sling (a sheet twisted into a rope). One end of the sheet is passed around the flexed leg below the knee from without inward, and tied or fastened with large safety pins. The sheet is then passed back of the shoulders behind the neck, over the opposite shoulder and fastened to the opposite leg in the manner described. Upright leg holders are commonly substituted for the sheet sling.

The lithotomy position is employed for operations on the external genitals, for plastic operations upon the rectum, vagina and cervix uteri, and for vagino-peritoneal operations.

The Edebohl Position. -This is commonly substituted in hospital practice for the lithotomy. This position is similar to the lithotomy position, except that the legs are only partly flexed and the feet are suspended by Edebohl's upright leg holders, or held by assistants, flexed and abducted well above the body.

FIG. 1.-The Sin s' position.

The Sims' or Left Lateroprone Position.—The patient is placed on her left side at the edge of the table, with the left hip at the left lower corner of the table, and her left arm is behind her back or back of the body and lying parallel with it. The thighs and legs are moderately flexed and drawn up toward the chest, the right knee being higher than and in front of the left, and both resting on the table (Fig. 1).

The Sims' position is used for examination with a Sims' speculum for certain cervical, vaginal, rectal and pudendal operations and for local treatments.

The Genupectoral or Knee-chest Posture. The patient kneels on the table with the knees slightly separated and the feet projecting over the edge; the thighs are upright, the side of the face rests on a soft pillow, and the upper chest is flat on the table; the arms are thrown back, while the forearms run forward and parallel to the sides of the table, which are grasped by the hands. The thighs must be perpendicular to the surface of the table and the chest must be as close as possible to the knees.

FIG. 2. The genupectoral or knee-chest posture.

The knee-chest posture is useful for repositing a retrodisplaced or prolapsed uterus or prolapsed ovaries or for colonic lavage or for rectal and sigmoid examinations. It is also used with advantage for direct cystoscopy (after Kelly's method) as it favors air dilatation of the bladder which exposes the ureteral orifices and facilitates direct ureteral catheterization.

The Trendelenburg Position. The patient lies on the back on an inclined plane of 45 degrees, the legs and the feet hanging over the edge of the table (special tables are devised to give the Trendelenburg posture).

The Trendelenburg position is used to favor the gravitation of the intestine from the pelvis toward the diaphragm, and is generally employed in celiotomy for procedures upon the pelvic organs, in

order that the intestines may be removed from the field of operation; and also in certain examinations, as where it is necessary to determine if an abdominal tumor has a pelvic origin.

The Walcher Position. The patient is placed on the back with the buttocks resting on the end of the table, the thighs and legs hanging down, the thighs well extended. This position increases the conjugate vera by lowering the pubis and throwing the sacral promonotory backward.

The Walcher position is useful in delivery by forceps and in breech extractions while the head is passing the brim, but possesses no advantage in gynecological procedure.

The Pryor Position.-This is a combination of the lithotomy and Trendelenburg postures. It permits the intestines to gravitate out of the pelvis and is useful in vaginal celiotomy and in direct cystoscopy.

Physical Examination. -The student or the physician will be less liable to fail to observe important data in making a physical examination by adopting a definite order of procedure. The patient should empty the bladder immediately before being placed on the examining table. The order of examination should be as follows:

1. Inspection and palpation of the thyroid gland and breasts. 2. Examination of the heart and lungs.

3. Abdominal examination.

4. Inspection of the external genitals.

5. Vaginal examination.

6. Vaginoabdominal or rectoabdominal examination (bimanual). 7. Instrumental examination.

8. Examination of the rectum and bladder.

9. Bacteriological examination of the discharges.

Urinalysis, hemanalysis, blood chemistry, a blood Wassermann and blood-pressure readings have important diagnostic significance, and should be made in order that the physical findings may be properly interpreted.

Abdominal Examination. To make an abdominal examination the patient should be placed in the horizontal posture, with the knees drawn up sufficiently to relax the abdominal muscles; the waist and corset must be removed and the remaining clothing loosened. The entire abdomen should be exposed, the lower extremities being covered with a sheet.

Inspection. By inspection we note the size and general contour of the abdomen, the shape and outline of any tumor, the pigmentation, the prominence of veins, the presence of linea albicantes, eruptions or scars, the position of the fat pads and the respiratory movements of the abdominal wall. All tumors of the abdominal wall move with the wall and may be lifted up with it. Tumors of the intraperitoneal organs and viscera move with the respiration under the abdominal wall, unless adherent to it. The nearer the diaphragm the greater the excursion. Uniform enlargement is common in tympanitis, large ascitic collections and in thin walled cysts filling the entire abdomen, while in the moderately ascitic abdomen the anterior surface is flattened and bulging may be noted in the flanks. Palpation. In palpating the abdomen the hands should be warmed and the palpation made with the palmar surface of the finger-tips. Palpation determines the situation, size, shape, sensitiveness and mobility of the intra-abdominal organs and of new growths. It reveals the nature of an abdominal enlargement, making it possible to differentiate between the tense elastic resistance of a cyst and the hard unyielding mass of a solid tumor. It allows the examiner to estimate the general tension and tenderness, areas of muscular rigidity and periodic alterations in consistency. A pregnant uterus is the only intra-abdominal swelling which contracts intermittently.

The sense of fluctuation and the presence of a fluid wave help to distinguish between fluid and solid growths. The examiner should begin his palpation by following a definite order of procedure, giving attention successively to the kidneys, observing their size, sensitiveness and mobility.

To the liver, noting its contour and size.

To the gall-bladder, noting the tenderness and muscular rigidity over its region.

To the spleen, determining its size and contour.

To the stomach, palpating the pyloric end for the presence of a mass in this location.

To the appendix, examining for tenderness, rigidity, or mass in this region.

To the cecum and sigmoid, for the presence of tenderness or

mass.

To the uterus, noting the height and position of the fundus, its smoothness or nodulation.

To the bladder, to determine its distention. An over-distended bladder presents as a globe-shaped tumor in central position in the lower abdomen, tense and tender.

The tension, thickness and diastasis of the abdominal walls should also be noted.

Gentle manipulation disarms the reflexes, while having the patient breathe quietly with the mouth open relaxes the abdominal muscles. Palpation will detect the presence of a tumor or mass and determine its size, contour, origin, mobility, the direction of its excursion and its density. Intraperitoneal tumors as pedunculated fibroids, ovarian tumors, intestinal and mesenteric growths are usually freely movable, but show a tendency to return to the region from which they grew. Retroperitoneal tumors are usually more or less fixed.

Thick and tense abdominal walls may prevent the satisfactory palpation of the abdomen; in such cases an anesthetic may be necessary to overcome the muscular rigidity.

Topography.-For the convenience of description and record, in designating the location of tenderness or of a mass, the abdomen may be divided into four quadrants by an imaginary horizontal line drawn from the ensiform to the pubis, passing through the umbilicus, and a vertical line passing through the same point, thus forming right and left upper and right and left lower quadrants (Fig. 3). Each quadrant has normally a definite anatomical content so that the presence of a mass in one of these regions immediately suggests its possible origin.

Percussion.-Percussion over the abdomen serves to confirm the information already gained by palpation. Percussion aids in outlining the viscera. Thus, the liver, gall-bladder, stomach, spleen, urinary bladder if distended, or the uterus if enlarged may be outlined by percussion; as may, also, new growths, or inflammatory masses be accurately outlined by their area of dullness. Solid and fluid tumors give a flat or dull percussion note, while the hollow viscera are tympanitic.

The area of deep or superficial dullness shows at what portion of the abdominal wall the tumor or fluid is in direct contact, or at what portion the mass is separated by interposed intestines.