UTERINE FIBROIDSAND

OTHER PELYIC TUMORS:THEIR

THERSPEDTIC TREHTMENTAND

GOZCsTIDTJGT TO THE nyEEEZCsTOH’jATJSH!.

By HENRY FRASER CAMPBELL, M. D.,AUGUSTA, GA.

Reprinted prom the February ( /88y) Number of the N. O. Med. and Surg. Journal.

NEW ORLEANS:L. Graham & Son, Printers, 99 & 101 Gkavier St.

ISS7.

I

UTERINE FIBROIDSAND

OTHER PELVIC TUMORS;their

THERAPEUTIC TREATMENTAND

CONDUCT TO THE MENOPAUSE.

HENRY FRASER CAMPBELL, M. D

AUGUSTA, GA.

In the present advanced day of oophorectomy, hyste-rectomy and other brilliant and bloody operations, one isintuitively prompted to explain, if not to apologize, in pre-senting himself as the reporter and advocate of medicinalexpedients in the management of these often perplexingabnormities. Nevertheless, the experience of the pastshould not be wholly lost sight of, even though largely sub-stituted by more direct, but not universally accepted and,albeit, often perilous methods.

Many circumstances and conditions render it expedientthat the individual experiences of those who have comefrequently in contact with any considerable number andvariety of such cases, at a period anterior to the sugges-

.tion of the surgical procedures now urged as the only al-ternative between active effort and entire abandonment ofthe woman to her fate, shall find a place in our currentteaching on the subject. A large number of the cases ofuterine fibromata and analogous growths, though appar-

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ently more or less rapidly approaching, from bloodless-ness, or other circumstances connected with the growth, afatal degree of exanimation, are not in a condition thatwould justify abdominal section for either hysterectomyor oophorectomy with or without salpingotomy. Othersubjects, when candidly informed of the discouraging sta-tistics of the one, and of the mutilation and barrennessof the others, absolutely refuse to submit to these opera-tions, or withhold their consent until the period of eventhe forlorn hope they offer has passed ; and yet anotherclass with tumors of varying size, location and histology,are of an age to regard the hope offered by the approachof the menopause as a promise of ultimate relief in thedecadence of vascular and trophic so universallyrecognized as an attendant on post-menstrual life.

These latter cases, as may be seen in the following quo-tation from Keith, have good ground and encouragementfor resisting both hysterectomy and oophorectomy as wellas salpingotomy, any of which operations indeed, in m3'own opinion, are seldom justifiable at that age, though thisas it seems to me, appears to be the only period of life atwhich the two latter procedures have been able to claimany marked success in arresting the menstrual nisus andflow.

“ To the woman with a fibroid uterus,” says Dr. Keith,*“who has passed the best of her years in weariness andpain, middle age brings relief, an 1 old age may be spent inpeace. Hence the difficulty in knowing how far we are justi-fied in advising interference, for a disease that troubles fora time, though it rarely kills. It is often said that theoperation for the removal of uterine fibroids is in much thesame position now, that ovariotomy was five and twentyyears ago. It is not so. It never will be so. The historyof these two diseases is entirely different. As a rule, ova-rian disease is a merciless one ; it goes on and kills. As arule, the active existence of an uterine fibroid is limited ;

* Contributions to the Surgical Treatmentof Tumors of the Abdomen. By ThomasKeith, M. D., LL. D., Edin., 1885.

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it rarely interferes directly with life. When menstruationceases, the troubles of the patient soon begin to pass away,while the tumor itself, after a time becomes smaller, and ina few years little or no trace of it may be found. Thepatient gets along, lives more or less comfortably, gener-ally not even aware of its existence, and dies of somethingelse. They havenot much to gain by chancing a dangerous operation, andthey may lose much, having much to lose.

“ Till of late years, uterine tumors were let lie undisturbedunless when they were mistaken for ovarian cysts ; but therestless surgery of to-day will let nothing alone ;it has nopatience for the menopause, and would attack all and sun-dry in some way or other, till one almost begins to thinkthat individual responsibility has become old fashionedand gone out of date. So far as operations for the cureof this disease have yet gone, the mortality is out of allproportion to the benefits received by the few.

“ Dr. Bigelow, of Washington, has lately collected all thecases placed on record up to March, 1884. At best, thismust be an imperfect list, and can only show the least badside of the operation. Of 359 operations there were only227 recoveries and 132 deaths, or a greater mortality thanone out of every three operated on.The sum of misery in the 359 operations to the subjects ofthem, and to their friends, is something simply incalculable.So far as hysterectomy has thus gone, it has done moreharm than good, and it would have been better that it hadnever been.”

Though I have thus quoted from Dr. Keith, as one ofthe highest, and perhaps the latest authority on uterinetumors, such principles as are in accordance with my ownviews, and the objects of the present paper, it would be in-justice to him to leave the impression that hysterectomy isbanished from his surgery. On the contrary, though heso strongly condemns the operation in cases offering thepossible chance of relief, by the limitation of the men-strul life of the subject, his record in cases forlorn of this

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hope—and these are his only admitted ones—has beenmarked by successes, the most brilliant and sometimes,wonderful to contemplate.

Unquestionably then, the menopause must be regarded asthe great crisis in the life, activity and growth of the greatmajority of pelvic tumors, but especially of the uterinefibromata, and of the softer non-malignant growths of thisorgan. Whatever methods of management have beenfound to sustain the life of the patient, and in anymeasure to lessen the exhausting hemorrhage, or to retardthe growth of the abnormity, until the advent of this periodof reprieve, are certainly worthy of our careful considera-tion.

All the several classes of cases just mentioned ;viz, thosewhich cannot, those which will not, and those which oughtnot to be operated on by abdominal section are known—-many of them—besides the burthen of the growth, to be sub-jected also to the most profuse, alarming and exhaustinghemorrhages. Their pale and oedematous faces, theirdropsical limbs, their oppressed and gasping respiration,and the tumultuous action of the feeble heart, tell us, at aglance, of a stage of exsanguination almost incompatiblewith continuedexistence. In profound interest, not unmixedwith alarm, we debate in our minds the momentous ques-tion: “Can she hold out to reach the longed-for goal ofher relief?”

Wide observation in regard to many subjects even in theextreme condition here represented, endorses the answergiven by Keith :

“ Even in the worst of them, the chancesare, that they will live on—not in comfort, certainly, someperhaps in misery—but still they will live, and not die.”

It is in behalf of such cases and others of a less threaten-ing aspect and milder type, that I advocate the record ofour experience and the results of such treatment as theyadmit of.

With a cordial recognition of the fact that such casesare not generally left without attempts to repress the hem-orrhage, and to stay the exhaustion incident to the advance

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of the disease, I desire to give a brief statement of themethods I have pursued in regard to them from-an earlyperiod of my professional life.

For this treatment, I lay claim to no special originality,except perhaps for the systematic combination of the me-dicinal agents; but I would urge its adoption as suitable toa large number of those cases of uterine fibromata andother pelvic tumors in which operative procedures havebeen decided against, and in those that are in expectancyof the menopause. Few women with uterine non-malig-nant and pelvic growths have applied to me in the past thirtyyears, and more especially where bleeding and atonic con-ditions were involved, who have not been placed withmarked benefit upon the treatment herein reported. Inthe large majority of these cases the blood-losses weregreatly diminished and a better condition of health andstrength secured; in many the rapidity of the growth wasobviously retarded, while in a few the diminution andfinal removal of the tumors seemed to be the happy resultof the continued medication.

In condensed statement, I may say that the iodide ofpotassium in 'combination with tartrate of iron andpotassa, and ergot in combination with quinine—theseagents being persistently continued, constitute the basis ofthe medicinal treatment referred to.

I will not here discuss the physiological action or the ther-apeutic efficiency of agents so widely familiar to the pro-fession, and so generally resorted to, in many conditionsof disease.

I will tersely make a statement of the method and modeof their administration adopted.

For many years the following was the formula for theiron and iodide of potassium

If. Ferri et potassas tart".Potassii iodidi aa- • 3vj.Syr. zingiberis.Aqua aa Siv.

M. S. Shake the vial, take i or 2 teaspoonfuls 3 times aday, in y2 glass of water before meals.

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The above was found to be a muddy and unacceptablecombination from precipitation, though the therapeuticeffect of the medicines seemed not to be impaired.

At the present time, the following is the preparationused :

ty. Ferri et potassas tart svj.Syrupi Sviij.

M.Potass, iodidi svj.Elixir, simplicis (vel aquae) sviij.

M. S. Take one or two teaspoonfuls from each vialthree times a day in half a glass of water, before or aftermeals.

In addition to the above, I seldom omit, whetherthe cases are marked by excessive hemorrhage or not, toplace the patient upon the following combination :

Quinias sulph ~...sij.Ext.ergotas solid siss.

Mix and divide in forty pills, cover with capsules.S. T<ike one pill twice daily.In the submucous variety of uterine fibroids—intra-uterine

polypi—metrorrhagia is frequent and profuse, or it may beconstant and in a milder flow, but the subjects are alwaysanaemic, somewhat dropsical, with heart and lung pertur-bation under the least fatigue.

The indication in such cases, is not so much to checkthe growth, or to diminish the size of the tumor, as it is tocheck the hemorrhage, rehabilitate the blood and promotethe expulsion of the fibroid from the uterus, that it may beremoved by operation.

In this class of cases I therefore eliminate the iodide ofpotassium from the treatment, and place the patient on thefollowing:

Ferri et potassas tart. .. .: siijExtract, ergotas solid. .sijQuinise sulphat sij

M. and divide in 40 pills. Take one pill morningand noon before eating.

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Under the above treatment the tumor is expelled into thevagina in from two to six weeks, the metrorrhagia greatlydiminished or arrested, the complexion and strength im-proved, while the patient is put in better condition for theoperation, whether by ligature, ecrasseur or excision. Inthese cases of course the expulsive efforts of the uterus areprincipally promoted by the ergot, but to the quinine,besides its action as a general tonic, I attribute a materialinfluence in giving steadiness and persistence to the uterinemuscularity. Its effect also on the middle or musculartunic—of unstriped fibre —of the arteries, is as I have else-where stated* similar to that of ergot on the uterinemuscle, constructed of the same kind of fibre. By thissame physiological action, and its attribute of lessening themorbid supply of blood to the growth, I believe it to bevaluable in checking the increase of the subperitonealfibromata, as well as that of other tumors and infarctionswithin the pelvic cavity unconnected with the uterus.

As to the action of iodide of potassium as an elementof this treatment, in view of the wide-spread and, accord-ing to many, still widening influence of syphilis, trans-mitted or acquired, over histological economy, this agentmay be supposed, on this account, to exercise a beneficialinfluence in the reduction of these neoplasms in somecases.

In the present connection it must not be regarded as farfetched or out of place, to refer to some of the circum-stances by which many of the women laboring under pelvictumors and infarctions are conditioned, especially those inthe South and Southwest and in other malarial regions ; alongwith their local disease and the exhausting drain attendingit, they are the subjects of an abiding tox<emia, imposingupon them a constant liability to intercurrent paroxysmsof fever of the most depressing character. These not onlyinterrupt treatment, but increase the turgidity of the morbidgrowth, increase the blood-losses and superadd complica-tions every way undesirable. Apart then from any special

* See Transactions American Gynecological Society, Vol.V, 1880. The Prophylacticand Therapeutic Value of Quinine in Obstetric and GynecicPractice.

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influence over the growth, the widely recognized prophy-lactic and antidotal influence of quinine will render it ac-ceptable as an element of treatment in such tumors to alarge number of observant practitioners.*

The considerations heretofore presented have had incontemplation women in the middle and later stages ofmenstrual life, who have been discovered to be the subjectof uterine and other pelvic growths and suffering from thedisturbing and exhausting results attendant upon theirpresence and advancement. This is the period at whichmost of these tumors come under the purview of the gy-naecologist and general practitioner. It is the period ofgreatest activity of the growth, of the most frequent andabundant hemorrhage, and of the greatest exhaustion anddanger to the woman. From this time to the completionof the menopause, all expedients are exhausted to checkthe hemorrhage, to sustain the vitality of the patient, and toprop her in her staggering journey towards the goal of herrelief. This is the period, too—treatment having beenneglected or failed to stay her downward progress—whenabdominal section with the view to oophorectomy, extirpa-tion or hysterectomy, can, not unwarrantably, be debated ;

but as I think, always only as a last and desperate resort.It is in view, as I have said, of cases in this stage of

menstrual life, that I have endeavored to formulate andfrom the records of a somewhat extended ex-

perience a persistent course of medication and management,that may serve to sustain and guide the woman through thebight and narrows of the most perilous strait in the progressof her disease.

I will here distinctly state that the treatment is not insti-tuted with the expectation of removing the enormousgrowths and uterine fibroids that distend the abdomen, butfor rendering them less burdensome ; not with the expect-ation of entirely arresting or preventing the hemorrhage,

* I here take pleasure in referring to a valuable paper on “The Sulphate of Quinine”published in the Virginia Medical Monthly and afterwards in a separate volume by Prof.O. F. Hanson, M. D., of Richmond, Va. This paper defines the uses and extends theapplications of quinine, and is well worth the perusal of every practitioner of medicine inthe South.

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but rendering it less profuse and exhausting ; not with theexpectation of restoring health, but for rendering disease,dire and dreadful, more endurable.

It may be asked if the treatment herein presented hasbeen found always more or less beneficial in uterine fibroidsand other pelvic growths?

In reply, I may say I do not remember ever to haveknown a simple or multiple fibroma of the uterus to directlycause the death of the subject, but in the low condition ofexsanguination and exanimation caused by the hemorrhageand irritation of fibroids, I have seldom failed to realizemarked improvement in the general condition of the pa-tient, and in many cases I have observed what appearedto be a notable retardation in the increase of the growth.In several pelvic and abdominal tumors of both menand women, unconnected apparently with the uterine ap-paratus, I can report decided benefit to the general healthand marked reduction and even disappearance of the tu-mor, in the prolonged use of iodide of potassium in com-bination with tartrate of iron and potassa. Of course,there are some cases of pelvic tumors or infarctions inwhich, while this or something similar may be the onlyrational medication practicable, yet, no reasonable expect-ation of relief can be entertained. The following is a nota-bly disastrous case of this kind :

Mrs. H. S. G., the mother of many children, all grown,had long passed the menopause ; aged 56; when a hardresisting tumor, the size of an orange, was found pressinginto the cavity of the pelvis. It was situated below thesacral promontory and appeared firmly attached to theanterior face of the sacrum. Its pressure soon interferedwith the passage of fasces, which for a while was accom-plished by mechanical means. The progressive growthand tight impaction soon caused perforation of both therectum and bladder resulting in free escape of fasces andand urine into the vagina. Numbness and paralysis cameon from pressure on the sacral nerves. The circulationbecame interrupted by pressure on the large arterial trunks

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at the pelvis, and the patient died in less than one yearfrom the discovery of the tumor, with irritative fever andexhaustion from gangrene of both her lower extremities.

Extirpation of the tumor, either by the vagina or by ab-dominal section, did not appear to be a very practicable orhopeful measure, and the attempt was persistently rejectedby the patient.

The above case is recorded here more as an illustrationof the .phenomenal disasters which attend the detention andlocking of a growing tumor within the bony pelvis, thanfor the purpose of exhibiting the success or failure of anytreatment, either medicinal or operative. An}r sub-perito-neal uterine fibroid that happened in a certain stage ofgrowth to be detained in the bony pelvis, might become ina like manner impacted with an equally fatal result.The ascent of these uterine fibroids out of the bone-girt pel-vis into the more roomy cavity of the abdomen, must berecognized as an important episode in the history of theirgrowth for the safety of the patient. On more than oneoccasion I have been able to relieve patients from distress-ing iPa *n by a simple dislodgement of the tumor, when par-tially jammed in the pelvis.

As I have heretofore said, my remarks have related tocases of fibroma and other pelvic tumors in the middle andlater stages of the menstrual life of the woman, when thereduction of the growth was less the object of treatmentthan that of carrying them on sately to the period whentheir gradual decline and subsidence might be hoped forby the advent of the menopause. Vailing from this class,I find among my records the notes of two cases of womenat an earlier period, in which treatment seemed to be fol-lowed by the removal of all traces of the pelvic infarction,together with the perturbations of menstruation which hadmarked their presence.

Miss S. A., of Washinghton; Ga., aged 22 years, in thespring of 1869 was referred to my care by the late Prof.Jos. A. Eve, of Augusta. This young woman had been thesubject of impaired health for over two years. Her symp-

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Toms, as reported, were disturbed and irregular menstrua-tion, the flow being sometimes deficient, and at othersamounting to profuse hemorrhage, with general emacia-tion and enlargement of the abdomen, which last featurehad recently greatly increased.

On examination with Dr. Eve and Dr. H. H. Steiner,the patient was found to be anaemic and extremely ema-ciated. The abdominal enlargement resembled that of awoman eight months advanced in pregnancy. This wasprincipally due to ascitic accumulation in the peritonealcavity. By firm pressure nodulated masses could be feltin the hypogastric and iliac regions. Vaginal explorationfound the uterus fixed in the pelvis, and bimanual pressureindicated the connection of this organ, apparently, withthe pelvic tumor. There was more or less vesical tenes-mus, with scanty and turbid urine. The bowels, thoughtorpid and constipated, presented no indication of me-chanical obstruction.

After some previous treatment with laxatives and diu-retics, the patient was placed within ten days upon the fol-lowing prescription:

lodide of potassiumFerri et potassas tart, grs. 320Water ,

Qinger syrup aa § iv.M. S. Take one dessertspoonful, three times a day,

befoVe meals, in one half glass of water.A highly nutritious diet was maintained.The case occurred at a period anterior to the free use of

hot water by the vagina as recommended by Emmet, andof hot water by the rectum as recommended by Chadwick,(see hot rectal douche, Amer. Gynaecological TransactionsVol. 5), and no local measures beyond a daily vaginalinjection of tepid water for the leucorrhoea, were recom-mended.

The patient remained under observation for two months,during which time the ascitic accumulation had disappeared,the pelvic tumors had become less prominent, and the

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uterus easily movable in the pelvic cavity. There was noreturn of menstruation during her stay in Augusta. Thecomplexion, strength and general health of the patienthaving been greatly restored she returned to Washingtonto continue treatment at home. Letters from the patientinformed me of the re-establishment and regularity of men-struation and of the complete recovery of her health.

The treatment withoccasional interruptions was continuedfor eight months.

By palpation over a year after, no trace of the tumorscould be discovered.* No vaginal exploration was made.

This lady called to see me several years after, as shekindly and truly said “ to show me that she was well, asshe knew I would be gratified at the success of my treat-ment.”

Mrs. G. 1., of Louisville, Ga., aged 24 years, came toAugusta, July 3d, 1885. She was weak, antemic and greatlyemaciated from loss of blood. She had spent most of hertime for several months upon her bed. In a recent “ turn ”

the hemorrhage had been so profuse and exhausting thather husband became alarmed and her medical attendantreferred her to me for examination and treatment.

The abdominal wall was flat and somewhat retracted.There was no indication of enlargement in either of theiliac regions, but in the hypogastrium there was a decidedelevation above the pubic brim of the pelvis, as if by a dis-tended bladder, or by the uterus in the fourth month ofpregnancy. The tumor was firm and resisting to externalpressure and apparently devoid of acute sensibility. Va-ginal exploration revealed the same hard and rotund bod}r

pressing against the posterior face of the pubic wall andpushing the vault of the vagina downward, so as to oblite-rate the cavity. She had been for some time past troubledwith vesical tenesmus and some dysuria. Where the blad-der, with any degree of distension, could be accommo-dated in this thorough occupation of the pelvic cavity, itseemed difficult to say.

On making the most careful and extended efforts to ex-

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plore the cervix it was found to be entirely out of reach,from the extreme anteversion of the enlarged uterine globe.The organ was firmly fixed—impacted—in this anteriorobliquity.

A few days later, my friend, Dr. John S. Coleman, wasrequested to assist me in a more thorough examination bythe vagina and, if possible, in an exploration of the uterinecavity. In no position, whether dorsal, semi-prone orgenu-pectoral, could our combined efforts secure anychange in the position of the massive uterus, or bring thecervix within the reach of the finger. The patient beinggreatly enfeebled from her recent loss of blood we wereunwilling to fatigue her further, or to attempt probing un-less guided by the touch.

I placed the patient, the day after arrival upon the fol-lowing :

Potassii iodidi sxij.Elixir simp • •

■ ■ OpMix and write : Dose one or two teaspoonfuls in com-

bination.Ferri et polassae tart sxjj.Syrupi zingiberis Oj.

Mix and write : Take one or two teaspoonfuls from eachbottle, before each meal, in y2 glass of water.

In addition to the foregoing; •

Ext. ergotas solid siss.Quinire sulph , sjj-

Mix and divide in 40 pills, cover with capsules ; write :

Take one morning and at noon.A tepid vaginal douche was directed to be made night

and morning. The patient was also requested to assumethe genu-pectoral position each night and apply the reposi-tor tube, to allow air to enter the vagina.

Though under this treatment the patient rapidly im-proved in color, in flesh and in strength ; though she wasable to leave her bed, and, once or twice, had goneupon the street, daily repeated examinations in knee-

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breast posture failed for a longtime to discover any diminu-tion in the size of the mass, or the slighest change of itsposition, under either digitalpressure or reversal of gravity.

On the 29th of July, over twenty days from the beginingof treatment, I perceived that decided movement in theuterine globe attended the entrance of air—and the patienttold me that for the last few days, air would puff out ofthe vulva after lying down from the knee-breast posture.This entrance of air indicated movement, and a less tightlyimpacted condition.

July 30th Mrs. J. returned home, with directions tocontinue treatment.

Sept. 20th, 1885, Mrs. J. returned to Augusta for furtherexamination and advice. Various letters had reported heras constantly improving in general health and activity sinceJuly 30th. Palpation could discover no tumor in the pel-vic region. On vaginal exploration the uterus was foundlow in the cavit} r of the pelvis, but only slightly anteverted.The most surprising diminution in the size of the organwas observable, and its perfect mobility in every directionwas apparent. On placing* her in genu-pectoral posture,air quickly entered and distended the vagina on openingthe vulva, and the uterus retired by reversed gravity abovethe normal plane. An elastic ring pessary 3 ]/2 inches in di-ameter was applied to sustain the organ in proper elevation.She had had two returns of menstruation without tendencyto hemorrhage. The uterus, though greatly reduced, wasevidently at this time still considerably above its normalsize and weight.

Recommended continuance' of treatment. Oct. 21st,1886; at this date Mrs J. paid her last visit. She called

for examination as to her condition, and to have the pes-sary, which she said added to her comfort, renewed. Onecould scarcely lecognize in this cheerful, ruddy and majes-tic woman, the dispirited, pale and almost bed-riddenpatient of over a year ago. She had continued treatment,somewhat interruptedly, to the present time.

Though I did not measure the cavity with the sound, I

may state that the uterus is reduced to the normal dimen-sions, and is normal in contour and position, except aslight tendency to prolapsus, due probably to its prolongedabnormal condition and relaxed ligaments. Menstruationhad been regular and normal for over a year, and in everyparticular her health seemed fully restored.

She was advised to continue her medicines for a whilein reduced doses, after which she might probably safelyabandon medication.

I have seldom witnessed relief from a grave and threat-ening condition, which appeared to be so directly attribut-able to the influence of the treatment adopted.

In conclusion, were I to endeavor to formulate ;principlesfrom the foregoing considerations, and from my own ob-servation and experience, the following may perhaps belegitimately stated :

First, that a large proportion of uterine fibro-mata and other pelvic tumors outside the ovariancysts, are not properly the subjects for surgical treatment,either by hysterectomy, oophorectomy, salpingotomy orexcision.

Secondly, though these growths, especially the uterinefibroids, seldom per se destroy the life of the subject,and are limited in the duration of their injurious influence,they yet impose upon the woman a prolonged period ofdepression, exhaustion and ill health, during which periodshe is liable to succumb to intercurrent invasions of diseasebefore the establishment of the menopause, or the time ofexpected relief.

Thirdly, that a systematic and persistent therapeuticcourse, rationally adjusted to the nature and condition ofthe disease, is highly desirable.

Fourthly, from the known physiological effects of ergotin combination with the salts of quinine, and of iron, withiodide of potassium, and in view of the results above pre-sented, we may regard such a combination as rationallyapplicable during the prolonged period of hemorrhage andexhaustion, so frequently marking the progress of thesepelvic growths.

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Fifthly, that while such medication cannot be expectedordinarily to remove large fibroids, or materially arresttheiradvance, it exercises marked influence in diminishingthe blood-losses, and in improving the nutrition and generalhealth of the subject of such tumors ; and in some rare in-stances, apparently in younger subjects, it results in theentire disappearance of the growth and its deplorable con-comitants.

And lastly, that in view of the danger of impaction,much pain being often produced from this cause, withincrease of bleeding, a womb with growing fibroidsshould be frequently lifted out of the cavity of the truebon}r pelvis, by nightly self-replacement in the knee-breastposture.