THE POSITION OF USE IN GYNECOLOGICAL TIONS.
simple vaginal examination, the most important of all methods, is performed in one or another position of the body, in standing, in the dorsal, abdominal or lateral position; but when it is desirable to make a complete examination, or when other means besides the touch are to be used, then that position is to be chosen, in which these methods may be resorted to in the simplest and most thorough manner, and with the least possible exposure of the patient.
Accordingly, for the purposes of a, gynecological examination, the following positions are of utility: 1. The standing; 2. The dorsal; 3. The abdominal; 4. The lateral. The dorsal position is subdivided as follows by Hegar and Kaltenbach: a. The flat dorsal, where the occiput, the spinous processes, the shoulder blades, the lower part of the sacrum, the knees and heels of the patient are in the horizontal line, or where the thighs are only bent sufficiently to make a right angle with the legs. b. The dorsal position, where the thighs are sharply flexed so that the knees rest against the thorax (Simon's position). 3. That position where the upper part of the body is lifted up, that is to say bent towards the pelvis, (the lithotomy position).
By the abdominal position is meant that in which the posterior sur face of the body looks upward. The pure abdominal position is of no utility for an examination of the genital organs, but the intermediate postures, such as the knee-elbow or the knee-chest, have many advantages.
Only that lateral position is of use where the thighs are bent at a right angle to the hips, and the sacral vertebral surface is brought upwards, a position which is a combination of the lateral and the dorsal. (Sims's lateral position.) For the purpose of these different positions, excepting of course the erect, an examining table is necessary. Where the patient is very sick we are often obliged to make our examination by the bedside, and the abdominal as well as the vaginal examination may be well instituted, provided the mattress be not too soft. Where it is necessary to use instru ments, a bolster should be placed under the pelvis of the patient, so that the external genital organs may be raised to a higher level, and the but tocks be brought to the very edge of the bed, the feet resting on chairs, and thus a fairly free access to the genital organs may be attained. The
majority of gynecologists use more or less complicated and convenient examining couches, such as those of Holmes, Baumgartner, Bozeman, Briihs, Leblond, Chadwick and others.
Whatever table is ased should have the following characteristics: It should be long enough and broad enough to allow of the assumption of any of the desired positions, and it should be accessible from all sides, with no elevated ridges. It should be high enough not to cause the ex aminer to stoop overmuch, in order to palpate or auscultate and inspect the genitals, without assuming a fatiguing position. The table should be firm, with no sharp edges, and it should have attachable feet supports, like those of Fritsch's, as well as a movable top, whiCh can be lifted up. A suitable couch may be improvised in almost any house out of a four legged table, with mattress and bolster, but tho feet of the patient must be held by assistants.
Whenever possible the examination should be conducted with the patient on such a table, and before a window with a good light. Still we are often obliged to rest satisfied with a bed or a sofa, and on the latter most of the methods of exploration may be used, provided it be broad enough and high enough not to strain the examiner, and provided there be a goon light.
[The table which the practitioner needs will vary accenting to the amount of gynecological practice he has. The construction of a table is a simple matter, and any carpenter can make one ample in every respect for general use. Aside from the desiderata mentioned by Chrobak, it is essential that the table possess both the lateral and the horizontal inclinations. Except in an emergency the sofa or the bed are utterly adequate for the purposes of a thorough examination. The various chairs are complicated. The tables which we figure are as convenient and in expensive as any, our individual preference being rather in favor of Goodell's, on account of its simplicity and perfect adaptability to any position. The Chadwick table has the disadvantage of not possessing the lateral inclination, a decided defect if the examiner has no nurse to hold the speculum. The Daggett table we have never personally used, but it is simple in construction, has the essential inclinations, and may be ob tained at very low rates.