Whittaker, Jas. J., American Practitioner,' vol. i, 1870. Richardson, W. L. External Manipulation in Obstetric Practice. Boston, 1871.

Barnes, Robert, Dr., Lectures on Obstetric Operations,' 1871, p. 90.

Dr. MADGE said that some French authors have stated it to be possible to make out the position of the fœtus in utero by auscultation, and he thought that it should at least be employed as an important aid in such an examination. The position could by this means be made out with tolerable accuracy; but the child's frequent movements and changes of position made the knowledge of but little practical value.

Dr. PLAYFAIR said that his attention had long been directed to the ease with which the position of the foetus could be made out by abdominal palpation combined with auscultation. In a paper read before the Society last year "On Irritable Bladder in the latter months of Pregnancy," he had shown how it could be turned to practical account, as by altering the abnormal position of the foetus this distressing symptom could often be removed. Dr. Edis did not describe at length how the position of the fœtus could best be made out. The method he (Dr. Playfair) used and taught his class was first to ascertain the direction in which the long diameter of the uterine tumour lay. If this was from above downwards the presentation must be either the head or the breech. In the former case the fœtal heart would be heard beating below the umbilicus, in the latter above it. When the long axis of the uterus did not correspond to the long axis of the abdomen, but lay more or less obliquely across it, the presentation was transverse. A hard prominence would be found at either of its extremities, corresponding to the head and breech. The foetal heart could be heard loudest near the extremity at which the head lay. These facts being made out, the position of the child could be altered at pleasure, and with great ease. He differed from Dr. Edis, however, in thinking that any examination need be made for the purpose of detecting the exact position of the foetus until labour had actually commenced. The position in which the foetus lies is constantly altering, and it would be found practically useless to change it artificially until labour had begun, as most probably it would soon find its way back to its former position. In several of his cases in which he had detected transverse position some time before delivery, the head presented naturally when labour

came on.

The PRESIDENT remarked that he would be the last to throw any cold water on the use of the external hand in midwifery. All his teachings and writings had been directed to the inculcation of its use, and yet it was from a practical knowledge of the difficulties of turning wholly from the exterior that he had made the remarks he had done in his work on 'Combined External and Internal Version.' It was a difficult mode even for those skilled in its use. He thought the cases in which the rectification was needed were few, much fewer than the advocates of rectifications before labour thought. The proportion of cases in which their plans were carried out were far in excess over the occurrence of transverse presentations in actual labour. The uterus by the gentle early contractions rectified most of the oblique positions of the foetus. At the same time he fully coincided with the opinion that we should at all times fully acquaint ourselves with the conditions of the uterus and its contents, so that when labour set in, and as soon as the os uteri admitted a finger or two, we should be prepared, if an error of presentation existed, to rectify it at once by combined external and internal version, and this, he thought, would be in nearly every case sufficient to meet the exigiencies of labours, and as much as was possible in ordinary private practice.

Dr. EDIs, in reply to Dr. Murray's remark that Dr. Braun, of Vienna, employed the process not so much with the view of remedying malpositions as of being ready at the earliest moment to give assistance, thought that this scarcely expressed it. The process was employed distinctly to obviate errors of position. As regards Dr. Madge's remark about auscultation not having been mentioned, Dr. Edis replied that he had purposely omitted it from his paper, though he always employed it in his practice, so as not to divert attention from the main object of the paper. Dr. Playfair had misunderstood the time at which Dr. Edis proposed resorting to examination; he only intended employing it during labour, and had never found any objection urged by the patient. It was true, complete version of the foetus by external manipulation alone was somewhat difficult, but as cephalic version was the method insisted on, this would seldom be requisite. He quite agreed with Dr. Phillips that in most, so-called, transverse presentations, the head rested on one or other iliac fossa, and the axis of the uterus was oblique-all the more reason why cephalic version should be employed by external manipulation alone before the membranes had ruptured.

NOTE ON THE TREATMENT OF SUPPURATING OVARIAN CYSTS BY DRAINAGE.

By J. J. PHILLIPS, M.D.

So much success has of late followed the complete removal of suppurating ovarian cysts that the operation of ovariotomy will probably in future be more frequently resorted to in such cases. Exceptional instances will, however, occur in which the removal of the tumour cannot be effected, or in which the attempt to extirpate it may be considered undesirable. Under such circumstances the practice of freely laying open the cyst, and stitching its walls to the margins of the abdominal wound, or the treatment by the drainage tube, will probably be considered to afford the best chances of success. In the case to be mentioned the drainage tube was used, the cavity of the cyst being daily washed out; and this note is recorded to illustrate one source of danger accompanying that plan of treatment. The point may indeed be familiar to the more experienced members of the Society, but I have seen no reference to it in any treatise on the subject, and it may therefore be worthy of brief notice.

Harriet W, æt. 30, was admitted into Guy's Hospital, under my care, in the summer of the present year. She was the subject of an ovarian tumour, and had been twice tapped at a provincial hospital. The abdomen was tensely distended, prominent and globular in form, with distinct fluid vibration from side to side. A vaginal examination revealed the posterior part of the pelvis to be occupied by a tense elastic swelling receiving no impulse from the abdominal tumour. The os uteri was high up in front, the uterus normal in length. The patient's general condition was unfavorable. She was a good deal wasted, perspired much at night, face pinched, eyes sunk, tongue raw. The temperature on the morning after admission was 101° Fahr., and on the few

following mornings it varied from 99.8° to 100.8°, while the evening temperature was about 102°, on one occasion 102.7°. The pulse beat 120 per minute, and the respirations averaged 22 per minute. She complained of no pain, and there was no tenderness over the abdomen. It seemed probable that there was suppuration of the contents of the cyst; and on tapping it thirteen pints of pus were withdrawn. A small solid mass was found on the right side, and the evacuation of the abdominal cyst had no effect on that contained in the pelvis. My colleague Dr. Hicks kindly saw the case, and we decided not to recommend excision, but to introduce a drainage tube and wash out the cyst daily with a weak solution of iodine. The cyst in the pelvis might, it seemed, be treated subsequently by vaginal drainage. The improvement in the patient's condition became very marked. The temperature on the evening of tapping fell to 100.7°, on the third evening it was normal, and continued so, except for a few days when there was a little suppuration about the wound, until the supervention of the unfavorable symptoms six weeks after paracentesis. A note made three weeks after the operation stated that the patient continued to improve, gaining flesh, and taking food well. The cyst was evidently contracting, pushing the tube gradually out, and not containing more than five or six ounces of the iodine solution. One evening three weeks later she became very feverish, face flushed, pulse 140 per minute. This was followed by abdominal pain, a temperature varying from 103° to 105°, all the signs of acute peritonitis, and death in six days. At the post-mortem examination the left ovary was found to form a single cyst, the size of a cocoanut, which lay in the pelvis behind the uterus; this contained a brown, rather viscid fluid. The abdominal tumour was formed by the right ovary, and was composed chiefly of the cyst which had been injected during life. It was now so much reduced in size that it would hardly have held a cricket-ball. Its lining membrane was slightly discoloured, and covered here and there with specks of cheesy matter; its walls were everywhere perfect, and there was no indication whatever that it

had given rise to the peritonitis. The explanation of this was, however, readily found. The chief adhesions were on the right side, and the small mass of compound cysts felt there during life contained gelatinous material, while their walls had undergone calcareous degeneration. There was, however, one small cyst the contents of which were purulent; this was firmly adherent to the mesentery, and its wall around the adhesion was thin and shreddy, and had an opening in it, through which pus had escaped into the peritoneal cavity, and could then be made to exude on pressure. It seemed evident that the contraction of the chief cyst had caused such dragging on the adhesion between this small suppurating cyst and the mesentery as to cause a gradual wasting of the cyst wall and its subsequent rupture, an accident probably also favoured by the contents being purulent. The other organs of the body were healthy, except that the right lung, below its apex, contained an old vomica filled with cheesy stuff, and that there were some calcified scattered tubercles in the summit of the left lung.

The case brings to my recollection another case of suppurating ovarian cyst treated by drainage, and which ultimately did well. The patient was seized, several weeks after tapping, and when the cyst had contracted to a small size, with rather severe peritonitis of several days' duration, the cause of which appeared obscure. I think it not improbable that rupture of a small secondary cyst occurred, produced perhaps in a similar manner to that in the case now recorded; but that its contents were not of such a character as to set up so severe a form of peritonitis as to prove fatal.

I may add that it does not appear probable that the untoward termination in the case just reported could have been averted if the case had been treated from the first by a free incision; for had any attempt been made to break down the compound cysts the small suppurating adherent cyst would not have been reached owing to the dense calcareous mass which intervened between it and the cavity of the main cyst.