with the thighs, it could not have been upon our apparatus that she was secured; and if she were. secured upon our apparatus, then it could not have been in the knee-elbow position, but in the right-angle knee and chest position, with the head and body supported horizontally, and forming a right angle with the thighs, as the thighs form another with the legs.

For these two positions to be alike, the arms and thighs would have to be of the same length. The dif ference between them is both theoretical and practical. One is secure and easy to the patient, allowing the surgeon to operate without assistance and with or without the administration of an anesthetic; the other is insecure and uncomfortable, and requires as many aids as can get round the table, to hold the patient. It is too dangerous to give anæsthetics in this position. Dr. Thomas would have had to forego the benefits of ether in it, or, if he had used it, instead of the successful result of his beautiful operation, he might have been obliged to record the death of his patient.

The only death I ever saw from chloroform occurred in the knee-elbow position, under the hands of an eminent surgeon of New Orleans. The knee and chest position has been employed in Europe for more than half a century. Easy and comfortable to the patient, she can be secured and managed in it without assistance, and can be kept under the influence of an anesthetic for hours together in it, if necessary. We have had it administered in this position more than fifty times during the last 2 years, and without one untoward symptom. In the New York Medical Journal for

Feb. 1869 we called attention to three points in which we claim to have improved this position, and by which we secure most important advantages.

ist. Extension and maintenance of the vertebral column to any desired extent, and relaxation of the abdominal muscles essential to free gravitation forward of the pelvic and abdominal viscera.

2d. Support and confinement of the patient, controlling muscular action at points desired, without encumbering the abdomen or interfering with the functions of respiration and circulation.

3d. The safe administration of anesthetics.

Now, with all these advantages, the exploration of the vagina, and execution of any operative procedure upon its walls, or upon the cervix uteri, becomes comparatively an easy matter. In all cases of urinary fistule, without exception, no other position can in our judgment compare with it.

In the semi-prone position of Dr. Sims, and in the dorsal position, or its modification, by Prof. Simon-his Steiss-Rückenlage-half the cases that present can be operated upon, but the other half cannot, the knee-elbow position being called for. In our improved knee and chest position every operation can be performed in every case, with or without anæsthetics. Fulfilling every indication, it leaves nothing to be desired.

THE HYPODERMIC SYRINGE A MEANS OF DIAGNOSIS IN OVARIAN DISEASE.

BY HENRY F. WALKER, M.D., N. Y.

In an operation so grave as ovariotomy, every means of diagnosis is valuable.

So difficult is the determination of the character of tumors concealed by the walls of the abdomen, that the uncertainty of their structure has passed into a proverb. For this reason, to confirm what palpation seems to reveal as to the nature of an ovarian cyst, or seeming cyst, the operation of paracentesis has often been resorted to merely as a means of diagnosis. But this operation, usually so innocuous in removing the accumulated fluid in ascites, has often a disastrous result in tumors of ovarian origin. This is due to the different situation and character of the two fluids. In ascites the fluid is already contained in the serous cavity of the abdomen; it is bland and unirritating, effused by purely mechanical causes, and its removal gives slight tendency to inflammatory trouble; but the fluid of an ovarian cyst, if it reach the peritonæum, may act as an acrid irritant, and excite a fatal inflammation. Again, the wound made by the trocar may be the cause of death by hemorrhage.

Courty in his tables, quoted by Thomas,* gives as the result of the first tapping (which of course is the only one to be considered here, dealing with the opera

* Dis. of Women. Phila., 1869, p. 556.

tion purely as a means of diagnosis), forty-six deaths in one hundred and thirty cases. Dr. Fock gives statistics of death occurring in one hundred and thirty-two patients after the first tapping; his tables being collated with reference to the time of its occurrence after the operation, a matter which does not concern us here.

So great are these dangers, that many surgeons prefer to omit tapping and have recourse to an exploratory abdominal incision at first. But this procedure has the unfortunate effect of hazarding life by all the dangers of gastrotomy in the very cases in which judicious surgery would forbid interference. This is seen in turning over the statistics of any experienced operator. Almost every table contains an ill success, because the tumor was colloid, melanoid, or fibro-cystic.

Now ovariotomy can never assume its rightful place among operations until it can be restricted to proper cases. The colloid and melanoid degenerations are not deemed fitting ones for its employment, and just as long as the ill success from diagnostic errors weighs down the favorable results of proper operations, just so long will surgical treatment of ovarian disease be deemed of questionable propriety.

These errors occur where every available means of diagnosis except tapping has been employed, this only being omitted from its hazard to life. By aid of the microscope, with never so small an amount of the fluid contents of the tumor, a diagnosis can be made in every case.

The means I would suggest, which possesses all the

advantages of tapping with none of its hazards, is the hypodermic syringe, with the finest of needle points. This little instrument has often been used in diagnosti cating purulent from serous effusions in the pleural cavity and pericardium, in detecting pus in cases of doubtful fluctuation under deep tissues, but has never to my knowledge been employed as a means of diag nosis in ovarian disease until within a few days, in the case detailed below.

The advantages it possesses are these:-1st, efficiency; 2d, harmlessness; 3d, painlessness.

1st. Efficiency. This is undoubted in determining the nature of the tumor, whether solid, cancerous, cancroid, or cystic. By plunging in the needle and retracting the piston sufficient fluid will be withdrawn by the suction exerted for microscopical diagnosis, even though it be of the most adhesive form of colloid growth. If it be proved a cyst with fluid contents, the kind of cyst may be demonstrated in many instances, for by introducing the needle at different parts of the abdomen, and comparing the character of the fluids withdrawn, it can readily be determined whether they be drawn from a single cyst with uniform contents, or from a multilo. cular tumor, containing fluids of various density and composition. This tells more than the clinical history, palpation, and all other means of diagnosis combined, for it lets us look within the tumor itself.

2d. It is harmless.-The fine needle of the hypodermic syringe can be introduced even into an aneurism without danger, while the wound it makes in the sac of an ovarian cyst is so small that nature ignores it.