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gynecological universe there and then changed front, and the modern school of gynecology was established in that humble, inconspicuous dwelling.

The late Dr. Henry F. Campbell, of Augusta, Ga., has written voluminously upon the physics of this posture and its application to the treatment of pelvic disease. My experience with it only confirms to a considerable extent the observations of Dr. Campbell. Bozeman, of New York, still prefers the genu-pectoral, or rather his modification of it,

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for fistula operations, in which he has attained conspicuous success by the employment of his button suture adjusted in this posture. I speak from a large experience in the management of pelvic diseases when I say that-leaving out, of course, all operative cases-I should be compelled to practically abandon the practice of gynecology if I was to be deprived of the benefits of the genu-pectoral posture. Another advantage connected with this posture resides in the fact that the intestinal canal can be inflated or flushed better with a patient in this attitude, in which the long rectal tube

can be passed with more convenience and less discomfort. The knees-elbows posture (Fig. 12), which is only a modification of the genu-pectoral, may be resorted to in cases where it is not competent or possible to employ the classical kneechest posture.

Let me speak for a moment as to the method of assuming this important pose. To begin with, a table or other firm foundation is necessary. Presuming that a table is used, its top forms the horizontal of a right-angled triangle which is to be completed by the patient's body. In this geometrical figure the thighs furnish the upright and the body the hypothenuse, when we thus have the triangle complete. I lay great stress upon the method of assuming this posture. Failure has over

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FIG. 13. The semi-prone posture-posterior view.

and over again come to the novice or amateur who has been directed to place his patient in this posture for obstetrical or gynecological purposes. The triangle figure is the one of greatest import and the easiest remembered. If the thighs are oblique, making the angle either obtuse or acute, gravity will be impeded. A woman once properly placed in the genupectoral posture, the abdominal organs, especially the intes tines, gravitate toward the diaphragm, the vessels unload themselves, and with comparative ease we may correct a retroverted womb, and apply the necessary mechanical treatment to retain it in position with the least possible discomfort to the patient.

It has been asserted that women will either refuse altogether to take this position, or, having taken it, will not keep it long enough to permit the necessary treatment of their conditions. I have never yet met such a woman. I am in the habit of using this posture daily, and, after a full explanation and understanding of it, my patients are more than satisfied that it is easy and effective. This is especially the case with women who have been treated by physicians who do not employ this posture, the contrast in postural ease and facility of treatment being so great as to occasion remark.

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FIG. 14.-The semi-prone posture-anterior view.

The Semi-prone Posture.-It is to the genius of Sims, as I have before hinted, that gynecology owes many of its most substantial improvements. This may be said to apply either to instruments or methods. It has been asserted that it were as well to give up the practice of gynecology as to attempt to do without the Sims posture and the Sims speculum. It certainly is an important pose, both with reference to minor and to operative treatment within the genital tract. But in order to obtain its greatest benefits and its most substantial results, this posture must be properly studied by the physician, and he must acquire dexterity in the several uses of this

pose. Strictly speaking, the semi-prone position is not an obstetrical posture, but it is so nearly allied to the left lateral recumbent that it easily becomes blended with it in some obstetrical procedures. It is a suitable posture for all manipulation connected with the curettement of the uterus, whether for retained secundines after abortion or for neoplasms or other abnormal conditions of the endometrium. Some operators, however, prefer the dorsal elevated postures for this operation. It is the essential posture for intra-uterine irrigation after labor, when that procedure becomes necessary. There are very few intra-uterine processes of instrumentation that are not better performed with the patient in the semiprone pose than in any other. The tamponade of the vagina for uterine hemorrhage can be adequately performed in this position, and it is the principal posture for rectal explorations. The hot rectal lavement administered through the long tube is rendered more efficient, because more certain of its reaching the high portions of the intestines, when administered with the patient either in this attitude or in the genu-pectoral posture.

It has been my experience on one or more occasions that forceps could be applied in the Sims posture after failure in all others. It is a posture that is often misunderstood, because frequently illustrations are misleading. I have endea vored to represent it faithfully in the photographs which I reproduce, though I confess it is not an easy matter to properly pose a patient in this attitude and then reproduce it accurately. I first show the posterior semi-prone, which will accentuate the fact that the right knee and thigh are drawn well above the left, and also that the left arm is released and hangs over the edge of the table, while the patient's chest comes in contact with its top. Sometimes it is requisite to give the table a tilt after the patient is posed, but I have found this rarely necessary unless there were some marked anatomical peculiarities in the patient.

Trendelenburg's Posture.—The Trendelenburg posture has been made use of chiefly by abdominal surgeons, who have been led to believe that the gravitation of the abdominal viscera toward the diaphragin would overcome many difficulties that otherwise frequently occur during the progress of opera

tions. Probably there is no one operative posture that is the subject of more disagreement just now than this. Some operators laud it beyond reason, while others decry it with a wholesale condemnation. It is highly probable that this posture, which means that the patient's body shall recline at an angle of about forty-five degrees, has some advantages which make it important to consider, and at least to be familiar with ; but it is not probable that it will ever supplant the ordinary

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horizontal pose for the largest number of abdominal sections in the hands of the largest number of operators.

The modified Trendelenburg posture, with the entire lower extremities elevated at an angle of fifteen to twenty degrees, sometimes is available in producing a reversal of gravity in pelvic disease. I have myself employed it with advantage. It is advocated by Emmet very strongly. I remember a patient that I attended about eight years ago that seemed to be nearly or quite cured from a threatened grave pelvic inflam

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