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coccus Mucosus, and the relatively high percentage of such cases requiring operative interference. In fact it has been found that capsule coccus otitis leads to mastoiditis and intracranial complications far more frequently than do the more common pus producing organisms. On the other hand Streptococcus Pyogenes infection is, according to these investigators, less virulent as a producer of mastoid complications, than has hitherto been supposed.
The structure of the mastoid plays a more important role in the causation of otitic sequelae than do either of the two factors above mentioned. For every acute otitis is an inflammatory disease of the entire continuity of the pneumatic cells and is productive of an exudate which serves as an excellent culture medium for germ propagation. For this reason the pneumatic mastoid is most prone to bone complications while the diploetic, by virtue of its rich blood supply, and the sclerotic, because of its dense consistency, are practically immune. Unfortunately we possess no method of diagnosing the nature of mastoid structure, but we are justified in suspecting a pneumatic condition when severe pain over the mastoid is a symptom of the onset of the disease.
While the anatomy of the mastoid is the principal cause of the extension of the morbid process, the nature of the infection is the determining factor in the subsequent course of the disease. When otitis, caused by the ordinary pus organisms, leads to mastoid involvement the process is an uninterrupted one, but when incited by the Streptococcus Mucosus, the disease progress is characterized by remissions or even intermissions. In fact, the entire course of capsule coccus infection is an insidious one. During the first or second week of the disease there appears to be a partitioning of the inflammatory process in the tympanum. Marked diminution of hearing persists with tinnitus and the membrana tympani presents the picture of a secretory catarrh. It appears moist and of a reddish hue, its light reflex not sharply outlined. There is no pain at this stage, merely a slight sensitiveness on firm pressure over the mastoid. Paracentesis shows the presence of the slimy or muco-purulent discharge. The disease remains in this stage until the progressive involvement has reached a vital structure or has become manifest externally. The tissue destruction disclosed when the mastoid is opened will be found to be out of all proportion to the mildness of the symptoms manifested. So slight may be the patient's discomfort as to leave him unaware of the presence of disease until intracranical complications set in.
822-824 Rose Building
BY WARREN C. MERCER, M. D., PHILADELPHIA, PA.
This subject and these positions are very important to every physician who does obstetrical work.
It is not my intention to write a lengthy paper, but to refresh your memory with these positions and their management during labor.
So as to thoroughly understand the mechanism the head goes through in posterior positions, I must go back to some observed facts or truths.
According to some authorities we have what is spoken of as two positions the first and second, i. e., the inlet or any plane from the inlet to the outlet is divided into two parts or halves, the left and right. Others have the planes divided into four, making four quadrants of the bony berth canal.
The former making only two positions of this canal the first and second. The left position is when we find the occiput in any part of the left side of the pelvis. Right position the occiput occupies any part of the right side of the pelvis. The latter dividing the pelvis canal into four quadrants. We have left anterior the first, position making L. 0. A. Right anterior the second, position making, R. O. P. Right posterior the third, position making, R. 0. P. Left posterior the fourth, position making, L. 0. P.
Then we have two anterior positions and two posterior positions. making them occur about 80% anterior and 20% in the posterior position. This varies with different authors. The head must go through a certain mechanism for the foetus to be born, and going through this mechanism the smallest diameters of the head are engaged, and to do this the head must be normally flexed. This makes the bi-parietal and sub-occipito bregmatic diameters engage, the smallest you can get.
It makes no difference whether we have the second or fourth position, we must thoroughly understand the mechanism of each.
Anterior positions the ociput rotates through less than 90° to come directly under the pubic arch, while in posterior positions it has more than 90° and may run up to almost 180o.
As I stated before, we have 20 to 21% occuring as posterior position, this we can divide between the sides in 17% to the right and 3 to 4% to the left. This making the right the most frequent of the two on account of the rectum filling up the left side of the pelvis.
According to this then we have one posterior position occuring to four anterior. Yet, it is not all the posterior positions that gives us trouble, it is only an occasional one, this makes the percentage small.
Why is it that our posterior positions are looked at with such dread? Sometimes you hear a man say I am afraid of posterior positions. Let us investigate. In the first place do we understand the mechanism? If so, we may have forgoten it, or probably discarded it, thinking it of little use. Let us read over our text-books on this subject, and you will find that the author says little about it except to picture it as a very dangerous position. Such is the teaching the man received while in college and how can he think otherwise ?
Will his experience disprove it?
Has our experience proved the posterior position to be so dangerous ?
I guess the most of us can recall such an experience. Was it the posterior position that was so dangerous, or is it the inefficiency of the physician, or on account of the slow progress that is made in the dangerous ones, that he gets impatient, or does the family work on his sympathy or demand interference?
You may have some other patients in need of your immediate service. If it is the difficult one, you may have time to answer the call if none of the danger signals are out. You are master of the situation and should know when interference is called for and not allow outside advice to influence you, unless it is professional. If you are engaged to attend the case and have visited it, it is up to you to give it your undivided attention.
If you could go over your records I think you will find that forceps were used in a very small per cent of your posterior position, and such has been my own observation both in hospital and private practice.
We would expect labor in occiput posterior position to be longer and more tedious than anterior ones. In posterior positions the occiput has to transverse through a greater arc, which we would expect to require more time and much severer pains to make the occiput rotate under the arch.
Time is a great factor and will accomplish much if the conditions of both patients will stand it. Time and pains will cause considerable moulding of the head, and many times it is surprising the amount of moulding that will take place and without any apparent injury to the brain.
I think if we will make close observation we will find that a very few of our posterior positions are really serious cases, and these only when we have some pelvic deforinity, or a very large head, or where the head fits the pelvic canal tightly, and it may be a medium sized head in a large pelvis where there is not enough resistance offered to the head to cause it to rotate.
A poorly flexed, or in other words, a head midway between flexion and extension is very apt to occur in posterior positions; this causes the occipito frontal diameter to engage, it being a longer diameter than the sub-occipito bregmatic, which should engage normally. You know what the longer diameter will mean to labor.
Here we may give them assistance which will materially shorten some cases. First we have postural version, and by this we put the patient on her side corresponding to the side the occiput is on, by so doing the force is exerted down the spine of the child, causing flexion of the head, and by so doing aids rotation and flexion. Sometimes you can assist this rotation with your fingers by making pressure anteriorly.
Many times I have seen these manipulations work wonders in shortening labor. Of course the occiput does not rotate until dilatation is complete or until the head has descended into the cavity of the pelvis.
There are many cases that may prevent the head from rotating. Some of the most common are any type of pelvic deformities, but these deformities being mild; and rigid conditions of the material soft parts. These will cover many of them in general, so will suffice with that as it would make a long story.
We have certain definite indications for interference, and no physician is justified in interfering until he has them. They can be summed up under three, i. e., they are: danger to the life of the mother, danger to the life of the foetus, and uterine inertia. .
They can be recognized by the pulse and temperature of the mother, by the foetal heart decreasing to one hundred beats per minute. Uterine inertia is recognized by the decreasing of the frequency and severity of the uterine contractions after some time of active labor.
It has been quoted several times that modern obstetrics and the modern doctor require that the patient can not be allowed to suffer, but requires immediate delivery.
If immediate delivery, there is only one way and that by forceps, if forceps, that means more rapid delivery. This is followed by a greater number of lacerations, which may mean invalidism for life
and loss of the baby too. You may say, that will occur anyhow, so it may, but not always nor as extensive. Some advise rotation of the occiput anterior by external manipulation in the early part of the first stage, so it can, if you can gain any benefit from it. It is hard to do and many times impossible.
If the forceps are required in these positions, we have two applications to select from.
Scanzoni's manuvere and the cephalic application. Some consider them the one and same thing but they are not. Scanzoni is a double application, while the cephalic is only one.
To a certain extent the physician must have some practice or he will do a lot of damage to the material soft parts and in the meantime his technic must be perfect or infection will follow. To impress this I might quote DeLee of Chicago, who says, “How long will it be before the profession recognizes that the proper conduct of an ordinary labor case, mind you an ordinary one, requires an enormous amount of learning, acute powers of observation and great technical skill?'! How about the difficult ones?
Then to conclude, I wish to make this plea. That we each thoroughly understand the mechanism of labor. Study it in each individual case, and when the call comes for interference in whatever way it may, that we use our armamenterium to the best advatnage, following the normal mechanism, and by so doing relieve the suffering of our patient and save life at the same time.
TWO CASES OF ACCIDENTAL ABORTION AND THEIR
BY M. A. WESNER, M. D., JOHNSTOWN, PA.
Abortion is the premature expulsion of the embryo or immature ovum from the uterus at any time before the end of the sixth month of utero-gestation. These expulsions may take place at any period within the time herein mentioned, but they are by far of most frequent occurrence between the first and fourth month of pregnancy. Should they occur during the first month they are usually termed ovular; from the beginning of the second to the end of the third month, embryonic, and from the end of the third to the end of the sixth month, foetal.
* Read before the Homeopathic Medical Society of Pennsylvania, September 21, 1909.