either of the latter with the os internum. Not rarely, however, an isosceles uterus becomes an equilateral one; the base may even be longer than the sides. Then the uterus is not a long, but a transverse one. In the latter case, there is often a saddle-shaped depression of the base. The uterus then becomes heart-shaped or bicornuate.

At the end of pregnancy the human fetus finds room in the comparatively short uterus only by being compressed into a curved form. This is usually the case over the ventral side, because the fetus develops in this direction, and hence lies thus most readily without being incited to movements. More rarely, and generally but temporarily, the curvature takes place over the dorsal surface. The face position is nothing but this uncommon curvature. Indeed, it is not such a one in its purity, but rather a transitional frontal position. As the result of the mechanism of labor, there subsequently ensues the presentation of the chin, an over-stretching.

As to the manner in which the reverse curvature of the fetus in utero is brought about, the two cases of the author give some information.

In the first case the uterus was depressed at the base; second position of the skull; breech in the right cornu; head in the upper part of the cervix. If the ovum is to lie in an equilateral uterus without forcing it to change its form, breech and head must lie in two angles, and the curvature of the body toward the side of the third angle. If it lie toward the side of the line of junction of the two occupied angles, the uterus is greatly distended in this direction beyond its regular shape; it reacts upon it by its power of restitution, pressing the breech against the head. If the formerfor instance, owing to the depression of the fundus-cannot escape from the occupied horn into the other one, and the head is likewise retained in the cervix, the dorsal flexion occurs, and to the greatest extent at the place of the movable neck of the fetus. In this way the foramen magnum is changed from its former to the opposite location; the face position is complete so far as it can occur during pregnancy, or at the beginning of labor. The question, how the breech came to occupy the angle of the uterus not belonging to it, can be answered thus: that this takes place in living fetuses simply by a not uncommon very great active exten sion of the fetal legs. In dead ova, of course, this cannot be the case. But in them the dorsal flexion finds less resistance, and therefore can also be brought about by slight forces, for instance, traction on the cord in the beginning of labor, distention of the abdomen, etc.

In S.'s second case, the child lay as in the first, but the fundus was not depressed. Here it might be anticipated that the breech, having been pressed into the right cornu of the uterus by the extension of the legs, should again go back into the left horn with

the subsidence of the extension. But it must be borne in mind that when the breech is vigorously pressed into the right horn, and the uterus reacts against the great elongation with its restitutional power, the rounded back, itself crowded out of the right side, effects a displacement to the left of the fetal neck over the pelvic inlet. If the head is at the same time freely movable over the pelvic inlet or the internal os, it is pushed in toto toward the left: an oblique or transverse position arises. But if it lies half in the pelvis, or a similar concavity formed by the lower uterine segment, it cannot give way laterally; the head is twisted as in a ball-joint; the foramen magnum, hitherto at the right, now comes to be at the left.

S. believes that the above-described mechanism applies not only to similar, but also, mutatis mutandis, to many other cases; for instance, when the second twin lies over the back of the first in such a way that the latter can curve only dorsally, or when a tumor inverts the curvature in like manner. In a uterus which is considerably inclined to the right after the internal os has dilated, the fundus in toto will, to some extent, assume the function of the right cornu, and the concave curvature toward the right of the genital canal will be able to produce a face position of a child situated in the second position.

It is also possible that the narrowness of the pelvis and the dolicho-cephalic shape of the head (Hecker), which, according to Winckel and Hecker, are not rarely associated with face position, may have some influence in the above-described mechanism. In the latter case, the foramen magnum occipitale is situated more in the centre of its basis than in the brachy-cephalic form. Hence it will be more easily displaced laterally from the cervical vertebræ. In a contracted pelvis, especially when the diameter is straight, the head often represents a cylinder whose axis is formed by the line of junction of the tubera parietalia, and projects with its ends above the brim of the pelvis. If now, in the second position of the skull and a uterus inclined to the right, the foramen magnum is pressed to the left from the neck, a change into a face position will occur more easily with the dolicho-cephalic head than with a brachy-cephalic one, especially because the axis of the cylinder in the former case lies dorsad of the atlas joint, but in the latter ventrad, and because, at the same time, the resistance at the pelvis in the former is more to the right than in the latter. Of course, it requires in addition a sufficiently free mobility of the head in the pelvic inlet, and a diminution of the resistance by the child against the unusual position. In conclusion, the author requested that attention be paid as to how frequently the abovedescribed mechanism, in which the face position is produced solely by the equilaterally triangular form of the uterus with or without indentation, finds application in nature.

W. A. FREUND (Strassburg) agreed with the previous speaker in

that he had likewise observed that changes in the form of the uterus might lead to the origin of face positions. But in his cases the changes were in the lower segment, of acute origin, not those of the fundus, which are congenital.

BAYER (Strassburg) had also arrived at similar results in some respects. His inquiry, whether, in the two cases mentioned by the author of the paper, the location of the placenta had been noted, and where it had been, was answered by S. to the effect that in one the placenta was situated in the horn not occupied by the breech. B. himself had had opportunities for observing face positions, in which the placenta was situated in one tubal angle, which was much thinned, while the breech occupied the other cornu. In the lower cervical portion a peculiar spastic stricture was found. Owing to the attachment of the placenta in the tubal region, and the consequent expansion of the latter, the uterus assumes an arcuate form, which disappears post partum. B. would not maintain on principle that this location of the placenta is of causal importance for face position. Otherwise he refers to his paper published in the Gynækologische Klinik, edited by Freund, particularly the chapter on face positions with strictures of the cervix. LOEWENTHAL (Lausanne) read a paper on

SOME FACTS LEARNED DURING ARTIFICIAL SUPPRESSION OF THE MENSTRUAL FLOW.

In the following remarks L. aims to give some practical illustrations of his paper on menstruation. He first discussed the modus of the suppressio mensium. If the old method, rest in bed and injection of hot water, is to be effective, special regard must be had that the injected water is hot enough (i. e., 50° C. or 122° F., and rather more), and reaches the vagina in the same state. L. has observed that water of only 46-47° C. (115-117 F.) acts no longer hemostatically, but on the contrary, like luke-warm water, permitting hemorrhage. It is necessary, moreover, that rest in bed should be maintained, even for some time after the cessation of the hemorrhage. In some cases, though they are rare, hot water has no hemostatic effect at all; then the flow will disappear on the application of ice-water. This experience has also been confirmed by an American physician.'

The material at L.'s disposal at present comprises twenty-three cases, which he has had under observation for some time. Of these, eighteen were cases of pronounced chloro-anemia, with very troublesome nervous sequels, such as grave nervous dyspepsia, hysteroid general symptoms, hysterical convulsions, and two cases of hystero-epilepsy. Of the remaining five cases, two were of grave hysteria, three convalescents after exhausting diseases. In these latter, only a shortening of the convalescence and a more rapid return of strength was aimed at, and was attained. In the eighteen chloro-anemic patients a remarkably rapid improvement occurred without further medication, generally after the first suppression; recovery ensued in the period from after the second to

'P. F. Mundé, "Minor Surgical Gynecology," 2d Ed., 1885, p. 150.

the eighth suppression. Of the two hysterical patients, one was greatly improved; not so the second, but in this case the suppression was instituted without any real indication, as the last resort, after years of other and ineffectual treatment.

In all these cases, the nervous, dyspeptic, and hysterical symptoms had appeared after the occurrence of the menses, generally long after, and had exacerbated after each menstruation. In some cases, childbirth, abortions with profuse hemorrhages, and in two cases typhoid fever, were the first cause of the disease, which was kept up or made worse by the menstruation.

L. has never observed untoward accidents in artificial suppression of menstruation. He is desirous of finding some simpler method for its production, because rest in bed is unwillingly maintained by most patients, and hot-water injections are often made insufficiently when not supervised by the physician.

NIEBERDING (Würzburg) has observed suppression of the menses to occur after prolonged intrauterine employment of tincture of iodine, and that not once only, but repeatedly. The patients suffered in consequence various symptoms, especially dysmenorrhoic pains and disturbances of the general health, symptoms of congestion, etc. N. decidedly opposes the opinion expressed by Loewenthal that in these cases we had to deal, not with sequels of menstrual suppression, but with concomitant phenomena of a metritis, which possibly may have been heightened by the injection of iodine. The uterus and surroundings were not sensitive on pressure, and there were no inflammatory symptoms. The dysmenorrhoic pains had been the most important.

KUGELMANN (Hannover) stated that he had used hydrastis canadensis for the suppression of the menses with good effect, sometimes with the addition of tincture of iodine. It is strange that some women lose more blood during menstruation when at rest in bed than when they are about. As regards the indications for the suppression of menstruation, K. thinks it to be very important that they should be more sharply defined. In all nervous conditions, the effect is by no means a good one. Thus it happens that in hysterical patients the affection becomes worse after the suppression of the menses.

LOEWENTHAL (Lausanne) stated again that he had never observed pains, sensibility to pressure of the uterus, or other disturbances of any kind after suppression by means of hot-water injections. In reply to a question previously directed to him by Kugelmann, he stated that he pleads not only for the suppression of excessive, but also of the normal menstruation, especially in chloro-anemic women and those in whom morbid symptoms, of the kind mentioned, occur or become worse with or in the train of menstruation. Thus in hysterical patients he endeavors to suppress the menses only when hysterical attacks occur always after them or when chloro-anemia is present.

DOEDERLEIN (Erlangen) read a paper on

ANESTHESIA BY NITROUS OXIDE WITH OXYGEN.

After giving a comprehensive historical review of the employment of nitrous oxide or laughing-gas as an anesthetic, and ex

plaining the danger of asphyxia connected with it, which can be avoided by an admixture of oxygen, as has been shown by the experiments of Best and Klikowitsch, the author describes the mode of preparing the two gases in use for the past year in the obstetric clinic of Erlangen, as well as the apparatus employed. The nitrous oxide gas is procured by heating pure nitrate of ammonium to 215° C.; the oxygen is prepared from manganese and potassium chlorate. As the latter contains poisonous admixtures, it requires a process of purification, which is effected by passing the gas in part through a fifty-per-cent potash lye, in part through Bunsen's wash-bottles filled with English sulphuric acid. The mixture of the two gases takes place in a large gas-holder of two hundred and fifty litres capacity, from which it is conveyed, in pipes, to the parturient ward along the wall at the height of the bed. The mixed gases are employed in the Erlangen clinic generally only in the second stage, during which the pains of the patient reach the highest degree. Despite continuous inhalation for from onehalf to one hour, no cumulative effects or threatening symptoms were observed.

The sensations during the narcosis-D. has had it repeatedly instituted on himself—are not disagreeable. They consist first in a peculiar prickling feeling passing through the body, slight darkening before the eyes, and in a vivid mental activity standing in marked contrast to the lethargic, somnolent state of the body, but especially in an anesthesia which is at first incomplete, and later becomes complete. In most parturients, ten to fifteen inhalations, according to their depth, sufficed to quiet them without any phase of excitation, and even to cause them to sleep. Usually there is no consciousness remaining. although the patients react to calls, that is to say, promptly answer questions. Restored to consciousness by a few breaths of ordinary air, most of them know nothing of what has happened. Herein, however, the individuality plays a decided part. In about sixty cases it was not possible to demonstrate any influence of the narcosis on the frequency and effect of the pains, or a retardation of the labor. Sometimes the latter was even hastened by a very energetic bearing down. In operations such as versions, in which a relaxation of the uterus is desirable, the gas will not be appropriate, because the pains continue. But in normal labors and such manipulations as do not require any remission of uterine activity, D. feels impelled to strongly recommend the mixture of nitrous oxide with Oxygen for the mitigation of pain. It is also applicable to labors outside of institutions. The Erlangen clinic possesses a rubber balloon of about two hundred litres capacity (made by Metzler & Co., Munich) which can be inflated with the mixed gases, and thus transported.

The author sought to ascertain the influence of the gas on the cardiac activity, as well as its action on the blood by an experiment