THE GYNECIC USES AND VALUE OF THE

GENU-PECTORAL POSTURE.

BY WILLIAM WARREN POTTER, M.D.,

BUFFALO, N. Y.

AMONG the many influences in active operation productive of pelvic disorders in women, posture must, without doubt, be assigned an important place. The law of gravitation is busily and silently at work everywhere in the economy; the solids and fluids of the body are as submissive to its mandates and as susceptible to its influences as anywhere else in nature.

The reproductive organs of women are so generously supplied with blood-vessels as to make them peculiarly subject to the influences of gravitation, while their extreme mobility renders them especially liable to displacement under the action of the gravitory law. If this be true in health, when all the functions of the body are normally performed, how greatly must the tendency be augmented when these organs are increased in bulk, or changed in structure through the influences of disease. That which is physiological under certain conditions, becomes pathological under others. Here it is, indeed, but a step across the health line.

The mischievous effects of certain postures upon the pelvic organs of women are mainly due to the universal action of gravitation.

Since gravity, therefore, become a factor of so much importance, etiologically speaking, in the sexual disorders of women, it is of the first importance, in their treatment, to overcome or neutralize, as far as possible, the evil consequences of the gravitory law.

To accomplish the reversal of the normal gravitation of the blood and viscera, and thereby relieve the reproductive organs of the vascular distention, hyperemia, blood-stasis, and impac

tion consequent upon uterine and ovarian dislocations, is to fulfill one of the most prominent and important indications of treatment which these cases usually present. Whenever it becomes advisable to reverse the action of gravity upon the pelvic organs of the female, or to remove the pressure and impaction of the superincumbent viscera, the genu-pectoral posture furnishes a most precious way of accomplishing this result; moreover, through its systematic, intelligent, and persistent employment we lay a broad foundation of relief upon which to construct the ultimate superstructure of possible cure.

The genu-pectoral posture has such a wide range of usefulness in both obstetric and gynecic practice, that it would be obviously impossible to compass the entire field of its applicability in the necessarily limited time allotted here.

These remarks will, therefore, be restricted to a consideration of some of the gynecic uses of this most valuable expedient. It is a well-known fact that when a woman is properly placed in the knee-chest posture, the pelvic and abdominal viscera gravitate toward the epigastric region; and that, upon separation of the labia, air rushes into the vagina, thereby dilating it to its fullest capacity, and rendering its entire surface visible at a single glance. The accidental discovery-perhaps I should say re-discovery—of this fact by Sims, in 1845, marked a new era in the intra-pelvic surgery of woman.

New instruments were devised to meet the requirements of the new order of things, and soon many of the accidents of parturition, hitherto entirely beyond the ken of the most skillful surgeon, were repaired with the greatest ease.

While, therefore, the superior advantages of the genu-pectoral posture, or some modification thereof, have since been recognized by gynecologists in bloody operations upon the genital tract, I feel sure that I am within the limits of truthfulness in asserting that its application to the commoner ailments of woman has not been as universally admitted.

In the treatment of retro-displacements of the uterus and in prolapse of the ovaries, it has an especial field of usefulness. Having accustomed myself to its employment in the management of these cases during several years past, I can speak most confidently of its superiority here. Under its timely and judicious employment many of the most obstinate varieties of retroversion and retroflexion may be made to yield.

So much depends upon minute attention to details in the successful use of the measure, that I may be pardoned for occupying a little time in describing the various steps necessary in adapting it to one of these cases. Suspecting a case of backward displacement of the womb, the patient is placed upon the table in the dorsal position, when the diagnosis can generally be made out by digital and bi-manual examination. The sound is rarely necessary in the diagnosis of this form of displacement, but may be appealed to in doubtful cases.

Having ascertained that the uterus is retroverted, the next step is to effect its replacement, and the patient is, therefore, directed to assume the knee-chest posture. She will require explicit instructions in order to assume the position correctly, and I think it a good plan to explain its mechanism and just what it is expected to accomplish. This once done, I have yet to meet an intelligent patient who has objected to the attitude. The dress-skirt having been slipped off, and the underskirt fastenings and corsets loosened, the patient should be made to kneel upon the front edge of the table, and to cast the trunk forwards and downwards, until the upper portion of the chest touches the mattress. A thin pillow for the face, turned sidewise, to rest upon, adds to the comfort of the patient. The thighs should be perfectly vertical, and form a right angle with the plane of the table, thereby affording a greater inclination of the trunk. A triangle is thus formed with the aid of the table-the thighs furnishing the upright, the trunk the hypothenuse, and the table the base. The phenomena which ensue when this posture is taken in the manner described are:

First.-Reversal of normal visceral gravity.

Second-Marked elongation and expansion of the vagina. The co-operation of these forces appears to accomplish the reposition of the retroverted womb, oftentimes, without other aid. The gravitation of the abdominal viscera towards the epigastrium, makes way for the pelvic viscera to follow, thus carrying the uterus to its proper level; upon opening the hymenial orifice, air rushes into the vagina, expanding it to its utmost capacity, and becoming a powerful supplementary aid to the gravitory law.

If there are no adhesions, and if the fundus is not too firmly wedged into the sacral excavation, the joint action of these forces will, most likely, effect replacement of the organ. In

this position the weight of the superincumbent viscera is taken off the uterus and its appendages, the pelvic hyperemia and impaction which the erect and other postures may have caused or augmented, are either modified or disappear in obedience to the law of gravitation, while the power of tenesmic resistance is wholly abolished. There is complete suspension of intraabdominal pressure in front, and a powerful intra-vaginal pressure behind. The vagina becomes expanded to its greatest capacity, folds and wrinkles are smoothed out, and the cervix is seen at the most distant part of this shining, dome-like vault.

It is well, in these cases, to prepare them by a somewhat gradual process for the use of the pessary or permanent support, by columning the vagina with cotton tampons. It is my custom to commence the treatment by filling the post-cervical space, now so well exposed to view, with pledgets of cotton about the size of an English walnut (30 by 40 m.m.) Each pledget is secured in a loop of strong sewing-thread; and they should be prepared in advance in sufficient quantities to meet the requirements of the case. The first two or three pieces are usually saturated with carbolated glycerine, and placed well behind the cervix, extending over 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, thus being carried gently but firmly to its place.

This support should usually be allowed to remain in forty-eight hours, when it can be removed by the patient, who is directed to make traction upon the threads, which have been previously united in a single knot, and the superfluous ends cut away.

After the removal of the cotton packing, the vagina should be thoroughly cleansed with a copious hot-water lavement, administered in the dorsal position; immediately thereafter the knee-breast posture is assumed, and the vagina again columned, in the same manner as just described. This process should be repeated with regularity and precision until the parts are sufficiently prepared for the reception of a more permanent support, -unless, perchance, a cure is effected by it alone, which is by no means impossible. This method of treatment possesses a twofold advantage :—

First: It furnishes a most complete and painless splint to the replaced organ; and second, It is, in effect, a poultice to

the hyperæmic and tender uterus, the inflamed ovary, or other intra-pelvic viscera and tissues which, by reason of exquisite tenderness, forbid the immediate use of harder and more permanent kinds of support.

This is a most servicable method of treatment in those cases of retro-displacement of the uterus, with impaction and fixation of the fundus in the hollow of the sacrum. Placing the patient in the knee-chest posture, the dilating speculum and perineal retractor are introduced, whereupon the outlines of the uterine body can readily be seen occupying the lower pelvic space, stretching across it from bladder to rectum, with the fundus joined to the pelvic connective tissue with more or less firmness according to the duration of the malposition and the extent of the previously existing cellulitis. The procedure is quite similar to that just described, except that fewer pledgets of cotton will be required; sometimes, indeed, but two or three will be tolerated at first, and it may be necessary to remove even these in a few hours. This will, assuredly, be the case if there is much uterine tenderness, or hyperesthesia of the intra-pelvic tissues. After a little time, however, it will generally be found that the parts become more tolerant of the treatment when the number of cottons can be increased. This should be done gradually, and continued until reposition of the organ can be effected. The case is then ready for a more permanent support. Occasionally a hard-rubber pessary can be introduced at once, with the expectation that it will be well borne; but, speaking generally, it is well to begin with a more flexible instrument. I have found the Albert Smith pessary, made of steel springs and covered with soft rubber, to serve a good purpose in many cases, during the period intermediate between the suspension of the cotton treatment and the final employment of the permanent support.

The permanent pessary, however, should be made of hard rubber, and I confess to a growing preference for the Albert Smith modification of the Hodge pessary, which, in some size or other, seems adapted to the greatest number of cases.

If, in addition to the retroverted or retroflexed womb, we also have a prolapsed ovary to deal with, we shall find the genu-pectoral posture of almost indispensable usefulness. When these abnormalities co-exist, they will, speaking generally, have set up a train of symptoms of the most distressing nature, VOL. XXXII.-15.