The objection urged against the examining table, that the patient will demur against lying on it, is not at all valid. There is absolutely no more exposure on it than when the patient is in a chair, or on a lounge, and the greater ease in examination, as well as the more perfect results, are unquestionable.—En] As regards the position of the pelvis in the various positions, we borrow the following passage from Hegar and Kaltenbach: In the erect position the plane of the pelvic inlet makes an angle of with a hori zontal plane passed through the upper border of the symphysis, and an angle of 45° with a similar plane passing through the centre of the sym physis; the apex of the coccyx is on a little higher level than the lower border of the symphysis pubis (according to Nagele .8 of an inch), its upper border about 3.5 inches below the level of the promontory. The foramen ovale is a trifle lower than the inferior border of the symphysis; the vagina runs from in front downwards, and from below upwards, its orifice and the external genitals looking nearly directly backwards. The urethra lies forwards, the anus behind the introitus vaginae. The intra abdominal pressure, in the ordinarily erect posture, is positive, measuring according to Schatz, from 25 to 30 cubic centimetres, being lessened on marked protrusion of the abdomen, and increased on marked contraction. The normal and normally movable uterus sinks down a little and forwards, and seems heavier on account of the weight of the superincumbent ab dominal contents. Displacements of the uterus are generally intensified, although they may be lessened. The changes in position of the pelvic organs give frequently very valuable information in regard to the state of the ligaments under the influence of pressure, from distension of the neighboring rectum and bladder. While, for example, when the bladder is empty, the uterus is anteverted, which position is intensified in the erect posture; and while in case of distended bladder in the upright position, the uterus sinks deeper, where there exists shortening of the ligaments on one side, which is not detected in the dorsal position, in the erect position lateral deviation may be recognized.
The examination in the erect position must needs be incomplete. Simple vaginal touch may be made, but the bimanual is impossible, owing to the contraction of the abdominal muscles, and the advantage of having the uterus nearer the finger is offset by the fact that the thick nates prevent deep insertion of the hand. Inspection of the external and in ternal genitals cannot, of course, be resorted to. Notwithstanding, the erect position is frequently used when we are desirous of quickly inform ing ourselves of all that is possible by the vaginal touch, and further, in case of version, flexion, or descent of the uterus, when we desire to de termine the influence of abdominal pressure on the displacement or on any body foreign to the pelvis, or on the position of tampons or pessaries, which we may have inserted into the vagina.
In Germany and in France the dorsal positions are mainly used for purposes of examination, and it has wrongly been objected to these posi tions that they are more uncomfortable and exposing than the lateral position, which the Americans and the English use. Since Sims popu larized examination by means of the speculum in the lateral position, it has also frequently been used for the vaginal touch, and under certain conditions it has advantages even as has the knee-elbow. In the dorsal position palpation, percussion and auscultation may be performed to better advantage, the vaginal touch, the sound, and inspection certainly as well as in the lateral, but the bimanual palpation can unquestionably be better resorted to in the dorsal than in the lateral or abdominal posi tions, and chloroform is more readily administered.
The simple dorsal position, with the body straightened out, is the most unfavorable for examination. The abdomen is ordinarily convex externally and tense, the intra•abdominal pressure, although less than in the erect position, is greater than when the thighs are flexed at about a right angle, and the entrance into the genitals is more difficult in com parison with any position where the pelvis is lifted up or bent back wards. In this position the plane of the pelvic inlet forms an angle of 30° with a horizontal plane through the sacral promontory, the angle opening outwards, the symphysis from above backwards and from below forwards, at an angle of 45°, and a horizontal plane through the promon tory cuts the upper half of the introitus vagime, and the dorsal column makes with the conjugate an angle of 135° opening forwards. When in this position the thighs are flexed, changes of various kinds occur. Slight flexion Is expended at the hip joint, and the inclination of the pelvis is not altered. When the flexion is greater the pelvis is lifted, the vertebral column is straightened out, there is movement between the vertebrae and slightly at the sacroiliac synchondrosis. The angle at the junction of the dorsal vertebrae with the sacrum is increased, and that with the plane of the pelvic inlet is lessened. \There the flexion is not exaggerated, the pelvis rests on the middle of the sacrum, but in case of great flexion the sacrum is lifted up so much that it only rests on its upper transverse processes, and on the lower part of the iliac crests. The symphysis ap proximates the horizontal plane, and its upper surface the promontory and the manubrium of the sternum. The symphysis becomes the highest point of the bony pelvis, the foramen ovate lies directly under it, or a trifle anteriorly, the vagina extends from above and it points sharply downward and backward, its direction approaching the perpendicular.
The amount of intra-abdominal pressure is very variable; the more the pelvis is lifted upwards against the thorax, the less the abdominal pressure, although it may be increased by the sharp flexion of the thighs and traction on the pelvis, since thus the space in the abdominal cavity is lessened. Nevertheless it is possible to render the pressure in the ab dominal cavity negative by lifting up the pelvis of the patient, and by a combination of certain respiratory movements. (Sdhatz, llegar.) The position most frequently used for operations (Simon's), where the thighs are flexed and slightly abducted, may be assumed on any flat table without the presence of assistants, provided the soles of the feet are sup ported. The abdominal walls are relaxed, so that external and combined palpation may be resorted to with great ease, and there is ample space for the use of the sound or the speculum, in cases where we do not intend attempting a difficult operation within the pelvis. Every other dorsal position, with greater inclination of the pelvis, requires the help of at least two assistants, or of some apparatus for holding the legs. It is ad vantageous, in addition, to lift the pelvis up by means of one or more pillows, or by means of a movable central portion of the examining table.