TRENDELENBURG'S POSTURE IN GYNECOLOGY. 
BY 
FLORIAN KRUG, M.D., 
Fellow of the Academy of Medicine ; Fellow of the American Association of Obstet- 
ricians and Gynecologists; Fellow of the American Gynecological Society ; 
Member of the New York Obstetrical Society; Member of the 
German Medical Society; Member of the New York 
County Society ; Attending Gynecologist to the 
German Hospital, New York, etc. 
REPRINT FROM TRANSACTIONS, 1891. [Reprinted from the Transactions of the Association of American Obstetricians and 
Gynecologists, September, 1891.] 
TRENDELENBURG'S POSTURE IN GYNECOLOGY,.. 
By FLORIAN KRUG, M.D., 
NEW YORK. 
The value of Esmarch's bandage and the artificial anemia 
produced by it, is fully understood. No surgeon would now- 
adays think of performing an operation on the extremities 
without availing himself of the advantage which this valuable, 
though simple, addition to our surgical means affords him. 
Now, I venture to state, and I am sure that I am not claim- 
ing too much, that Trendelenburg's posture is as valuable a 
help and deserves to be as fully appreciated in abdominal sur- 
gery as Esmarch's bandage is in operations on the extremities. 
I confidently believe that within a short time abdominal sur- 
geons will recognize its value more generally, and will then no 
more think of dispensing with the facilities offered by this 
simple and effective procedure, than they would deprive them- 
selves of Esmarch's bandage in their general surgical work. 
What is Trendelenburg's Posture? 
It simply consists in raising the patient's pelvis and letting 
the body slant down at an incline of from 45 to 60 degrees to 
the horizontal. This can be accomplished by very simple 
means as well as by very complicated appliances specially de- 
vised for that purpose. However, before entering into details, 
I would like to give a short historical sketch of the evolution 
of this procedure. 
The idea of elevating the patient's pelvis is indeed quite old. 
Fabricius ab Aquapendente (born 1537), already recommended 
to hang up the patient by the legs and to shake him well, in 
order to reduce an incarcerated hernia. Without a doubt, 
many a surgeon has since lowered a patient's head and raised 
the lower portion of the body for one reason or another. 
Freund, in describing his first operation for extirpation of the 
cancerous uterus, mentions the fact that he put the patient in 2 
FLORIAN KRUG, 
such a position as to have her head toward the window and 
lower down than the pelvis. Kocks, of Bonn, has also raised 
the foot-end of the operating-table; so has Noeggerath, 
formerly of New York. However, this can in no way detract 
anything from the credit due to Trendelenburg for having first 
adopted this method systematically, to have scientifically 
understood its advantages, and proved them to the profession, 
inducing others to follow his course. 
The first publication on the subject appeared in Langenbeck's 
Archiv fur klin. Chirurgie, in 1885, and was written by Dr. W. 
Meyer, who was then Prof. Trendelenburg's first assistant. 
Eigenbrod, also one of Trendelenburg's assistants, wrote on 
the same subject in 1888, in the Deutsche Zeitschrift fur Chir- 
urgie. In 1890, Trendelenburg published his own views in 
Volkmann's Klinische Vortrage, p. 355. 
Prof. Trendelenburg himself states that he began using it 
in 1880, in supra-pubic cystotomy, in order to gain a good 
inside view of the bladder. His idea was to use the negative 
pressure thus obtained, in order to cause the incised bladder to 
gape according to the same principle that is brought in effect 
by Sims's position. During the winter of 1887-88, he com- 
menced using it in all sorts of abdominal surgery and has ever 
done so since. 
As will be seen from these dates, the gentleman who made 
the statement last winter in the Obstetrical Society of New 
York, that he had seen Dr. Noeggerath, formerly of this city, 
make use of this method in 1876 or 1877, and heard him call 
it Trendelenburg's method (see page 599, May number Journal 
of Obstetrics, 1891), will have to confess to a chronological error. 
Early in 1888,1 witnessed one of Dr. W. Meyer's supra-pubic 
cystotomies, and was immediately impressed with the enormous 
advantages this posture would offer in gynecological operations. 
I at once started to make use of it in my abdominal work, not 
being aware, at that time, that Trendelenburg used it for any- 
thing else besides supra-pubic cystotomy. In the beginning I 
only applied this method in cases where I expected to meet 
with special difficulties in the depth of the pelvis; but soon I 
found that it worked so very well that I employed it in almost 
every case of abdominal surgery with but few exceptions. 
The total number of laparatomies done by me in this posi- 
tion exceeds 150, so that I might justly be entitled to speak of 
its merits. 
I have since had the pleasure of demonstrating its utility to 
a great number of operators, to whom it has been a revelation, 
every one of them having become an ardent follower of this 
excellent method. Proof of this is, that several new devices Trendelenburg's posture in gynecology. 
3 
and modifications of operating-tables have been brought out 
in New York during the last year.1 
What are Its Advantages? 
They can be pointed out in a few words: Following the 
law of gravity, all the contents of the abdominal cavity fall 
toward the diaphragm, and the pelvis becomes free and easy 
of access. If the narcosis is at all sufficient, a protrusion of 
the gut, which so often disagreeably happens in the horizontal 
position, is impossible. A single flat sponge will suffice to 
keep the intestines out of view during the entire operation. 
All unnecessary handling of them, particularly eventration of 
the same, which operators have sometimes found necessary 
when operating in the horizontal position, is thus strictly 
avoided. 
The main advantage is, however, that the operator can see 
everything he is doing. The entire true pelvis is before him 
as in an anatomical demonstration. He can see the ureters 
and easily avoid them; every bleeding-point is at once detected 
and easily tied; no accumulation of blood or pus in Douglas's 
pouch is possible, as it is readily recognized and easily wiped 
off. 
I have been told by some gentlemen who have not yet taken 
the trouble to investigate this method, that they did not need 
in their pelvic operations the information that eyesight gives, 
as they could feel everything as soon as they were able to in- 
sert two fingers into the peritoneal cavity. I will admit that 
the sense of touch can be trained to a high degree of perfec- 
tion, but I think the blind man feeling his way through crowded 
streets could claim with the same right that he can find his 
way as safely and quickly as the one who has the use of two 
sound eyes. 
Are there Any Disadvantages to the Method? 
None whatsoever. It certainly does not interfere with the 
anesthesia, no matter whether chloroform or ether is ad- 
ministered. On the contrary, shock due to sudden anemia of 
the brain is much less liable to occur than in the horizontal 
position. 
1 In an editorial note of the March number of the Archives of Gynecology, p. 
148, is to be found the following remark : 
" To Dr. Florian Krug, of this city, is due the credit of popularizing Trendelen- 
burg's method in this countryTo see him operate after this method one 
can easily recognize the many advantages it offers over the usual horizontal position.'' 4 
FLORIAN KRUG, 
The objection has been raised by operators who have no 
personal experience with this procedure, that pus from a 
ruptured ovarian abscess or pyosalpinx would flow all over the 
intestines and contaminate the entire peritoneal cavity. The 
facts are just the reverse of this theoretical assertion. In the 
first place, if Trendelenburg's posture is used, you are less 
liable to rupture an intra-peritoneal pus cavity, since you are 
not groping in the dark, but see what you are doing, and can 
in most instances avoid this accident. In fact, it has rarely 
happened to me, since using Trendelenburg's posture, that I 
did not get out even the most difficult cases of pus tubes and 
ovaries without rupture. 
Should it, however, occur, the flat sponge covering the 
intestines prevents their coming in contact with the infectious 
material, and everything can be wiped off, and, if thought 
necessary, the pelvis may be packed with iodoform gauze after 
Mikulicz's method, before the patient's pelvis is lowered again 
and the sponge removed. 
Again, the objection might be raised, that to gain a full view 
of the pelvis and to operate upon its contents under control of 
the eye, a larger incision is required than is the case if one 
chooses to rely upon his two fingers. But is there really any 
serious objection to a larger opening? Ventral hernia is as 
liable to occur in a two-inch as in a four-inch incision, if the 
wound is not properly sewed up. Again, the obsolete idea 
that the peritoneal cavity is contaminated by the entrance of 
air, and that the amount of danger is, therefore, proportionate 
to the length of the incision and the quantity of air thus 
allowed to enter, might nowadays be dismissed from scientific 
consideration. 
On the contrary, the practice of making as small as possible 
an incision with the patient in the horizontal position, cannot 
too strongly be condemned in view of the dangers it engenders. 
Time and again I have seen operators make an incision just 
large enough to admit of two fingers. Then they would com- 
mence digging about in the pelvis, while the intestines were 
constantly slipping in between, until finally, after displaying a 
good deal of exertion of the arm muscles, an indefinite mass 
of ruptured pus tubes and ovaries was rudely torn from its 
adhesions and tied off. Without being able to satisfy himself 
where the bleeding came from, nor to determine if any infec- 
tious material had been left behind, the operator would then 
indiscriminately pour hot water into the peritoneal cavity, and 
would rely upon the so-called " washing out," leaving the rest 
to Providence and the drainage-tube. 
In no other branch of surgery would such practices be toler- Trendelenburg's posture in gynecology. 
5 
ated, and the sooner they are abolished in gynecology, in favor 
of sound surgical principles, the better for the patients. 
Without a doubt, a great deal of so-called persistent pain 
after laparatomy is to be attributed to lesions of the serous 
covering of the intestines and pelvic contents due to these un- 
surgical methods. The apparently frequent occurrence of 
fistulas after laparatomy seems also to be traceable to such 
defective technique. 
Special Indications for Trendelenburg's Posture. 
To be brief, only a few shall be mentioned : 
1. As has been pointed out already, in cases of removal of 
diseased tubes and ovaries, particularly when they are the seat 
of purulent disease and are bound way down in the pelvis by 
firm adhesions, advantages are gained through this method, 
even in the hands of the tyro, which cannot be equalled by 
the highest skill and attainments of the expert, should he 
choose to deprive himself of this procedure. 
2. In ruptured ectopic gestation the bleeding-point is dis- 
covered at once, and readily tied without the often troublesome 
interference of the small intestines, as will be generally the 
case if the patient is in the horizontal position. If you have 
to operate while the patient is in profound shock owing to the 
intra-peritoneal loss of blood, Trendelenburg's posture is of 
special advantage, as it prevents sudden collapse from acute 
anemia of the brain. 
3. The abdominal extirpation of the uterus, be it for myo- 
matous or cancerous disease, is rendered very much easier by 
this method. 
In over twenty cases of total extirpation which I have done 
in this posture, it has proved itself to be a most valuable help. 
The most difficult part of Freund's operation, viz., the dis- 
secting off of the lower third of the uterine attachments, is 
incomparably easier in Trendelenburg's posture than in the 
horizontal position. Trendelenburg's posture has enabled me 
to shell out large myomatous nodules, which had unfolded the 
broad ligaments, in such an easy and uncomplicated manner 
that it was a revelation to myself as well as to the spectators. 
4. Transperitoneal hysterorrhaphy, viz., stitching the pro- 
lapsed or movable retroflexed uterus to the anterior abdominal 
wall without opening the peritoneal cavity, a method devised 
by me and described in a paper read before the Obstetrical 
Section of the New York Academy of Medicine, in November, 6 
FLORIAN KRUG, 
1890,1 is only feasible in Trendelenburg's posture. Without 
it, I must consider any operation of this kind-as, for instance,. 
Howard Kelly's, which he has since abandoned-most serious 
and dangerous on account of possible injury to the intestines. 
Many other instances could I point out, like dermoid, intra- 
ligamentous, parovarian cysts, etc., where Trendelenburg's 
posture is most essential in facilitating difficult operations, but 
I want to be brief, and, therefore, shall mention only one more 
of its manifold advantages. Leon de Mendes has first called 
attention to the fact, that this posture is a most valuable help 
in gynecological examinations, the negative pressure thus pro- 
duced in the true pelvis affording a great facility to explore its 
contents. No special apparatus is necessary for that purpose, 
as an ordinary couch or sofa iti the physician's office will 
readily answer. The patient's head rests about in the centre 
of the lounge, while her pelvis is placed on the top of the 
head-rest, thus forming the highest point, and allowing the legs, 
to hang over. 
Fig. 1. 
1 New York Medical Journal, January 3, 1891. Fig. 2. 
Showing detachable inclined plane adjusted to operating table. 
Fig. 3. 
Showing patient in Trendelenburg's posture. TRENDELENBURG'S POSTURE IN GYNECOLOGY. 
7 
How to Place the Patient in Trendelenburg's Posture. 
As I have remarked before, the elevation of the patient's 
pelvis to the desired angle can be accomplished in a very simple 
way, as well as by expensive and complicated apparatus. The 
main point, however, is that the angle be not less than 45 
degrees. I must call special attention to this, as I have had 
occasion to witness operations, since claimed asjhaving been 
done in Trendelenburg's posture, where a single cushion or 
small wooden wedge was placed under the patient's back, 
which did not raise the pelvis sufficiently, furnishing an incline 
of not more than from 15 to 20 degrees to the horizontal. As 
this is apt to give disappointment and will only throw discredit 
on the original procedure, I like to emphasize this point. 
In my earliest operations I had a nurse standing at the end 
of the operating-table, holding the patient's legs over his 
shoulders. (See Fig. 1, which is taken from Dr. W. Meyer's 
article in Langenbeck's Arch. f. kiln. Chirurg., xxxi. 3.) But 
I soon gave it up, after a nurse had fainted during a somewhat 
prolonged operation. After some experimenting, I finally 
adopted a very simple contrivance, which can be easily attached 
to any kind of operating-table, and which, also, can be readily 
removed. As the accompanying two figures fully illustrate its 
use, a further description is unnecessary. (See Figs. 2 and 3.) 
For hospital use it meets all requirements, but I often wished 
for an easily portable apparatus. In case of emergency I have 
nailed an ordinary laundry chair upside-down on a table and 
sawed off the upper pair of legs. If then covered with a 
cushion and a rubber cloth, it is ready for use. 
Lately, I had a very simple appliance constructed, which 
answers the purpose in every respect. It .consists of two gal- 
vanized cast-iron frames (see Fig. 4). The lower one can be 
fastened to an ordinary laundry table as well as to any kind of 
operating-table, either by screws or by cabinetmaker's clamps. 
The upper frame is jointed to the lower one and is covered 
with heavy sail canvas, on which straps are provided for 
the knees and ankles of the patient. After the abdominal in- 
cision has been made, the upper frame is raised to any desired 
angle and held there by supporters on both sides, as shown in 
the figure. 
The following are the advantages of this contrivance: 
1. The galvanized-iron frame is easily kept clean and aseptic, 
while the canvas can be readily sterilized by steaming or 
boiling. 8 
Trendelenburg's posture in gynecology. 
2. The apparatus can be easily transported, thus facilitating 
its use in the patient's house. 
Fig. 4. 
3. Compared with other apparatus specially devised for this 
purpose, its price is a very moderate one and places it within 
the reach of all.