of putting her 
head below the plane of the body. For the ordinary ex- 
aminations with my speculum, and even with the perineal 
elevator alone, this position was all that was required. 
For its ready utilization, all I had to do was to improvise 
a chest support, which I did by simply placing a few 
books with the pillow or cushion at hand on a couch, ta- 
ble or office chair, and requiring the patient to place her 
elbows on them, thus bringing her body up to the hori- 
zontal plane. 
Of course the great object in employing any one of 
these positions was to enable me to judge accurately of 
the space to be occupied by the flattened sponge cylinder 
or compressor and to apportion it accurately to the degree 
of hard pressure that could be borne by the patient. 
After the dislodgement of the uterus, by this mode of 
applying graduated pressure, from its fixed position against 
the rectum, and the replacement of the organ by the uterine 
sound, where this was practicable, I would adjust in the 
usual way a Hodge’s pessary and complete the cure. 
When the latter instrument, however, could not be 
borne, which was frequently the case, I would continue 
moderate pressure by the flattened sponge cylinder as a 
pessary in accordance with the rules before mentioned. 
Not only did I employ these sponge cylinders as soft pres- 
sure pessaries for retroflexion of the uterus with fixation, 
but also for retroversion when a Hodge’s hard pressure pes- 
sary could not be tolerated owing to sub-involution and 
tenderness of the uterus, displacement of the ovaries or 
other complication. In this way great relief was afforded 
the sufferer, and she was saved the necessity of the con- 
stant care of her physician, as she could make and intro- 
duce the cylinders herself. 
It was, therefore, by persevering efforts thus directed 15 
that I was enabled to secure results of beneficial utility 
and importance, which were impossible before by the use 
of Hodge’s pessary alone. Besides, a closer study now, of 
the pathology of retroflexion of the uterus with fixation 
satisfied me that the immobility of the organ did not al- 
ways result, as was then generally believed, from adhesion 
between the fundus of the uterus and the anterior wall of 
the rectum, or rather the opposed surfaces of Douglas’ 
fossa, but from thickening and shortening of one or both 
of the broad ligaments, arising from pelvic cellulitis and 
.peritonitis which were amenable to successful treatment 
in a very large proportion of cases by this mode of grad- 
uated and elastic linear or perpendicular pressure as above 
advocated. 
In 1869, when I began to use hard rubber dilators, in 
place of the sponges in oil-silk bags in order to avoid the 
trouble of the latter, I tried to utilize them also in the 
treatment of retroflexion with fixation; but the result was 
not satisfactory, owing to their want of elasticity and the 
discomfort they generally caused the patient by undue 
pressure upon the rectum, bladder and urethra when the 
diameter or length happened to be a little too great for the 
space they were intended to occupy in the vagina. It is 
true they had the advantage, in common with the Hodge’s 
pessary, of being less troublesome to both physician and 
patient, but they were found to be far inferior for the reas- 
ons stated, and the fact of their being slower in the ac- 
complishment of the same end, the softening and stretch- 
ing of the tissues around the uterus and appendages. 
From these considerations, I gradually laid them aside as 
means by which retroflexions of the uterus could be satis, 
factorily treated. As a valuable means, however, of treat- 
ing the complications of vesico-vaginal fistule they were 
continued just the same. 
In the hope, therefore, of finding some other material 
better suited, than hard rubber or metals, to supplement 
or take the place of my sponge cylinders in oil-silk bags 
with which to make graduated pressure, I turned my at- 
tention to dry cotton on account of its softness and elas- 
ticity, although in the] latter quality differing widely 
from that possessed by sponge. 16 
I had, in my earlier experience in the treatment of 
prolapsus and ulcerations of the os uteri with the old cyl- 
indrical speculum in the recumbent position, been accus- 
tomed to introduce into the vagina, after my applications of 
nitrateof silver, columns of dry cotton. This I did by taking 
pieces or balls the size of a pullet’s egg, with loops of thread 
thrown around them with ends five or six inches long for 
removal, and with long straight forceps crowding piece 
after piece into the speculum until it was filled for two 
and a half or three inches. This being completed, and 
the end of the column steadied by the forceps held in the 
right hand, the speculum would be slowly withdrawn with 
the other hand, thus emptying the instrument of its con- 
tents and leaving in the body of the vagina the column 
thus constructed, with all the ends of the looped threads 
hanging out of the vulva to enable the patient to remove 
it herself. Thus was placed a cylindrical column of dry 
cotton, intended to elevate and keep up the uterus and its 
appendages, for a time, at least, with the pubic arch and 
perineum acting as the point of support. 
This column of cotton, in the milder forms of prolapsus 
uteri, afforded very considerable support, and, I found, 
often gave great relief to the sufferer. The patient was 
required to remove it at the end of thirty-six or forty- 
eight hours, and use the warm vaginal douche. At the 
end of three or four days, another application of caustic 
would be made and the column renewed as before de- 
scribed. 
This column, from being dry, applied itself closely to 
the walls of the vagina, and, from its being slow to absorb 
the secretions, it maintained for some time its linear re- 
sistance to the superincumbent weight of the uterus. 
Being, however, essentially cylindrical, and too small to 
fill the upper part of the vagina as applied in decubitus* 
it did not give the full amount of support required to the 
uterus and its appendages, and consequently was defective 
and limited in the scope of its usefulness. 
Seeing, therefore, the superior advantages dry cotton of- 
fered over the old methods in the treatment of the ordinary 
diseases of the uterus and its appendages with the cylindri- 17 
cal speculum, I naturally used it after the invention of my 
self-retaining speculum. I also tried wool, knowing that it 
possessed equal elasticity,or even more than dry cotton, but 
patients so often complained of its harshness and its irri- 
tation of the vagina, that I gradually gave up its use, em- 
ploying only the cotton, which I found to be free from 
these objections. 
With my self-retaining speculum and perineal elevator,, 
with the patient in the knee-elbow position, I soon dis- 
covered that I could introduce between the two walls of 
the vagina a flattened column of cotton, in the manner of 
padding. The pubic arch and perineum I considered the 
points of natural support. The inverted cone shape of 
the vagina, to which my speculum had been adapted by 
the flaring expansion of its blades, particularly favored 
this mode of using the flattened or pad form columns of 
dry cotton, and I soon found that my patients could not 
only bear this form of support better than the soft sponge 
cylinders, but could walk and exercise with far less in 
convenience and fatigue. Besides this, I also-found that 
this plan was attended with a great deal less trouble to 
the patient and myself. All the patient now had to do 
after the stipulated time was to remove the deranged or 
broken-down column by drawing the threads loopedl 
around the several pieces of cotton used, and then to take, 
as usual, the warm vaginal douche. This I required to be 
done at the end of thirty-six or forty-eight hours, accord- 
ing to the necessity arising from leucorrhoea or other 
causes. I repeated the columning, at first, very much, as 
I had formerly been accustomed to do when using the 
cylindrical columns of cotton through the old glass specu- 
lum, about every three or four days, but afterwards reduced 
the time, as stated. 
It will suffice here to say that it was not long, after 
beginning this new mode of treatment, before I learned 
that a larger proportion of retroflexures of the uterus, 
whether simple or complicated, could be managed even 
more satisfactorily by dry cotton pressure than by sponge 
pressure, because it admitted of a more extended applica- 
tion, and could be so modified in each case as to meet the 18 
peculiarities presented without causing discomfort or un- 
necessary suffering to the patient. From these circum- 
stances I gradually came to employ it in all forms of 
uterine., para and peri-uterine disease connected with 
displacements and distortions, very much as I had been 
accustomed to use sponge dilators in oil-silk bags for the 
complications of vesico-vaginal fistule; but, owing to my 
lack of hospital facilities, it was several years before I 
came to realize fully the great value of the principle of 
dry cotton columning associated with my self-retaining 
speculum and the knee-elbow or knee-chest position. 
I will here describe the modus operandi without an as- 
sistant. The patient being in the knee-elbow or knee- 
chest position, and the vagina dilated laterally to the re- 
quired extent with my second sized speculum and back- 
ward and forward moving perineo-rectal elevator, the latter 
held in my left hand, while standing at the left side of the 
patient, I seize, with my curved uterine forceps held in 
the right hand, the first piece or ball of dry cotton looped 
with thread, and place it at the top of the posterior cul de 
sac, or against the posterior surface of the retrofiexed 
uterus, as the case may be. A second, third and fourth 
ball follow in rapid succession, and are placed and com- 
pressed with the forceps so as to occupy the entire width 
of the space behind the stationary points of the lateral 
blades of the speculum, when the whole is caught on the 
end of the backward and forward moving perineo-rectal ele- 
vator and held in position until several other balls are con- 
secutively compressed and caught, thus avoiding, in every 
movement of the forceps and perineal elevator, direct force 
backwards or forwards against the rectum or bladder. The 
flattened column or pad of cotton, thus begun, with its 
broad base and now brought downwards and forwards, 
slightly narrowed to come within the body of the flaring 
blades of the speculum, is next extended onwards ob- 
liquely across the axis of the speculum, until the point 
<Vappui is reached jast within the pubic arch, and the 
contracted range of the perineum, at about the junction 
of the upper two-thirds of the vagina with the lower 
third. In course of the construction, piece by piece of the 19 
column, the flaring blades of the speculum fulfill most 
important ends: a. in securing and maintaining uninter- 
ruptedly complete separation of the lateral walls of the 
vagina; b. in distending and steadying absolutely the 
vesico-vaginal and recto-vaginal septa by joint action 
with the perineal elevator; c. in presenting for working 
purposes, by virtue of their flaring expansion, an inverted 
cone in accordance with the anatomical requirements of 
the parts; d. in serving as a guide and as a protection 
against undue lateral pressure, and consequent unpleas- 
antness and pain to the patient; e. in guarding against 
undue pressure by the column upon the bladder or rec- 
tum, or both, by virtue of lateral distension of the anterior 
and posterior walls of the vagina instead of antero-pos- 
teriorly, as with the perineal elevator alone or with the 
univalve speculum; f in allowing the firmest transverse 
compression of the column in its lower two-thirds, thus 
leaving the upper third soft and free for upward disten- 
sion, pressure and movement of the uterus and ovaries, 
whether simply impacted or fixed; g. in adapting to the 
two laterally distended walls of the vagina a soft, dry, 
elastic and absorbing column of flat or pad form, wide at 
its upper extremity, where pressure is most needed, and 
narrow at its lower end, where the urethra opposes it; 
and in permitting itself to be removed, without derange- 
ment of the column, hy simply steadying the lower end of 
the column with the uterine forceps still held in the 
right hand and inclining it backwards, and collapsing the 
blades with the other hand while reversing the screw. 
It is proper to state that whatever medication to the 
cervix uteri is thought to be advisable, it is applied upon 
or in a special pad of cotton through the agency, usually, 
of glycerine and then placed in position as preparatory to 
the step of columning. The column is allowed to remain 
in position for thirty-six hours usually, when it is removed 
by drawing the threads left for that purpose. AVhen by 
rest of the patient, coupled with the warm vaginal 
douches, for another thirty-six hours, the column is re- 
newed as before, and so on to the completion of the cure. 
As an illustration of niy early appreciation of the 20 
principle above applied in practice, I will cite here a 
somewhat unique case of retroflexion of the uterus with 
fixation and supposed prolapsus of the ovaries, which came 
under my observation March 13th, 1874. 
Mrs. S., aged 32, married eight or ten years, no children, 
•stout and seemingly in robust health, consulted me on ac- 
count of her extreme nervousness and inability to ride in a 
carriage or omnibus for nearly a year. Any quick move- 
ment of. the body, as in sitting down, was intensely dis- 
agreeable,but the distress caused by riding over rough streets 
in an omnibus was agonizing. Sometimes, so sudden and 
•intense would be the pain, she would involuntarily spring 
to her feet and abruptly leave the vehicle, in the greatest 
embarrassment. The cause seemed to her, she remarked, 
a “soreness of the womb.” She had been undar the treat- 
ment of several eminent physicians of New York without 
deriving any benefit, and having suffered so much from 
the trial of hard pessaries, one after another, in addition 
-to her other troubles, she was quite disheartened as to the 
prospect of being cured. 
An examination in the knee-elbowT position, by digital 
and speculum exploration, readily revealed what I had 
suspected from the symptoms, namely : retroflexion of the 
uterus with fixation. There was prolapsus of one ovary; 
this being also slightly fixed behind the uterus. My col- 
umning of the vagina was at once begun, and then kept 
up, as above described, for nearly two months, with the re- 
sult of restoring the uterus and ovaries to a fair position 
and relieving entirely all her pains and nervous symp- 
toms. Being prevented from following up the case on ac- 
count of my visit to Europe, I ordered an intra-vaginal 
sponge cylinder in oil silk (for day use only) to be worn 
for two or three months as a Hodge’s pessary. It acted 
splendidly from the first introduction. 
In August, 1877, something over three years after the 
treatment was discontinued, this lady called to see me, 
having just returned from San Francisco, and she said her 
health had remained perfect from the time of her dis- 
charge. An examination now showed that the axis of the 
uterus was above a horizontal line and that the ovaries, 21 
«o far as could be determined by the finger, were out of 
harm’s way. She remarked that she had been able, ever 
since my treatment, to ride in a carriage or omnibus as 
far and as long as any one without discomfort. 
Dr. F. W, Owen, of Morristown, N. J., placed another 
•case under my care about the same time I began the treat- 
ment in the above case. Here, there was left latero-retro- 
flexion of the uterus with fixation, and with imprison- 
ment of the corresponding ovary. Columning of the va- 
gina by my method was recommended and carried on 
jointly by Dr. 0. and myself for several months, with the 
result of relieving almost entirely the confined position 
of the uterus and restoring the patient, after a year or two, 
to almost robust health. In connection with the column- 
ing with dry cotton there was used also, from time to time, 
my intra-vaginal sponge cylinder. The latter was finally 
used alone in place of the Hodge’s pessary which could not 
be borne. 
Dr. J. F, Chanorin, of this city, also consulted me about 
the same time (March, 1874) with regard to a case of retro- 
flexion of the uterus with slight fixation, occurring as a 
result of a miscarriage at sea which was followed by a 
mild attack of pelvic cellulitis. This took place three or 
four years previously, and the lady not having become 
pregnant since believed that she labored under some 
serious uterine disease, which induced her to apply for 
medical treatment. I recommended to the Doctor column- 
ing of the vagina with dry cotton according to my method, 
which he understood very well from having frequently 
witnessed its application in my practice. The treatment 
was continued about two months, at the end of which time 
the uterus was found quite restored to its normal position. 
No pessary or sponge cylinder was used as after-treat- 
ment. 
Pregnancy soon followed and in due course of time a 
fine healthy child was born without difficulty. The pa- 
tient, I learned from the Doctor a few days ago, remains 
after eight years perfectly well, and has given birth to 
another child. 
Owing to the loss of health now (July, 1874) I visited 22 
Europe and during the three years I was abroad, there was 
almost a complete suspension of my labors as regarded 
the employment of my new method of treatment for uterine 
and ovarian displacements. I saw but one case during the 
time I was away from New York and that was in the per- 
son of a young German lady, laboring under retroflexion 
of the uterus with fixation, whom I saw in consultation 
October, 1874, with Dr. Muller of Coburg, Germany. I 
recommended my method of treatment, but it was not 
properly carried out and consequently no decided benefit 
resulted from it. 
In June, 1877, just after my return from Europe, I was 
appointed consulting surgeon to St. Elizabeth’s Hospital 
of New York, under the direction of Dr. 0 Sprague Paine,. 
Surgeon in Chief. The Doctor then had a very bad case 
of retroflexion of the uterus with fixation and prolapsus 
of the ovaries under his care in the hospital. He asked 
me to see the case in consultation with him, which I did. 
The overshadowing feature of the case wras epilepti- 
form hysteria. I recommended columning of the vagina 
with dry cotton according to my method, which, at the 
request of Dr. P., I undertook myself. 
After a couple of months of persevering effort, during 
which time the patient had only one of her old attacks of 
hysterical convulsions, decided progress was made toward 
the replacement of the affected organs, and the patient 
felt she was greatly benefitted. At this stage of the treat- 
ment I made a trial of my new vaginal support intended 
to take the place of the column and to brace the uterus in 
its partially elevated position by acting on the cervix 
uteri, the short arm of the lever, and thus to avoid pres- 
sure upon the implicated ovaries by the crowding upwards 
of the posterior cul de sac, as with the Hodge’s pessary; but 
the instrument was in a crude state of evolution at that 
date and failed to meet the ends proposed. It was, there- 
fore, laid aside for the time. In order to adopt some form 
of support to the ovaries, under these circumstances I rec- 
ommended my old and ready expedient, the intra-vaginal 
sponge cylinder in oil-silk, and I instructed the patient 
how oo use it. During the treatment of this case, quite a 23 
number of my medical friends, of this city, visited the 
hospital to witness my mode of columning the vagina 
with dry cotton. Among them, Drs. Isaac E, Taylor, 
Meredith Clymer, Jean F. Chanorin, Monteferro J. Moses 
and others. Sometime afterwards the patient called to 
see me at ray office, and an examination showed the uterus 
in about the same stage of elevation in which I had left 
it, but she was not relieved of her hysterical attacks and 
was much depressed as to her prospects of recovery. She 
afterward, I learned, consulted a distinguished gyneecol 
gist of this city, fond of using the knife, and he performed 
the operation successfully, of extirpating both ovaries. 
The precise condition of the patient at the present time 
I cannot state from ray own knowledge, but I learn from 
Dr. Paine that her health has been much improved by 
this operation. 
I will now cite a most interesting case of anteflexion 
of the uterus as an illustration of the value of my new 
method for this form of displacement, and to point out its 
precise mode of application in the recumbent position. 
Mrs. P., of this city, aged 30, married ten years, sterile, 
general health much depreciated by a long train of nerv- 
ous complications, which had existed almost from the 
time of her marriage, consulted me November 9th, 1877. 
She had been under the care of eminent physicians, who 
had tried a variety of pessaries, none of which, however, 
she could wear without the greatest discomfort. On ex- 
amination I found a deep anteflexion of the uterus with 
slight endometritis and an irritating discharge which had 
resulted in vaginitis and vaginismus. Having before made 
applications of my method of dry cotton in similar cases 
I was led to try it here. The plan pursued was this : The 
patient resting in the recumbent posture upon a table, bed, 
couch or reclining chair, my second size speculum is intro- 
duced into the vagina and the blades expanded by turning 
the thumb-screw to the required extent. The detached 
blade is then slid in upon the perineo-rectal wall and after 
depression of the latter with it, adjustment is effected upon 
the projecting arches of the heel of the blades as indica- 
ted by Fig. 1. .At this stage of procedure the cervix 24 
uteri will usually be seen thrust back toward the hollow- 
of the sacrum and the body of the organ presenting for- 
wards and downwards at an angle of about 45° to the axi» 
of the vagina. Next, the spatula double hook, held in the 
left hand, is planted in the anterior lip of the cervix uteri 
the spatula part holding up, at the same time, the urethral 
portion of the vagina. With this control the whole specu- 
lum is now pressed gently backwards with the angular 
end of the perineo-rectal depressor held between the 
thumb and index finger of the right hand, at the same 
time the cervix uteri is drawn downwards and upwards- 
with the hook. Thus the cervix is lifted from its displaced 
position and brought partially, if not completely within 
the field of the instrument, when the hook is removed and 
it settles down securely upon the inner face of the depres- 
sion. Now the anterior columning begins. The dry cot- 
ton pads being prepared as before described, one is seized 
with my uterine forceps and placed firmly against the cen- 
ter of the vesico-vaginal septum, carrying the latter before 
it upwards and backwards to the highest point of eleva- 
tion. While thus pressed up it is caught by my narrowr 
curved, smooth spatula, held in the left hand, which allows 
the forceps to be removed, and so ball after bail of cotton 
is deposited the entire width of the anterior wall of the 
vagina and held in position. In this manner a firm col- 
umn is made obliquely downwards and backwards to a 
point between the body of the blades of the 
Here the firmness of the column is increased on account 
of the interposition of the flaring blades and the protec- 
tion of the lateral walls of the vagina against undue pres- 
sure. This point having been passed, the column is con- 
tinued on to the surface of the rectal depressor just within 
the contractile range of the perineum. 
The column now being still pressed upwards and back- 
wards with the narrow-bladed spatula, held in the left 
hand, the perineo-rectal depressor is disengaged and with- 
drawn with the right hand. Next, by reversal of the screw 
and the inclining backwards of the collapsed blades, the 
column becomes disengaged. The speculum is removed 
and afterwards the spatula. With the removal of the 25 
speculum the lower third of the perineo-rectal surface 
mounts upwards to the support of the newly-constructed 
column. Acting in this way the pressure upon the vesico- 
vaginal septum through the column is continued upwards 
and backwards against the body of the uterus, the long 
arm of the lever. Gradually the anterior wall of the va- 
gina stretches, and with it the utero-vesical ligaments 
yield. The column is allowed to remain thirty-six hours, 
when the patient removes it herself with the looped 
threads left for the purpose, and takes her usual warm 
vaginal douche. Rest and vaginal douches twice daily are 
allowed for thirty-six hours, when the column is again 
introduced. No assistant is required for the procedure. 
Here it is again seen that the flaring blades of the spec- 
ulum fulfill most important ends, as pointed out in con- 
nection with the plan previously described for retroversion 
and retroflexion of the uterus which it is unnecessary to 
repeat. 
Suffice it to say that my columning against the vesico- 
vaginal septum, in the way described, was kept up at inter- 
vals of two or three days for five weeks, with the result of 
placing the uterus in a good position and restoring the 
normal contour of the vagina. 
Having made important improvements in my vaginal 
support, since it was used in St. Elizabeth’s Hospital five 
or six months before, I concluded to try it in this case. 
This I did December 14, 1877, and the result was most 
t'• j • 
satisfactory. The patient wore it with the greatest com- 
fort, and soon the uterus was made to stand alone in its 
normal position. About three weeks afterward, when her 
menstrual period was just over, and she was still wearing 
the vaginal support during the day only, pregnancy oc- 
curred. The support was worn a month longer, or until 
after the time.for the next period, when it was thought to 
be unnecessary. The pregnancy progressed satisfactorily 
and terminated favorably to mother and child. It is now 
five years since my treatment was made, and the patient 
remains perfectly well. 
Here then was a successful application of the principle 
of anterior columning of the vagina with dry cotton for 26 
anteflexion of the uterus according to my method, and 
based upon the idea of pressure which really astonished 
me. It was upon the principle of the parallelogram of 
forces that I constructed this vaginal support, and it is, I 
conceive, only by a just appreciation of this law in me- 
chanics that my form of pessary or support, intended for 
the vagina, can be made to subserve its highest aims. It 
was devised with the idea of supplementing the use of the 
columns in all forms of vaginal, uterine and ovarian dis- 
placements, resulting from whatever cause. 
In February, 1878, when I was appointed surgeon to 
the Woman’s Hospital of the State of New York, I found 
a broader field for observation and particular study of the 
class of diseases under consideration than I had before en- 
joyed. I now introduced into this institution my peculiar 
methods of treatment regarding not only the graver, per- 
forating lesions of the organs concerned in paturition, but 
the milder ones resulting from changes in former relation- 
ship and function, Prominent among these methods were 
dilatation of the vagina for cicatricial and contracting 
bands as complications of vesico-vaginal fistule (kolpos- 
tenosis) with hard rubber and sponge dilators, and the 
columning of the vagina with dry cotton, together with 
my speculum and supporting and confining apparatus for 
the knee-chest position. With regard to the columning 
of the vagina, especially, the old nurse who had been con- 
nected with the institution almost since its foundation 
was quite amazed, not only as to the quantity of cotton I 
used, but at the facility with which I disposed of it with- 
out her valuable assistance as a speculum holder, which, 
until then, she had believed to be absolutely indispensa- 
ble for all forms of vaginal and uterine treatment. 
For the innovation of using dry cotton she claimed the 
right to dub my dry cotton balls with looped threads, 
“snow-balls” in contradistinction to the old form in use 
there, “ the butterfly ”—a single pad of cotton saturated 
with glycerine and likewise secured with a loop of thread 
for removal, intended for medicated applications, alone, 
to the cervix uteri. Not only this, but the suddenly in- 
creased expenditure for cotton was such as to attract the 
attention of the Lady Managers and to excite comment. 27 
As to what I have accomplished in the Woman’s Hos- 
pital by my peculiar methods of practice, designated these 
sometimes, “the new element” it is not necessary for my 
present purpose to indicate. It is a matter of record and 
is well known to a large class of physicians scattered over 
our country. So much, then, for my understanding the 
principle of using dry cotton in the treatment of diseases 
of the uterus and ovaries at this date. 
This brings us to the consideration of my paper pre- 
sented to the American Gynaecological Society, September, 
1878, to which reference has already been made at the 
beginning of this article. As it may not be generally 
understood, I will here repeat the objects I had in view 
in the preparation of that paper. 
1. To record my protest against what I considered to 
be an abuse of the bloody operation for the superficial 
lacerations of the cervix uteri. 
2. To explain what I believed to be the true “ Mechan- 
ism of retroversion and prolapsus of the uterus considered 
in relation to the superficial lacerations of the cervix 
uteri.” 
3. To point out the relationship of prolapsus and im- 
prisonment of the ovary, or ovaries, to the retro-displace- 
ments of the uterus, and especially to retroflexion with 
fixation. 
4. To give a general idea of my mode of columning 
the vagina as a means of reducing to narrower limits 
bloody operations for superficial lacerations of the cervix 
uteri, and of successfully treating all forms of displace- 
ment of the uterus, ovaries and other appendages, includ- 
ing, also, pelvic exudations and adhesions. 
5. To present to the notice of the profession a new 
vaginal support, constructed upon the principle of the 
parallelogram, and intended to supplement my method of 
columning the vagina. 
In my remarks relating to the mechanism of prolapsus 
and retroversion of the uterus, I pointed out the counter- 
acting forces concerned in maintaining the organ in its 
normal position ; also endeavored to show that the dis- 
placements in question took place only when the expul- 28 
sive forces of the body, residing mainly in the diaphragm 
and abdominal muscles, preponderated; that is, exceeded 
the pelvic forces by reason of the gradual development of 
the acquired forces, the result of disease. I further said 
there was not a single counteracting force residing in the 
cervix uteri below the vaginal attachment where superficial 
lacerations occur, and that any denudation and suturing 
of whatever notch, rent or laceration, occurring here from 
parturition, could not, from the very nature of things, 
however skillfully executed, elevate or restore the organ, 
as a whole, to its lost position any more than the simple 
denudation of the same parts and the processes of granu- 
lation and cicatrization could accomplish this result. The 
principle, I believed, had no foundation in logic nor in true 
surgery, and I still fail to see the importance attached to it 
by Dr. Emmet and other writers all over our country. To 
forcibly invert the lips of the cervix uteri for the purpose 
of elevating the whole organ, without mechanical sup- 
port, is, to my mind, opposed to all the teachings of phi- 
losophy. 
Laceration of the anterior lip of the cervix uteri with 
the vesico-vaginal septum will cause retroversion or retro- 
flexion, and the reparation of both structures will cure 
the displacements. Why ? Because one of the principal 
counteracting forces to hold the uterus in position resides 
in the vaginal walls, and to repair these lesions is to cure 
the particular form of displacement resulting from them. 
This, I believe, I was the first in this country to demon- 
strate. (See New Orleans Medical Journal, May, 1854, and 
Southern Medical and Surgical Journal, Augusta, Ga., Au- 
gust, 1855.) 
In my paper under consideration, I spoke of complete 
procidentia uteri as a result of the yielding of all the 
counteracting forces, and said that the persistency alone 
of the integrity of the broad ligaments would prevent 
this form of displacement in the following manner: “While 
there is a joint action of the expulsive and the acquired 
forces, the broad ligaments may not yield at all, or only to 
a slight extent, and the further descent of the body of the 
uterus be prevented. 29 
“In the event of the broad ligaments yielding, the 
same forces will drive the fundus farther down upon the 
rectum and thus cause retroflexion. One or both ovaries 
often become involved in the process, are crowded against the rec- 
tum, and in that manner the most intense suffering is produced.” 
In my explanation of the mode of using dry cotton in 
the knee-elbow, or knee-chest position with a suitable 
speculum, (my self-retaining speculum) for the treatment 
of displacements of the uterus and ovaries, from whatever 
cause, I simply offered to the profession my own views 
upon this subject for what they were worth, and based 
them upon nearly twenty-five years experience with the 
use of sponge, hard rubber and cotton. This is shown as 
regards pressure with cotton in these words : 
“There must be formed a firm pyramidal column of 
carbolized cotton or wool, extending from the posterior va- 
ginal cul-de-sac obliquely downwards across the axis of 
the vagina to a point just within the pubic arch and the 
range of the perineum. 
“ By this mode of procedure it can be seen that, for the 
time being at least, the abdominal or expulsive forces are 
made to operate only at the greatest mechanical disadvan- 
tage; in other words, their action is reduced to the mini- 
mum degree. 
“The uterus, the bladder and the rectum are thus made 
to gravitate beyond healthy limits, and so give the most 
perfect relief to all the structures in which the counter- 
acting forces reside. The flattened column of cotton thus 
constructed with its base upwards, is in a position to sup- 
port, not only the uterus and the walls of the vagina, but also 
the ovaries, which are so frequently prolapsed in these cases. 
“The flattening of the column ofcotton is intended 
also to save the rectum and bladder from undue pressure, 
such as may interfere with their functions. The narrow- 
ness of the column of cotton is also to be observed, in order 
that the lateral walls of the vagina may not be distended, 
but rather encouraged to contract. 
“ The pieces of cotton or wool with which the column 
is formed, may be secured in loops of strong sewing thread, 
so that the patient can remove them at the end of two or 30 
three days, and take the vaginal douche of warm water, 
preparatory to a renewal of the procedure. When the 
above indications are all fulfilled, the woman assumes the 
upright posture and performs her daily duties.” 
I also said that wool might be used, subject to the same 
rules, but certainly did not recommend it, for long before 
this time I had regarded it as far inferior to dry cotton, 
for the reasons already stated. With reference to the 
principle of columning the vagina and employing after- 
ward a suitable vaginal support to complete the cure, I 
said ; 
“The modus operandi of this mechanical method of 
treatment, whether called preparatory or curative, is, I 
think, simple and can be easily understood by the patient. 
“ There are, however, objections to this plan of treat- 
ment : 
“First. The time and attention, on the part of the phy- 
sician, required to carry it out. 
“ Second. The prejudice of the physician against the 
knee-elbow position. 
“ Third. Defectiveness in the specula ordinarily employ- 
ed, (including among them every form of univalve having 
simply a pubo-sacral or ante-posterior action.) 
“jFourth. The pessaries in common use do not have the 
proper shape to give the required support after the pre- 
paratory treatment. * * * * * 
“I have labored long to devise a suitable vaginal sup- 
port to take the place of the carbolized cotton, but it is 
only within the past year I have sueceeded in bringing 
the instrument to a degree of perfection which enables 
me to predict its ultimate success.” 
Of the general uses of this vaginal support, I further 
said: 
“ This instrument is not only useful for maintaining 
the uterus in an elevated position after retroversion and 
prolapsus have occurred, but it is also a most valuable in- 
strument with which to accomplish the same end after 
the retroflexed and fixed uterus has been dislodged from 
the hollow of the sacrum by means of the cotton columnt 
or compresses already described. 31 
“ After proper preparatory treatment, by means of th& 
cotton columns directed obliquely against the vesico-vagi- 
nal septum from the perineum as point d'appui, the instru- 
ment can be used with equally satisfactory results in the 
cases of anteflexion and anteversion of the uterus. * * 
“Suffice it to say that retroflexion and fixation of the 
uterus in the hollow of the sacrum, constitutes, both in 
the primiparte and in the multiparae, the largest class of 
uterine displacements, and often the most deplorable, 
which we are called upon to treat. Hitherto, treatment 
of these cases by means of the uterine sound and stem pes- 
sary has been unsatisfactory, and, according to my experi- 
ence. a more comfortable, safe and effective method is 
unquestionably a great desideratum. The plan of treat- 
ment which I have described is - nothing more nor less 
than an application of some of the principles of orthopedic 
surgery to uterine distortions, and I think will accomplish 
the end desired. 
“Since I first adopted this plan of treatment, now, 
nearly seven years ago, I have relieved a number of most 
unpromising cases, such, I am sure, as could not have been 
cured by the use of the uterine sound and the stem pessary. 
These were cases in which one or both ovaries were impris- 
oned and unduly compressed, chiefly by the supplementing 
or acquired force residing in the rectum.” 
As to the principle and construction of my vaginal sup- 
port, I will here quote the description then given : 
“ This instrument is constructed upon the principle of 
the parallelogram. 
Fig. 5. 
Fig. 6. 32 
“It is elastic and thoroughly self-sustaining. The in- 
strument is made of coiled steel wire. It has vesical and 
rectal branches which are covered with thin rubber up to 
points near the heel of the instrument, where an opening 
is left for the escape of the menstrual and other discharges. 
“Upon the vesical branch is set a hair cushion which is 
to receive and support the vesico-vaginal septum. The 
covering of the rectal branch is distended with air in order 
that it may adapt itself uniformly to the recto-vaginal 
septum. The two upper uneven points are united by a 
broad elastic apron, which like a chair is to receive the 
cervix uteri, and to a certain extent to support the weight 
of the entire organ. When viewed edgewise, the instru- 
ment presents somewhat the appearance of a jockey’s cap, 
and a medical friend suggested it should be called the 
“jockey cap’’ pessary. However, to avoid the name of a 
uterine pessary, I prefer to call it a vaginal support. This 
name is in strict accord with the action of the instrument, 
for it leaves the uterus and its relaxed ligaments to take 
care of themselves in their normal relation and position. 
This is an attainment of the highest aim I can conceive 
for any form of instrument employed for the latter pur- 
pose. 
“This instrument is not only useful for maintaining 
the uterus in an elevated position after retroversion and 
prolapsus have occurred, but it is also a most valuable in- 
strument with which to accomplish the same end after the 
retroflexed and fixed uterus has been dislodged from the 
hollow of the sacrum, by means of the cotton columns or 
compresses already described. 
“After proper preparatory treatment, by means of the 
cotton columns directed obliquely against the vesico-vaginal 
septum from the perineum or point d’oppui, the instrument 
can be used with equally satisfactory results in cases of 
anteflexion and anteversion of the uterus.” 
After the foregoing description of this vaginal support 
was published, I made some important improvements in 
its construction. These improvements will be readily ap- 
preciated by reference to Fig. 6; first, the hair cuhsion on 
the vesical, or upper branch, is replaced by plain and solid rubber; second, the air-distended covering of the rectal 
branch is now simply the double thickness of the rubber ; 
and third, the elastic apron extending only around the 
points of the two branches is now carried from the toe 
toward the heel of the instrument about two-thirds the 
distance. Beside these noteworthy changes in the general 
configuration of the instrument, it is now much lighter, 
thus admitting of greater elasticity between the sides and 
branches. The extension of the elastic apron proved to 
be of inestimable value in preventing the lateral walls 
of the vagina from falling between the vesical and 
rectal branches. Possible injury to the cervix uteri from 
the edge of the old apron is also obviated. 
Fig- 7- 
Fig. 7, in section, illustrates the instrument in position, 
both as regards ante and retro-flexions with prolapse of 
the ovary (o) in Douglas’ fossa. The positions (g and &) 
indicate the points of supposed displacement of the uterus, 
and the reversal of the arrows (e and a), the general 
direction of the two forces by which the organ from anterior 
or posterior columning of the vagina, has been carried to 
its present normal position. The divisions of the two 
branches at their centre are shown (at 1 and 2) with the 
elastic apron stretching from one point to another and 
supporting the uterus as in a swing. The arrows (e and 
a) represent the anterior and posterior lines of descensus 
uteri under the operation of pressure and the expulsive forces, residing in the diaphragm and abdominal muscles,, 
supplemented by the acquired forces of disease. The first 
line of descent in unopposed anteflexion of the uterus, 
would be towards the star at the junction of the perineum 
with the recto vaginal septum ; the second in retroflexion 
towards the star on vesico-vaginal septum opposite the 
root of the urethra. Any form of pessary, therefore, with 
a single branch, acting in either of these lines, intended 
for anteflexion or retroflexion, must necessarily find a 
centre at one or the other of these stars, with the resulting 
impingement or pressure upon the opposing hollow organs. 
Unite, however, the two single branches in accordance 
with the principle of the parallelogram and the effect of 
the resultant will be found at the circled star indicated by 
the arrow (c). As the acquivalent of all the component 
forces arising from downward movement or pressure of the 
uterus and walls of the vagina. 
(üßy any number of forces acting together for a given time, a 
body is brought to the same place as if each of the forces, or one 
equal and parallel to it, had acted on the body separately and 
successively jor an equal time.”—SUUmani) 
Thus is placed in the vagina an instrument which is 
elastic in every direction upon which pressure falls, self- 
acting and self-sustaining in the axis of the organ, with 
no tendency to escape when properly adjusted. By the 
side action at the heel of the instrument, the same as that 
of the antero-posterior, it is rendered additionally secure 
against the several forces directed upon it from above, be- 
fore and behind. In the adjustment for anteflexion of the 
uterus, the cervix is brought from behind the extremity 
of the rectal branch (2) and made to stand on the elastic 
apron, while the extremity of the vesical branch (1) aids 
in preventing the falling forward of the body of the organ 
upon the bladder; for retroflexion, the cervix uteri is 
caught upon the elastic apron beneath the extremity of 
the vesical arch (1) and carried back to the same position 
as in anteflexion, as is here represented in the cut. Thus, 
in both forms of displacement, it is seen that the cervix 
uteri—the short arm of the lever—is acted upon instead of 
the long arm, as is the case in the use of the Hodge’s pes- 
sary and its various modifications. The advantages of the mechanism of my instrument 
over the latter, with regard to the ovary (o) in the retro- 
peritoneal fossa, are self-evident, not only as seen in this 
diagram, but as actually observed in my every-day practice. 
Before leaving this part of my subject, it is proper for 
me to say that any one employing this instrument with the 
idea that he can introduce it into the vagina and relieve 
any sort of uterine and ovarian displacement, without the 
necessary preparatory treatment, by vaginal columning, 
will soon find himself doomed to sad disappointment. 
The successful use of the instrument depends upon the 
thoroughness with which vaginal distortions and uterine 
displacements are first overcome by the columning of the 
vagina, supplemented or not, according to circumstances, 
by the pressure of sponges in bags of oil-silk or taffetas de 
soie. The great value of the instrument is to maintain the 
cure and to enable the patient herself to do this, especially 
in the large class of cases where a hard pessary cannot be 
borne. 
It is true there are many cases in which there is 
retroflexion of the uterus with fixation, and in which it 
is impossible to elevate the organ beyond the axis of the 
vagina. Even in such cases, the instrument will hold 
the uterus, with the ovary when prolapsed, up to this 
line with the greatest comfort to the patient, and thus 
enable her to lead a life of moderate activity, which she 
could not do with a hard instrument requiring constant 
watching by a physician. 
This instrument is intended to be worn only during 
the day, when the patient is upon her feet. She removes 
it at night and introduces it in the morning. The great- 
est objection I have heard urged against the use of the 
instrument is the disagreeableness of the odor produced 
by the warmth of the body and the ordinary secretions of 
the vagina and uterus, but this is an objection generally 
urged by physicians and not by patients. The latter are 
usually more impressed by the benefits derived from wear- 
ing it than by any unpleasant odor. In fact, when the 
patient can afford it, and two instruments are at hand for 
alternate use, the objection indicated may be almost en- 36 
tirely overcome. A solution of permanganate of potash 
(3j—§i), in which the instrument may be left over night, 
contributes greatly to cleanliness. 
There is another fact I will state in regard to this in- 
strument, which is necessary to be known in order to ap- 
preciate the limit of its application; it is that a higher 
degree of intelligence is required for its use than is to be 
found in the lower walks of life. In short, the patient 
must have sufficient intelligence to understand the char- 
acter of the displacement under which she labors, and the 
object sought to be attained by the instrument placed in 
her hands for the maintenance of the cure. On these 
points, however, I find no trouble in private practice. In 
fact, I sometimes have patients so familiar with the use 
of the instrument, and so thoroughly relieved from their 
troubles of years’ standing, that they will not lay it aside 
when they are really cured, fearing a relapse. I could cite 
a number of cases of this class if I had the space. One 
from the State of Georgia I may be permitted to mention. 
This patient had retroflexion of the uterus with fixation 
and imprisonment of one ovary, and was on the verge of 
insanity when she consulted me in the autumn of 1879. 
From posterior columning of the vagina she soon recov- 
ered her health, and gained upwards of twenty pounds in 
weight in less than a year. She has now been wearing 
the instrument nearly three years, and says it is no more 
trouble to her than putting on her stocking, and she 
means to wear it as long as she lives. Another case is 
that of a young unmarried lady of New York who came to 
me for treatment May 17th, 1878. She suffered from a bad 
form of anteflexion of the uterus. She was treated by an- 
terior columning of the vagina and cured. My vaginal 
support was introduced to maintain the cure, and soon af- 
terwards she left for Europe with her parents for a two 
years’ trip. Notwithstanding she was told to lay aside 
the instrument after three or four months, she continued 
to wear it the whole time she was abroad, having fresh 
instruments sent regularly from New York every five or 
six months. On her return home she reported herself at 
my office, well and hearty, with a rosy complexion, saying 37 
the support was no trouble to her, and that she preferred 
to wear it longer, rather than take any risk of a relapse. 
Finding her thoroughly cured in every particular, I again 
advised her to stop the use of the instrument. 
I will mention another fact in relation to treatment by 
columning the vagina and employment of the vaginal 
support, that is, restoration of the lost power on the 
part of the patient to exercise in the open air and to 
maintain her wonted interest in out-door life. The unin- 
terrupted monotony of home life, and the varying scenes 
of hospital residence, sometimes gloomy and depressing, 
are not always conducive to mental and physical effort, 
and something is needed to arouse her dormant energies 
and restore confidence, that she may be able to perform 
those daily duties which were formerly a pleasure to her. 
That something is the elevation and support of the uterus 
and its appendages to the highest limit of their tether, and 
relief, not only from actual pain, but from that “dragging, 
good-for nothing feeling,” with cold hands and heavy 
lower extremities which only such patients know how to 
describe. Once prove to such a patient the practicability 
of accomplishing this, confidence comes and often enthu- 
siasm, at the prospect of regaining her lost health and 
the power of well-doing. By far the largest proportion of 
cases in my private practice belong to this class. After 
having been under the care of a dozen or more physicians, 
and in not a few instances having passed through the 
trying ordeal of a bloody operation for laceration of the 
cervix uteri alone, or in conjunction with a bloody opera- 
tion upon the anterior vaginal wall, or in conjunction 
with both of these an operation upon the perineum. In 
these very cases, wholly unrelieved by these successive 
bloody operations, where the perineum had even to be cut 
down to its normal depth to allow treatment, I have suc- 
ceeded in an incredibly short time in restoring confidence 
by columning the vagina alone, and securing power to 
exercise in the open air. I have even had patients, know- 
ing the muscular and nervous strain of a day’s visiting or 
shopping, who have come to me for treatment in the 
morning before beginning their round, saying it was only 38 
by this aid that they could hope to carry out their inten- 
tions. With my vaginal support, under such circum- 
stances, the same power to undergo fatigue is maintained, 
and a cure ultimately effected by the individual efforts, as 
it were, of the patient herself. 
From the general character of my paper in 3878, fol- 
lowing upon my long experience in the treatment of dis- 
eases of the vagina and the uterus by graduated pressure, 
I think it will be conceded that I had at least decided 
views at that time upon the several points here brought 
out, and perhaps none more positive than those with refer- 
ence to the bloody operation for superficial lacerations of 
the cervix uteri, and also the frequent relationship of pro- 
lapsed ovaries to retroversion and retroflexion of the ute- 
rus. So, also, with regard to columning the vagina which 
I had already been using for years in connection with my 
intra-ischial or bilateral acting speculum. 
In September, 1879, at the annual meeting of the 
American Gynaecological Society, held in Baltimore, Dr. 
P, F. Munde, of New York, submitted a paper on “Pro- 
lapse of the Ovaries,” and in the discussion which followed, 
in which several of the members took part and corroborat- 
ed with marked unanimity his statement with regard to 
the value of the “ cotton tampon ” in the treatment, I 
said: 
“ According to my observation, prolapse of the ovaries 
is of frequent occurrence, and it is a subject which has in- 
terested me for many years. I agree fully with Dr. Skene 
and Dr. Goodell with reference to the mechanism by which 
the symptoms are produced. lam not sure, however, but 
that, in the majority of cases, it is the retroflexion, which 
is almost invariably associated with the prolapse, that 
gives rise to the pain, rather than the difficulty in defaca- 
tion. I have seen cases in which there was almost com- 
plete obstruction of the bowel, in which not only was pain 
occasioned by the retention of the feces, but the habit of 
constipation was the result. 
“With reference to disease of the organ, it certainly 
exists in many cases, although, as Dr. Munde has stated, 
it is not, to all appearance, diseased in many cases. I re- call one case in which the ovary was prolapsed into Doug- 
las’ pouch, where it became fixed to the uterus, and un- 
derwent cystic degeneration, rupturing and discharging 
into the uterus at two different times. 
“The treatment which has been proposed by the au- 
thor of the paper is very good, so far as it applies to sim- 
ple cases. But where the organ is prolapsed, and has be- 
come fixed, I think he has not given sufficient importance 
to pressure while the patient is in the knee-elbow posi- 
tion ; cylinders of cotton are placed in the vagina, so as to 
bring pressure directly against the fixed ovary. 
“ I have found the iodoform ointment, applied to the 
cul-de sac and kept in place by a column of earbolized cot- 
ton, of great value to relieve the tenderness and hyperes- 
thesia which always exists in these cases. As Dr. Munde 
has mentioned my name in connection with support of 
the prolapsed organ by means of the cotton vaginal tam- 
pon, X will merely say that such has been my practice for 
the last twenty years. 
“ I have seen fixation of the ovary not only by retroflex- 
ion and latero-flexion of the uterus, but it is also often 
fixed in the posterior cul-de-sac low down, by anteversion, 
thus giving rise to the same symptoms that have been 
mentioned at considerable length. I have seen the great- 
est relief of the symptoms from the use of pressure when 
the ovary is prolapsed and adherent. Of course if the 
ovary is firmly fixed in that position is not to be sup- 
posed that by pressure it can be disengaged, but it is pos- 
sible to carry the uterus up and with it the ovary, by which 
means the vesical symptoms are relieved.” 
In September, 1881, at the annual meeting of the same 
society, in New York, Dr. Ely Van De Warker read a paper 
entitled “ Forcible Elongation of Pelvic Adhesions,” which 
was also discussed by a large number of the members, and 
with singular unanimity the practice was condemned. 
For my part, I said: 
“I have been much interested in this class of cases, 
retroflexion with fixation of the uterus, frequently accom- 
panied by prolapse of the ovary. My attention was first 
called to it in 1859, in connection with a vesico-utero- 40 
vaginal fistule. My operation, at that time, was to make 
incisions from the right and left angles of the fistule 
through the vesico-vaginal septum, for the purpose of dis- 
engaging the uterus, and then to place cylinders of sponge 
in oiled silk bags in the vagina. These cylinders were 
introduced and crowded into the posterior cul-de-sac daily, 
and the treatment was kept up for weeks. I found that it 
was possible by this means to restore the uterus ultimately 
to its proper position and thus disengage the cervix from 
the bladder. I have also treated these cases complicated 
with incarceration of the cervix in the bladder with car- 
bolized cotton, “columning the vagina,” and this method 
I brought before this Society in 1878 and 1879. It is a 
practice to which I resort almost daily, and consists simply 
in placing the patient in the knee-elbow position, and 
making these columns in the vagina rest against the pu- 
bic arch and the perineum. By this continuous pressure 
I have been able to stretch the posterior vaginal wall of 
not more than two and one-half inches in length, to the 
depth of five or six inches, thus gradually loosening the 
uterus, so that it has been restored to its natural position. 
These columns are usually allowed to remain about thirty- 
six hours, when they are removed by the patient by means 
of the little cords attached, and the vaginal douche of 
warm water is used. At the end of twelve or twenty-four 
hours they may be renewed. Of course other means may 
be employed in connection with this method, as iodine, 
hot water, etc. The principle of elongating the posterior 
wall of the vagina is most important. When the elonga- 
tion has been completed, and the uterus brought into proper 
position, the ovary is usually restored with it, and the 
patient can, as a rule, wear a Hodge’s pessary or my vagi- 
nal support, presented to the Society in 1878 ” 
From these remarks it will be seen that I had already 
given special attention, when these two papers were dis- 
cussed, not only to the pathology and mechanism of pro- 
lapsed ovaries and pelvic adhesions, but to their success- 
ful treatment. I have introduced the above report to 
show the progress and development of what I have come 
to regard as the only rational method of dealing with such 
difficulties. 41 
We will next turn our attention to the published views 
of one or two other physicians who have had experience 
with my mode of columning the vagina in diseases of the 
uterus and ovaries. 
Dr. Rudolph Tanszky, of New York, gynaecologist to the 
Out-door Department of Mt. Sinai Hospital, whose atten- 
tion was directed to my special modes of intra- 
vaginal and utero-ovarian diseases as early as 1872, men 
tions sixteen cases of prolapsus of the ovary and fifty-eight 
cases of retroversion and retroflexion of the uterus in 3/1 
patients applying for treatment from December Ist, 1877, 
to December Ist, 1878. The mention of these cases can be 
found in the report of the Hospital for that year, and he 
treated them by columning the vagina according to my 
method. 
Here is a proportion, then, of 27.58 per cent, of cases of 
prolapsed ovaries out of 58 cases of posterior displace- 
ments, and 4.30 per cent, out of 071, the whole number 
of cases treated. This statement is interesting from a sta- 
tistical point of view. 
Dr. Tanszky’s estimate of the value of my of 
columning the vagina, after several years experience with 
it, may be inferred from an article by him in The ]\ew 
York Hospital Gazette, April 5, 1879, entitled “The Tampo- 
nade of the Vagina Successfully Applied as a Curative 
Agent for Uterine Displacements with Adhesions and 
Prolansed Ovary.” He ably discusses the pathology of 
displacements of the uterus and ovaries and their treat- 
ment, and especially of chronic inflammation of the womb 
when retroverted instead of retroflexed, giving the pre- 
vailing views of leading writers upon this latter point as 
well as upon the proposal of the bloody operation, or 
trachelorrhaphy, as it is now sometimes called, for super- 
ficial laceration of the cervix uteri when this lesion is 
found to exist. After acknowledging the failure of all the 
ordinary resources, including trachelorrhaphy, to relieve 
the cases of retroversion of the uterus with adhesions, he 
proceeds to give his experience with my vaginal columns 
of cotton as follows : 
“But still there were the adhesions and the displace- 42 
merit which no surgical operation, no internal or external 
support of the womb, and no medication known to me, 
would have relieved to such a satisfactory degree as the 
plan for accomplishing this purpose first used, I am told, 
twenty years ago by Dr. Nathan Bozeman, of this city, 
and which I have myself found to be of the highest value 
in the treatment of complicated or uncomplicated cases 
of uterine adhesions and displacements of the ovary in 
private practice as well as also in my service in the Mt. 
Sinai Hospital Out-door Department. This method con- 
sists in the gradual stretching, elongation of the vagina 
by means of carbolized cotton, (the use of carbolized cot- 
ton, of course, instead of the ordinary cotton is of recent 
date). 
“The simplicity, the safety, and the usefulness of the 
method for which the profession is indebted to Dr. Boze- 
man who claims, and with justice, the priority of this 
mode of treating uterine displacements and adhesions 
whether complicated with ovarian prolapse or not, will be 
apparent to the most skeptical after trial. * * * * 
“The rationale of Bozeman’s method of tamponing the 
vagina for the relief of uterine adhesions seems to me to 
be the following : The vagina is elongated and put some- 
what upon a gentle stretch ; the rugse become smoothed 
out; the fornix vaginee is elevated in the pelvis; the 
adherent uterus, ovar}% etc., are supported from below 
upwards by the soft cushion thus applied; the blood-ves- 
sels are relieved from distension and their hypereemic 
state, the plexuses and nerve filaments are also thereby 
relieved from direct pressure from the enlarged, fixed and 
displaced womb, and the surrounding, often accompanying 
exudation, which, if within the ligaments, may be gently 
and gradually moved. The cautiously exerted pressure, 
through the column of the cotton in the vagina, acts as a 
stimulus to the lymphatics and promotes absorption of firsf 
liquefied peri-uterine exudations. The bladder also being 
supported by the tampon, is more readily emptied than 
before, and often the great distress of painful and frequent 
micturition is greatly lessened. It is hardly necessary to 
state that each tampon has a string attached to it, for the 43 
purpose of its easier removal. The tampon remains for 
forty-eight hours usually, when the vaginal douche is 
used and the tampon is re-applied. In a few weeks the 
good results are manifest by the more comfortable feelings 
of the patient and the mobility of the uterus found to 
exist by the examining surgeon. 
“Since uterine adhesions and chronic pelvic exuda- 
tions have heretofore constituted a large majority of in- 
curable cases in gynaecological practice, the attention of 
the profession is hereby called to a simple method of re- 
lief, which it has proved to be in my hands at least, and 
those of Dr. Nathan Bozeman, to whose kindness I am in- 
debted for having first called my attention to it.” 
In February, 1882, at the annual meeting of the New 
York State Medical Society at Albany, Dr. William War- 
ren Potter, of Buffalo, submitted a paper entitled “The 
Genu-Pectoral Posture in the Treatment of Retro-Dis- 
placements of the Uterus, and in Dislocation of the Ova- 
ries,” in which he spoke of this position (meaning the 
exaggerated knee-elbow or knee-head position), of my 
speculum and of my mode of columning the vagina, as 
follows : 
“Having accustomed myself, during several years past, 
to employ the knee-chest position in the treatment of all 
backward displacements of the uterus, as well as in pro- 
lapse of the ovaries, I am prepared to affirm the superior- 
ity of this method over all others with which I am famil- 
iar, in the management of this class of maladies. Under 
its timel}T and judicious use, even the most complicated 
and obstinate kinds of retroversion and retroflexion, with 
fixation of the uterus in the hollow 7 of the sacrum, maybe 
made to yield. * * * * 
“Of the speculum: It is important, for knee-chest 
uses, that the speculum should be constructed with lat- 
erally expanding blades, and be more or less self-retain- 
ing. 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 admira- 
bly met in the instruments devised by Dr. Bozeman, and 
which bear his name. While the Sims’ speculum is, un- 44 
doubtedly, possessed of 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. * * * * 
“In every case it is my custom to commence the treat- 
ment 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 (one 
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 specu- 
lum, and finally the right index finger is introduced to 
steady the cotton column, while the patient is resuming 
the erect posture.” 
Although Dr, P. does not acknowledge, in his de- 
scription of the process of introducing the pledgets of 
cotton into the vagina through my speculum, the source 
of his information, still it is precisely given as he learned 
it in my office and in my service at the Woman’s Hospital. 
Thus far in my historical sketch of the value of grad- 
uated pressure in the treatment of diseases of the vagina, 
uterus, ovaries and other appendages, I have confined my- 
self strictly to the statement of facts, avoiding controver- 
sies entirely. I wish I could now feel that it was unneces- 
sary to say anything as to the bearings of the above rec- 
ognized advances in gyna3Cological surgery, or in vindi- 
cation of my claims to originality. I shall add, however, 
only what seems to be required to refute unjust criticism. 
I may, therefore, be pardoned for again referring to 
Dr. Campbell’s paper, published in 1876. (Op. cit.) On 
page 231, after pointing out the advantages of the exag- 
gerated knee-elbow, or, technically speaking, the genu- 
cephalic position, in a simple case of retroversion of the 
uterus, where “ reversal of gravity,” “ draft of the visce- 
ra,” and “pneumatic pressure” having in his hands 45 
reached their highest point of effectiveness, he remarks, 
“No dilating speculum is now required,” (italics his), re- 
ferring, no doubt, to my intra-ischial or bilateral-acting 
speculum. I say my speculum, because I know of no other 
instrument capable of such dilatation of the vagina as he 
describes, not only in such passive cases, but, when neces- 
sary, independently of the will and resistance of the 
patient, and it is hardly probable that he knew of any 
other such instrument at that time. Having avoided in 
his paper making mention of, or alluding in the slightest 
way to, my designating term “knee-chest” for the double 
right angle triangle position of the body of the patient 
upon my supporting and confining apparatus, and having 
then used the same term under the Latin guise of “ genu- 
pectoral” for the old exaggerated knee-elbow position, as 
shown in his cut, Fig. 2, presented on a former page, 
without acknowledging indebtedness, the inference, I 
think, is legitimate that his intention was also to ignore 
my speculum; hence the special allusion to the latter, as 
shown by his italicizing the usual qualifying word “ dila- 
ting.” It is no doubt true, that “no dilating speculum ” 
was needed to produce the results indicated by placing his 
patient upon her head, or as near it as he could, in the 
genu-cephalic position, as shown by his cut. 
Having, as he did, the full co-operation of the patient 
and no adhesions of the uterus, gravitation of the abdomi- 
nal viscera with the pelvic was all he really needed for 
his replacement. The uterus being naturally drawn into 
the vacuum thus made righted itself which would have 
been impossible in the large class of cases where co-opera- 
tion of the patient is nil and adhesions exist for which my 
“dilating speculum” is especially adapted, as was shown 
in my typical case cited in connection with the first use of 
this form of speculum, November 20th, 1867, and from 
which Dr. C. doubtless first learned the emphasized pe- 
culiarity indicated. In this case there was ante version of 
the uterus and an abnormally large vagina with relaxed 
walls, and associated with these conditions there was a 
small vesico-vaginal fistule high up having cicatricial and 
plated borders which it was important to display for op- erative purposes. The patient being incapable in the- 
knee-head or any other position of giving her co-opera- 
lion even with all the univalve specula and assistants that 
could be pressed into service, besides having fifteen pounds 
of atmospheric pressure to the square inch to aid her, she 
could not afford a complete view of her little fistule so 
much concealed. Here “reversal of gravity,” “draft of the 
viscera” and “automatic reduction by pneumatic pressure” 
had full sway, and yet after their utter failure, this woman 
had to be placed finally upon my supporting and confining 
apparatus in the knee-chest position, under the influence of 
an anaesthetic, in order to show this seemingly insignifi- 
cant fistule. This was done, independently of her will 
and resistance with this same “dilating speculum,” and 
the fistule wras closed in less than twenty-five minutes, 
without assistants further than to administer the anaes- 
thetic and to hand sponges. (See N. Y. Medical Record, 
January 1, 1868). 
I do not find fault with Dr. Campbell for omitting to 
mention all this in his paper, but I do complain of his 
misuse of my designating term knee-chest position for his 
knee head position, in scientific progress and honorable 
rivalry we all like to be in accord in thought and well- 
doing. If I have not properly utilized and named this 
knee-chest position in connection with my supporting 
and confining apparatus, or even my “dilating speculum,” 
it remains for Dr. C. to inform the profession at large in 
what particulars I have failed to secure their legitimate 
results in practice. 
There are other uses to which the knee-chest position 
has been applied in connection with my supporting and 
confining apparatus, and for which my designating term 
has been likewise misused. An important one is that of 
vaginal ovaritomy by Dr. T. G. Thomas. In the fifth 
edition of his work on “Diseases of Women,” page 731, he 
illustrates the position with the usual cut as “Bozeman’s 
Securing Apparatus,” giving at the same time the follow- 
ing description: “The patient having been etherized 
was placed in the knee-elbow position (italics mine), and 
secured upon the apparatus of Dr. Bozeman. This appa- 47 
ratus not only completely fixes the patient in the position 
by straps and braces, but makes the position perfectly 
comfortable for any length of time, and also favors the 
administration of an anaesthetic.” 
How Dr. T., with his usual accuracy in speaking and 
writing, could so overlook the laws of mechanics and 
physiology as to make this mistake of calling the knee- 
chest the knee-elbow position I do not understand, especial- 
ly after he has pointed out so lucidly the advantages of the 
position as to comfort and security of the patient which 
he knew could be obtained in no other anterior position 
than the knee chest. 
We come now to an examination of Dr. Taliaferro’s 
claims to notice to which reference was made at the outset 
of these remarks. For this purpose it is only necessary, I 
conceive, to show what he did publish in the spring of 
1878, with regard to pressure with sheep’s wool in diseases 
of the uterus; what changes he has since made in the 
principle of packing the vagina, and how he was led first 
to adopt the practice. (Reprint from the Transactions of 
the Medical Association of Georgia.) But before proceed- 
ing further it is proper to state that Dr. T., in his practice, 
adopts the exaggerated knee-elbow or genu-cephalic posi- 
tion of the patient, and uses the pubo-sacral or antero- 
posterior dilatation of the vagina with the univalve or 
Sims’ speculum. 
First. Pressure with sheep's wool in diseases of the uterus 
The mode of introducing the wool is as follows: “The 
pledgets of wool are then successively applied, dry, each 
one being first rolled upon itself rather tightly in order to 
give the requisite firmness and solidity to the packing. 
The vault of the vagina is first well filled and the pack- 
ing proceeded with carefully, the pledgets rolled upon 
themselves, being placed here and there, and packed with 
probe or dressing forceps; all parts of the vagina being 
packed as equally firm as possible, and yet not too solid at 
any point for discomfort. The vaginal canal is thus filled 
down to the muscular floor of the pelvis, but not below 
it.” (Italics his.) 48 
Fig. 8, copied and introduced here, being about one- 
fourth size, shows the limit of pubo-sacral dilatation of 
the vagina with Sims’ univalve speculum in position, 
Fig 8. 
and the space occupied by the wool, incident to such ac- 
tion of this form of speculum. The vagina is seen to be 
packed from the vault to the floor, and crowded back- 
ward and forward almost to the pelvic bones. The meas- 
urement, antero-posteriorly, on the basis of the size indi- 
cated, is three inches, about half an inch less than the 
outlet of the pelvis or the coccy-pubic diameter. As to 
the proportion of space allotted to the urethra and rectum 
respectively, for the performance of their physiological 
functions, it is not stated, but we are told that the tampon, 
so introduced, is to remain two or three days, when it is 
removed, with forceps, by the physician. 
A glance at the construction of this irregular and 
somewhat quadrilateral-shaped body, almost solid, leads 
one to conclude, that the model for its construction was 
the foetal head, occupying the pelvic cavity, and having 
a similar mechanism with the antero-posterior diameter 
corresponding to the occipito frontal. As the uterus is 
the favored organ of the pelvis, being placed above the 
range of antero-posterior pressure and having a shelf 
upon which to rest, it is out of harm’s way, if not of dis- 
ease, certainly, of the innovations of art Whether any 
woman is capable of enduring such mechanical pressure 
upon her rectum and bladder the two or three days it is 
allowed to continue is an open question, but it is not 
necessary here to discuss this point further. Any one who 49 
has had experience in tamponing the vagina for the pur- 
pose of uterine hemorrhage can form his 
own opinion as to the principle underlying the practice, 
the value claimed for it, and the suffering, if not the actual 
danger attending the mode of use. 
Second. Change in the principle of packing the vagina. 
Four years later, {Atlanta Medical Register, September 1882), 
Dr. T. furnishes us with an account of his improved mode 
of instituting pressure with cotton in diseases of the 
uterus, including also, this time, the ovaries. This is his 
mode of introducing the cotton : 
“I have long since discarded the sheep’s wool for cot- 
ton, which I originally used. I was induced to do this be- 
cause of the superior convenience of the cotton, and be- 
cause it can be made more compact, and hence a greater 
degree of pressure obtained. Instead of extending the 
tampon from the vault of the vagina to its floor, I now 
rarely extend it further than the upper third of the va- 
gina, and often not more than the upper fourth. In case 
an extra degree of pressure is desired, the upper half or 
etill more rarely the upper two-thirds' of the vagina is 
packed. In the large majority of cases of congestion, dis- 
placements and adhesions, the tampon is made to occupy 
only the upper fourth of the vagina. If tenderness of the 
organs admits it, this partial tampon should be very firm. 
If there is considerable tenderness the dressing should be 
very light, and the pressure gradually increased as the 
tenderness subsides, until the packing is made as firm and 
compact as it can be made. When pressure is desired, a 
loose packing is not sufficient, and the so-called columns 
of Bozeman are worthless. This column is simply 
a loose, flat tampon extending from the posterior cul-de- 
sac to the ostium vaginae. It can neither give support or 
pressure to the uterine organs. Its value consists mainly 
in separating and possibly softening the vaginal walls, for 
which it was used by its author until he read my paper 
in the spring of 1878. 
“The tampon applied only to the upper third of the 
vagina does not interfere with the bladder or rectum by 
its pressure upon these organs. The lower portion of the 50 
vagina closes in the tampon which occupies its vaults 
The tampon is thus securely held in place and rests upon 
the elastic column formed by the approximated vaginal 
walls. 
“The advantages of the tampon thus applied are: 1. 
It does not reach the urethra nor make uncomfortable 
pressure upon the bladder and rectum. 2. It answers all the 
Fig. 9. 
purposes of pressure of the more extensive tampon. 3. 
It does not interrupt the physiological mobility of the 
uterus. 4. It keeps in place more securely than the more 
extensive tampon. 
“In witnessing the application of the tampon by my 
medical friends, some of whom are familiar with uterine 
manipulations, I have been astounded at the awkward 
manner in which the operation is made. 
“Almost invariably, such a tampon utterly fails in its 
objects, and is worn by the patient with great discomfort. 
The packing should always be light and firm in the va- 
ginal vault, and if this is properly done, no advantage is 
gained by filling the lower part of the vagina.” (Italics 
his). 
I introduce here the accompanying illustration, Fig. 
9, which I have copied partly in section only, and let- 
tered it with arrows to enable me to explain the prin- 
ciple. Ido not hold myself responsible for the anatomical 
inaccuracies displayed in the cut; I simply represent in 
my copy the vagina, rectum, bladder and uterus, and their 
relationship to the pelvic bones as they are delineated in 
the original cut. 51 
Compare this illustration with the preceding, Fig. 8, 
and it will be seen to differ in several very essential par- 
ticulars. The vagina is here represented as being occu- 
pied only in its upper half with a flattened column ex- 
tending from above obliquely downward and forward. 
The rectum and bladder, instead of being crowded 
apart to the limit of a child’s head, as indicated by Fig. 
8, are here represented in the lower half of the vagina as 
being almost in contact. In short, the rectum is relieved 
entirely, and the bladder partially from pressure, due to 
diminution in the size and form of the column. The 
points 1 and 2 show the limit of former packing and dis- 
tension of the vagina. 
The flattened column, instead of acting antero-poste- 
riorly, as the wool in bulk formerly did, is made to act 
longitudinally, somewhat parallel, with the axis of the 
vagina, with one end extending loosely up into the pos- 
terior cul-de-sac and the other resting upon the upper part 
of the vesico-vaginal septum as 'point d’appui. The blad- 
der, instead of being and compressed against the 
pubis by the wool, packed as formerly, is here represented 
distended and elongated from the horizontal dotted line 
(a) obliquely across the axis of the vagina to form a 
cushion between the pubis and the lower end of the 
column. This displays a peculiar mechanical ingenuity, 
because it illustrates an attempt to utilize a physiologi- 
cally acting, hollow organ to counteract the law of gravi- 
tation. 
The uterus, instead of standing in a somewhat natural 
position or being shelved, so to speak, upon the hard- 
packed wool tampon above the line of pubo-sacral pressure, 
is here represented in a partially anteverted position, 
supposed to have been elevated to that point by the 
flattened short column, from some unknown retroverted 
position below the horizontal dotted line (c). The organ 
being thus elevated and sustained, in opposition to a 
well-known law in mechanics, to the effect that when two 
parallel forces act in opposite directions, the result is a 
revolution around the center, as at the cervix uteri, it 
naturally falls backward to its original position. The 52 
operation of this law, therefore, in the illustration before 
us, the uterus being on the line of the arrow (6), is to 
carry the short, flattened and somewhat semi-lunar shaped 
column to the point (1) in the direction of the arrow (d), 
or as far that way as the distended and already overworked 
bladder will permit. Such a column of glycerated cotton 
loosely lodged, as here shown, in the posterior vaginal 
cul-de-sac, without natural support below, and acting 
somewhat like a marble under the tongue, is wholly in- 
sufficient to give the uterus the support it requires in the 
position indicated. And as to the practicability of mak- 
ing the distended bladder, as shown, or rather the upper 
part of the vesicp-vaginal septum, hold up the column, the 
proposition is simply an absurdity. 
The question may be asked, in what other way could 
"this uterus be prevented from falling backward and caus- 
ing this form of column to revolve as around a centre, as 
above shown? I answer, simply by taking the star (a) 
opposite the root of the urethra in its normal relation as 
a point d’appui for the construction of the required column. 
Supposing the fundus of the uterus, whether retro- 
verted or retroflexed, to be at the point (2) as indicated in 
the same cut, the direction of the force by graduated pres- 
sure to elevate the organ would be at first to this point 
from star (a). This force, apportioned of course to the re- 
sistance to be overcome and the sensibility of the parts, 
gradually elevates the uterus and its appendages to the 
horizontal dotted line (<?), when both stars, (a and e), the 
opposing walls of the vagina, become in common the point 
d’appui. The column is now parallel with the axis of the 
vagina, but the pressure being kept up, the point d’appui 
is, by degrees, changed to star (e) and the line of force to 
arrow (o). Thus is given to the uterus the support neces- 
sary to maintain it in the upright position, and to favor 
the adjustment of a suitable pessary or vaginal support, 
as represented in Fig. 7 on a former page. 
Again, the patient now being in decubitus, the star (e) 
is taken as a point d’appui for the elevation of the uterus 
when anteverted or anteflexed to the lowest degree of 
pressure upon the bladder. The line of force, by graduated 53 
pressure, will be against the vesico-vaginal septum to ar- 
row (1), and so on to arrow (d), thus forcing the uterus up 
to a fairly normal position without distressing the blad- 
der, and at the same timej making the adjustment of my 
vaginal support easy and effective, as is also shown by 
Fig. 7. 
Whether either of these forms of columning of the 
vagina can be properly carried out with any other specu- 
lum than my own, it is not my purpose now to discuss. 
There is one point in the construction of my columns to 
which I would call particular attention, and that is the 
firmness and solidity given them in the lower third, 
and that is where the lateral blades of the instrument 
serve as a protection to the soft parts. There is no other 
speculum, with which I am familiar, possessing this ad- 
vantage, and from this fact alone is to be found, I think, 
the explanation of the failure of many physicians, who 
use other instruments, to obtain that firmness of the 
column which is necessary to support and sustain the 
uterus at a mechanical disadvantage. The value of col- 
umning the vagina, however, as a principle of graduated 
pressure being recognized by the profession, the question 
as to the best mode of doing it will necessarily be settled 
by experience in practice. Whether I copied from Dr. 
Taliaferro or he from me, as shown by our respective 
publications, is of no consequence to the profession, but 
having been openly attacked by him in a way to dispar- 
age my labors regarding this subject, I feel it my duty to 
state some of the circumstances, which I think will fully 
justify my course from first to last, so far as he is con- 
cerned. This brings us to the third consideration of his 
claims to notice. 
Third. How he was probably first led to adopt the practice 
of paching the vagina. In the spring of 1869, Dr. Monte- 
fiore J. Moses, having previously resided in Columbus, 
Georgia, for years on terms of great intimacy with Dr. 
Taliaferro, then resident in the same city, removed to 
New York. Very soon afterward he called upon me and 
became deeply interested in my special labors, at that 
time relating largely to vesico-vaginal fistule, its compli- 54 
cations and its treatment with my new speculum and di- 
lators in the knee-chest position, etc.; at the same time 
telling me how much his friend, Dr. T., was interested in 
these matters. In the course of the year he asked me to 
make out a list of my instruments, with which he had 
become familiar, saying that he wished it for Dr. Talia- 
ferro. The list was furnished and placed in the hands of 
Messrs. Otto and Reynders. They manufactured the in- 
struments, submitted them to my inspection and finally 
sent the case to Dr. T., at Columbus, Ga., April 18th, 1870. 
So far as I know these instruments gave entire satisfac- 
tion, if not to all, certainly to Dr. T., as I afterwards learned 
from his friend, Dr. Moses. So much for this assistance 
in putting him in the way of scientific study of dis- 
eases of women. 
Again in 1877, just after ray return from Europe, when 
I was engaged in treating a case of retroflexion of the 
nterus with fixation and prolapsed ovaries in St. Eliza- 
beth’s Hospital, in New York, by columning the vagina 
with dry cotton through my speculum, Dr. Moses accom- 
panied me on one or two occasions to witness the proce- 
dure, and in expressing his satisfaction at the result, said 
that his friend, Dr. Taliaferro, was then residing in At- 
lanta, Georgia, and would be very much interested, he 
knew, in what he had seen of my method of treating such 
cases. How much Dr. Taliaferro was enlightened as to 
the general character of my mode of columning the va- 
gina, at the time of which I am speaking, through the 
interest of his friend, I do not pretend to say. I simply 
state the fact, and know it was nearly a year prior to the 
publication of his first paper, in the spring of 1878. 
Also, in the Autumn of 1881, about a year before the 
publication of Dr. Taliaferro’s second paper, in which he 
makes the attack upon me, his pupil and associate. Dr. G. 
H. Noble, visited New York for the purpose of studying 
the diseases of women, and soon afterwards called upon 
me at my office to learn how he could best occupy his time 
while here. I gave him a note to my friend, Dr. Tanszky, 
in charge of the out-door clinic for diseases of women at 
Mount Sinai Hospital, of whom he could receive special 55 
instruction, and promised to show him all I could in my 
service at the Woman’s Hospital. He expressed a partic- 
ular desire to learn my mode of columning the vagina, 
and to see my instruments, for both of which he had am- 
ple opportunity at my office and in the hospital, as well 
as in the course of private instruction received of Dr. 
Tanszky. 
On Dr. Noble’s return to Atlanta, he becomes draughts- 
man to Dr. Taliaferro, and among his illustrations for 
Dr. T.’s paper is Fig. 9, copied on a former page, showing 
a modification of my column, which he had learned in 
my service at the Woman’s Hospital. 
But perhaps the most unqualified appropriation of Dr. 
T. without acknowledgment, is that of my perineal ele- 
vator, set upon the handle of Professor Simon’s speculum, 
under the following pretext : 
Fig. 10. Fig. 11. 
“ The blade is flat and thin, like that of Nott’s specu- 
lum, and flanged at the proximal end to separate and hold 
apart the nates. The handle terminates in a curve to fit 
the hand, and is light and more convenient for tamponing 
than an ordinary Sims’ speculum.” I reproduce the in- 56 
strument here in two forms. Fig. 10 is the original, 
copied from Dr. Hamilton’s work on surgery, 1873, and Fig. 
11 the duplicate. No one need be told, I think, that the two 
thin and flat blades shown are of one and the same pat- 
tern. Dr. G. H. Noble, Dr. T.’s associate, saw the original 
instrument in my office, and saw me use it in connection 
with my speculum in the Woman’s Hospital, seven or 
eight months ago, and probably took it home with him 
as a pattern for the modification here shown. 
So much for some of the sources of Dr. Taliaferro’s in- 
formation and the manner in which he has profited by 
them in his two publications. His attempt to keep them 
out of sight under the guise of originality and of liberal 
acknowldgment of indebtedness, on almost every page of 
his first paper, to Dr. Sims for the precedence of suggestion, 
when he had no more to do with the development of grad- 
uated pressure as a system of treatment in the diseases of 
the vagina, uterus and ovaries, than Dr. T. had, is too 
patent to require here more than this passing notice. His 
mode of packing or cramming the vagina with sheep’s 
wool, as shown by Fig. 8, copied from his first publication, 
I regarded from the first as not only unscientific and 
absurd, but dangerous and contrary to an intelligent un- 
derstanding of the anatomy, physiology and mechanics of 
the pelvic organs. This, in connection with some of the 
circumstances just related, is the explanation of my taking 
no notice of his practice in my paper of 1878. The result 
of the abandonment of his first teaching after the publi- 
cation of my paper, and his effort now to appropriate my 
flattened column of cotton and perineal elevator, as shown 
by the feeble attempt at modification, fully justifies, I 
think, my estimate of his pretensions from first to last. 
In September, 1879, just one year after I submitted my 
paper to the American Gynaecological Society upon the 
‘‘Mechanism of Uterine and Ovarian Displacements,” etc., 
and six months after Dr. Tanszky’s paper on “The Tam- 
ponade of the Vagina” appeared in the New York Hos- 
pital Gazette, Dr. Paul F. Munde read a paper before the 
same society, at its annual meeting held in Baltimore, en- 
titled “ Prolapse of the Ovaries.” He stated that his atten- 57 
tion had been first directed to the subject by a discussion 
at a meeting of the New York Obstetrical Society upon 
this topic, November sth, 1873, nearly two months after the 
presentation of my paper as above mentioned. He said his 
record of 145 cases, collated from 1600 unselected gynseco* 
logical cases, showed that the affection was of frequent 
occurrence, and that the subject was one which had re- 
ceived but little attention from the profession, especially 
in this country, and in the plan of treatment he recom- 
mended a variety of modifications of Hodge’s pessary. 
As to the use of cotton .for the same purpose, which he 
fully endorsed when the pessary could not be borne, he 
said : “ This method of packing the vagina was first recom- 
mended by Taliaferro, of Georgia, for cases of cellulitis, 
metritis and oophoritis, and displacements in which a 
pessary cannot be borne, but Dr. Bozeman, I am informed, 
claims the priority of the principle.” In his book, published 
more than a year later, entitled “Minor Surgical Gynae- 
cology,” 1880, he refers, under the caption of “ Tamponade 
of the Vagina,” to me and my claims with regard to the 
use of cotton in about the same words, and misapplies my 
designating term knee-chest for genu-cephalic, or knee- 
head position, and proceeds to describe the method of Dr. 
Taliaferro in accordance with the plan illustrated by Fig, 
8, using, however, instead of dry wool, glycerated cotton, 
which is equally objectionable, on account of its packing 
in a hard lump. It, therefore, calls for no further notice 
here. 
It is, I know, quite the custom for American medical 
writers to decry the labors of home contributors to the 
common fund of our knowledge, and to praise, sometimes 
unduly, those of foreign workers. Dr. Munde proved no 
exception to the rule in his paper referred to, on “ Prolapse 
of the Ovaries.” 
The fact that in his report to the Mt. Sinai Hospital, 
of the Out door Department for the diseases of women for 
the year ending Dec. 1, 1878, less than a year before he 
read his paper on “ Prolapse of the Ovaries,” he recorded 
475 cases, nearly one-third of the 1600 cases upon which 
his statistics were based, and that out of even this large 
5 58 
number not one case of prolapsed ovary is mentioned, 
while Dr. Tanszky, holding another service in the same 
hospital, as has been shown, found and diagnosed 16 cases 
of prolapsed ovaries out of 371 cases, is rather striking. Not 
only was this true with regard to Dr. Tanszky’s service, 
but he treated these sixteen cases by columning the 
vagina with cotton in the knee-elbow position, which at 
my suggestion, he had then been using in the institution 
for five or six years. 
As to my paper presented to the American Gynaecolog- 
ical Society a year before Dr. Munde read his, I would say 
that prolapsed and fixed ovaries in connection with retro- 
flexion of the uterus with fixation formed a prominent 
feature of my remarks. This was also true of the remarks 
of Dr. Tanzsky published in the N. Y. Hospital Gazette, as 
an endorsement of my views upon the subject, some six 
months, also, before Dr. M. read his paper. Yet, with 
this attention bestowed by both of us upon the subject of 
prolapsed ovaries, the Doctor did not find it desirable or 
convenient even to mention the fact of these prior obser- 
vations ! 
As to Dr. Taliaferro’s paper, however, in 1878, recom- 
mending the stuffing of “the entire vaginal canal from 
its vault to the floor of the pelvis, completely and com- 
pactly ” with dry wool, Dr. M. acknowledged his deep 
sense of obligation, and adopted without question the 
teaching, including in the same line of instruction the 
treatment of oophritis, but, in adopting the teaching of 
Dr. T., he used glycerated cotton instead of dry wool. In 
Dr. T,7s paper referred to, there is not the slightest men- 
tion of oophoritis or prolapsus of the ovaries, much less, 
treatment of the same by dry wool packing of the vagina. 
That Dr. Mnnde may possibly have observed sixteen 
hundred unselected gynaecological cases, out of which he 
found one hundred and forty-five cases of prolapsed ova- 
ries, it is not my purpose to question. Considering, how- 
ever, that this large number of cases was observed in a 
period of nine months, to-wit: from December 1, 1878, 
when he made his report to the Mt. Sinai Hospital, and 
had not recorded a single case, to September, 1879, when 59 
he read his paper before the American Gynaecological 
Society, we are naturally led to the conclusion that he 
must have encountered an unheard of epidemic of pro- 
lapsed ovaries at or just before the time he prepared his 
paper upon the subject. 
Even in his book (1880) I find under the heading of 
“Tamponade of the Vagina,” twenty pages devoted to 
the subject of using, instead of dry wool, glycerated cotton in 
the vagina, which he learned so well from Dr. Taliaferro, 
and yet not one line is given to a description of my meth- 
od of columning the vagina with dry cotton, further than 
to adopt my designating word “column,” as he does Dr. 
Tanszky’s term “tamponade of the vagina,” giving credit 
for neither. 
The remarks contained in this paper justify, I think, 
the following conclusions : 
1. That cicatricial contractions of the vagina (Kolpos- 
tenosis) and fixation of the uterus by pelvic exudations 
and adhesions following protracted labor, constitute the 
prime, and often insurmountable, obstacles to the cure of 
urinary and fecal fistules, and also of displacements of the 
uterus and ovaries. 
2. That previous to the year 1855, notwithstanding the 
fact that unopposed or passive vaginal dilatation by the 
pubo sacral or univalve-acting speculum in the knee-elbow 
and exaggerated knee-elbow positions had been, for nearly 
a quarter of a century, thoroughly understood in Europe 
and in this country, and some success had been reached 
in the closure of simple and small fistules, little or no 
attentien had been given to the stretching treatment of 
vaginal contractions and pelvic adhesions as the real ob- 
stacles to vaginal dilatation and the restoring of uterine 
mobility, further than to divide simple cicatricial bridles 
as they happened to appear in the way of immediate ex- 
posure of coexisting fistules. 
3. That, during the year above indicated, graduated 
vaginal and uterine pressure with pieces of sponge com- 
pressed in oil-silk bags of graded sizes in the form of 
vulvo-vaginal and intra-vaginal dilators, was first associa- 
ted with immediate division of cicatricial bands as a sys- 60 
tematic mode of gradual preparatory treatment; and that 
it was done with the idea, not only of overcoming such 
obstacles in and around the vagina as prevented exposure 
of the coexisting fistule, but of carrying vaginal dilatation 
and uterine elevation beyond the limits of cicatricial 
resiliency and fibro-pelvic restraint. 
4. That with this forward step in the utilization of 
graduated pressure, together with the aid afforded to the 
closure of large fistulous openings by drawing dowm the 
uterus and fixing it with the button suture in the knee- 
elbow and knee-chest positions, unprecedented success 
was attained, with preservation of the functions of the 
organs involved, in an average proportion of complicated 
cases, including retroflexion of the uterus with fixation 
and with displacement of the ovaries. 
5. That the pubo-sacral or univalve-acting speculum, 
with assistant always to hold it, while adapted, in simple 
cases, elevating and supporting the perineo-rectal wall in 
all the anterior positions of the patient, it failed in a 
large proportion of cases with or without relaxed vaginal 
walls, because it exerted no controlling influence over the 
anterior wall of the vagina in its normal condition, and 
but little over it and the lateral walls when they were the 
seat of outstretched cicatricial bands. For the latter reason 
the instrument did not favor the highest aims of gradu- 
ated vaginal and uterine pressure in the procedure of 
gradual preparatory treatment with incisions, but ren- 
dered kolpokleisis and kolpoplecosis necessary expedients 
for the relief of urinary and local fistulcs. 
6, That the intra-ischial or bilateral-acting speculum, 
self-acting and self-sustaining, requiring no assistant to 
hold it (1867), was found not only to dilate the vulva to 
the fullest extent and give steadiness to all the walls of 
the vagina, but to develop, hitherto concealed, cicatricial 
contractions and far-reaching, flattened, modular masses, 
w7hich with the univalve speculum had before passed un- 
noticed. For these reasons the highest limit of success, 
with this new principle of dilatation, was attained through 
graduated vaginal and uterine pressure as preparatory 
treatment, which is essential to absolute cure of urinary 61 
and fecal fistules and the avoidance of kolpokleisis and 
kolpoplecosis. 
7. That with the intra-ischial or bilateral-acting spec- 
ulum, columning the vagina with dry cotton for the relief 
of prolapsus, and ante- and retrc-displacements of the 
uterus, simple or complicated with adhesions and prolapse 
of the ovaries, was the natural outgrowth of columning 
the same organs with sponges in oil silk bags, as pointed 
out in connection with cicatricial contractions, and that 
the system as now employed can only be regarded as a 
modification or extension of the cotton under another form 
of graduated pressure. 
By graduated pressure thus made to the walls of the 
vagina and to the uterus and its appendages, the large 
class of cases indicated can be treated on rational and sci- 
entific principles, and it is now possible to reduce to very 
exceptional cases the necessity of bloody operations for 
superficial lacerations of the cervix uteri, or for prolapse 
of the anterior and posterior walls of the vagina. 
8. That, however successful columning the vagina may 
be in relieving the class of cases indicated, it is still neces- 
sary in a large proportion of them to maintain the cure 
for a time by strengthening the counteracting forces re- 
siding in the vaginal wails and uterine ligaments with 
some mechanical appliance introduced into the vagina, 
either manageable or not by the patient. In short, the 
support of the uterus and ovaries in an elevated position, 
with elongation of the walls of the vagina, requires, under 
such circumstances, Hodge’s pessary or the elastic vaginal 
support before described (1878.) When the preparatory 
treatment is properly carried out, this latter support ful- 
fills all the indications better than any other instrument 
hitherto devised, it being entirely managed by the patient 
herself. 
9. That distortions of the vagina due to prolapsus and 
ante- and retro-displacements of the uterus, associated or 
not with prolapse of the ovaries, as results of endometri- 
tis, metritis or peri-metritis, or all three together, coupled 
with plastic exudations and adhesions, cannot be overcome 
by cutting operations upon the infra-vaginal portion of 62 
the cervix uteri, or either, or both of the walls of the 
vagina, or all three structures together, as first insisted 
upon in 1878, and that such operations have no surgical 
importance in the mechanics of the pelvic organs; the 
distortions of the vagina remaining the same after their 
performance as before. 
10. That lacerations of the cervix uteri within the last 
few years, as factors concerned in the causation of neuro- 
logical complications and malignant developments, have 
been greatly overestimated, and that the most of the 
schemative illustrations of these so called lesions to be 
found in the gynaecological literature of the day, whether 
transversely, unilateral or bilateral, or transversely and 
antero-posteriorly trilateral or quadrilateral, are overdrawn 
and have no foundation in a true study of uterine path- 
ology. 
11. That the recognition of the frequent existence of 
prolapse of the ovaries in relationship with ante- and retro- 
displacements of the uterus with and without fixation, 
was a most important step as regards scientific treatment 
(1874), and that it is now only by a clear understanding 
of this relationship of the parts in such abnormal condi- 
tions, further advances are to be made in the line of suc- 
cessful practice. 
12. That the disposition of writers to misapply the 
designating term knee-chest position for the exaggerated 
knee-elbow, genu-cephalic or knee-head position is un- 
warranted, and opposed to true scientific progress in the 
treatment of an important class of cases which are the 
most difficult to manage and the least understood by the 
profession at large. ERRATA. 
On page 2, Bth line from bottom, read “ with two ” for “of two.” 
7, 6th “ top “ “ 1869 ” for “ 1859.” 
9, 7th “ “ “ “ Latin ” for “ English.” 
9, 18th “ “ “ the N. Y. Medical Journal.” 
16, 3d “ “ “ “as when ” for “ as.” 
12,11 th “ “ “ “ fecal” for “ faecal.” 
14,20 th “ “ “ “ the latter” for “it accurately.” 
14,215t “ “ “ “pressure” for “hard press- 
ure.” 
21 and 23, read “ Dr. Chauveau ” for “ Dr. Chanorin.” 
23, Ist line from bottom, read “ Fig. 3 ” for “ Fig. 1.” 
24, 15th line from top, read “ depressor” for “ depression.” 
“ 24,17 th “ “ “ “ balls ” for “ pads. ” 
26, 6th “ “ “ “ any form ” for “my form.” 
26, 18th “ “ “ “ form,” for “former.” 
27, 2d “ “ “ “ there” for “ these.” 
38, 4th “ from bottom, read “ the other ” for “another.” 
34, 15th ‘ “ top, read, “the equivalent” for “As the 
acquivalent.” 
38, Ist “ “ bottom, read “all ” for “ many cases.” 
41 and others, read “ Dr. Tauszky ” for “ Dr. Tanszky.” 
48, Ist line from top, read “ Dr. T.’s cut, fig. 8.” 
~ 29’ ** ** bottom, read “ Dr. T.’s second illustration.” 
51,17 th “ “ “ “ “ pubes ” for “ pubis.” 
60,12 th “ “ “ “ “ fecal ” for “ local.” 
60, 19th “ “ “ “ vesico-vaginal septum” for 
“anterior wall of the vagina in its normal condition.” 
61, 11th line from top, read “sponge columning ” for “the 
cotton.” 
62, 2d “ “ bottom, expunge “the most,” and read 
“ little ” for “the least.”