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SEATON, WILLIAM H.-Indianapolis (1873-1899). S. T. 1900, 336.

SEVERANCE, LA GRANGE.-Huntington (18391893). S. T. 1893, 256.

SEXTON, HORATIO G.-Rushville (1796-1865). Born in Andover, New Hampshire, Jan. 21, 1796. See Physicians of Rush County, Vol. ii, p. 202.

SEXTON, MARSHALL.-Rushville (1823-1892). S. T. 1892, 286. Son of the above. Born, lived and died at Rushville. Was surgeon for some months of the Fifty-second Reg. Ind. Vols. Was elected president of the State Medical Society in 1881 and presided in 1882. He contributed the following papers to the State So

SHIPMAN, NORBOURN N.-Seymour (1829-1902). S. T. 1902, 423. He contributed an article on "Preternatural Sleep," Trans. 1892, 146.

SHIRTS, ELMER.-Bloomfield (1861-1908). J. I. S. M. A., Vol. i, 112.

SHIVELY, JAMES S.-Marion (1813-1893). S. T. 1893, 260. He was born in Morgantown, Va., April 8, 1813. After due preparation for the practice of medicine he located in Marion, where he remained until his death. He was respected and honored by all. He was four times elected to serve his constituents in the State Legislature. To him, as joint senator, the profession is indebted for the present law governing the practice of

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ciety:

ISAAC M. ROSENTHAL.

"Case of Dislocation of Femur Upward and Backward, Reduced by Manipulation," Trans. 1869, 31; "Rupture of the Uterus and Vagina, Case Recovery," Trans. 1873, 107; and "President's Address, Boards of Health, Medical Legislation, and the Rights and Duties of Physicians Under the Law," Trans. 1882, 1. He is said to have been the first white male child born in Rushville and the first graduate of medicine in Rush county. See memoriam, I. M. J., Vol. x, 182. SHELLHAMER, CAREY.-Pioneer (1845-1907). S. T. 1907, 494.

SHIDLER, ARTHUR L.-Lakeville (1860-1899). S. T. 1900, 337.

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the same city, March 25, 1899. He was a graduate of Asbury (Greencastle) College. Graduated at one of the medical schools of Philadelphia. He was one of the members of the Medical Convention of 1849.-Mrs. Olive E. Sinex, Indianapolis, daughter-in-law.

SKIFF, CLARK.-Selma (1826-1888). S. T. 1889,

212.

SLOAN, GEORGE W.-Indianapolis (1835-1903). S. T. 1903, 354. A native of Pennsylvania, he came to Indianapolis as a child in 1837, and remained there until he died. He was not a practicing physician, but was a lecturer on pharmacy in the Indiana Medical College, and in 1879 and 1880 was president of the American Pharmaceutical Society.

He was a first lieutenant in Company B, 132d Reg. Ind. Vols., in the Civil War. See biographical sketch. I. M. J., Vol. xxi, 399; also, ib., Vol. xxii, 246.

SLOAN, JOHN.-New Albany (1815-1898). S. T. 1898, 392. Dr. Sloan was born in Westbrook, Maine, Sept. 15, 1815. Graduated at Bowdoin College in 1837, and located in New Albany in 1838. Here he lived until the date of his death.

"His was a long career. He was in active practice before the days of anesthetics, when calomel was the cure-all and blood-letting a 'fine art.' He was in the prime of manhood when the Civil War came and gave a new impetus to the study of surgery. The afternoon and evening of his life witnessed the advent and continuance of the antiseptic era.”—Dr. E. P. Earley.

He was present at the formation of the State Society in 1849, and at that meeting was erroneously accredited to Crawfordsville. See I. M. J., Vol. xvi, 414.

SMITH, ANDREW J.-Wabash (1830-1900). I. M. J., Vol. xix, 284.

SMITH, HUBBARD M.-Vincennes (1820-1907). Dr. Smith was well known as a physician, writer and educator. Following his graduation in 1847 he located in Vincennes, where he commenced the practice of medicine, and continued the same until his death. He was the first physician in Vincennes to recognize the presence of cholera in 1849.

He was among the first to champion the cause of Abraham Lincoln for President, through the columns of the Vincennes Gazette, in 1860, and was made postmaster at that place from 1861 to 1869.

Dr. Smith contributed an interesting article on "Medicine in the Northwestern Territory; A Contribution to the Early Medical History of Indiana," Trans. 1906, 438. This article was reproduced in the columns of this JOURNAL, February, 1909, 52. He was a poet of no mean order. A collection of his poems entitled "At Midnight and Other Poems" was published in book form by Carlin & Hollenbeck in 1898. His last contribution was "Historical Sketches of Old Vincennes."

He believed it to be his patriotic duty to take an interest in the affairs of his city, his state, and his nation on all matters of public interest, and he did so. For biography see JOURNAL OF THE INDIANA STATE MEDICAL ASSOCIATION, Vol. i, 29. Also, American Biographical History of Eminent and Self-made Men of the State of Indiana, 1880, Second District, p. 32. A letter, I. M. J., Vol. xxv, 462. See poem, "Conscience," I. M. J., Vol. xvi, 316.

SMITH, JOHN W.-Gosport (1830-1903). S. T.

1903, 355.

SMITH, LESTER F.-Brazil (1883-1907). S. T., 1907, 477.

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surgeon of the 161st Reg. Ind. Vols. in the SpanishAmerican War. Was accidentally killed by an express train near Delphi, Dec. 29. 1900. See I. M. J., Vol. xviii, 315.

SMYTHE, GONSOLVO C.-Greencastle (1836-1897). S. T. 1897, 354. Dr. Smythe began practice at Fillmore, near Greencastle, in 1860. He entered the army in 1862, as assistant surgeon of the Forty-third Reg. Ind. Vols., and served until the close of the war, when he began practice at Greencastle. In 1879 he was elected to the chair of Medicine and Sanitary Science in the College of Physicians and Surgeons at Indianapolis. In 1890 he was elected president of the State Medical Society. He contributed a number of papers to the State Society: "Acute Articular Rheumatism," Trans. 1888, 33; "The Hydro-therapeutic Treatment of Typhoid Fever," Trans. 1889, 60; "President's Address; The Influence of Heredity in Producing Disease and Degeneracy, and Its Remedy," Trans. 1891, 1, and "The Treatment of Alcoholism," Trans. 1895, 338. He was also a frequent contributor to medical journals. He is the author of a book on "Medical Heresies. Historically Considered," a book of 228 pages, published by the Blakiston house in 1880. It is claimed "that he was the first physician in America to use the hypodermic syringe." See I. M. J., Vol. xv, 382.

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SPANN, BENJAMIN F.-Anderson (1830-1894). S. T. 1894, 225. See I. M. J., Vol. xii, 329.

SPARKS, JAMES B.-Carthage (1833-1895). S. T. 1896, 253.

SPINNING, JOHN N.-Covington (1822-1890). S. T. 1890, 162.

SPURRIER, JOHN H.-Rushville (1829-1902). S. T. 1902, 424. He was assistant surgeon of the Sixteenth Reg. and later surgeon of the 123d Reg. Ind. Vols., serving in, the latter to the close of the war. STAGE, LEWIS J.-Vallonia (1828-1880). 1882, 195.

S. T.

STANTON, D. S.-Portland (1822-1906). S. T. 1907, 487.

STARR, ILER D.-New Albany (1874-1899). S. T. 1900, 338.

STEELE,

T. - Waveland (1834

ARMSTRONG 1884). S. T. 1887, 187. STEELSMITH, JOHN M.-Boone county (18251900). S. T. 1900, 339.

STEPHENSON, JOSEPH.-Pendleton (1819-1886). S. T. 1886, 213.

STEVENS, BENJAMIN C. - Logansport (18501908).

STEVENS, OLIVER P.-Maxinkuckee (1820-1888). S. T. 1888, 214. Formerly practiced at Kendallville, removed to Wisconsin, and during the Civil War was surgeon of the Forty-second Reg. Wisconsin Vols. At the close of the war he returned to Indiana.

SUTTON, GEORGE.-Aurora (1812-1886). S. T. 1886, 219. Dr. Sutton was born in London, England,

June 16, 1812, and came to America with his parents when young (1819). Graduated at the Ohio Medical College in 1836, and the same year began the practice of medicine at Aurora. In the spring of 1843 he was instrumental in organizing the first county medical society in Dearborn county. He joined the State Medical Society in 1852, and was elected its president in 1869 and presided in 1870. The State Transactions contain the following papers from his pen: "A Report

to the Indiana State Medical Society on Asiatic Cholera as it Prevailed in This State in 1849-50-51-52," 1853, 109; "Preliminary Report on Milk Sickness as it Prevails Within the State of Indiana," 1853, 176;

"Report on Erysipelas," 1856, 41; "Report on Cholera,"

1867, 85; and 1868, 51; "President's Address: Man's Power Over Nature, and Medicines as Means by Which He Aids and Controls the Laws of Life," 1870, 1; "Report on the Diseases of Indiana for the Year 1872, with a Brief Outline of the Medical Topography and Climatology of Different Localities," 1873, 61; "A

GEORGE SUTTON.

Report on Trichinosis, as Observed in Dearborn County in 1874," 1875, 109; "On the Reduction of Dislocation of Hip-joint by Manipulating the Femur as a Lever Over a Fulcrum Placed in the Groin," 1876, 139; "Placenta Prævia," 1878, 111; "Parasites, and Their Effects Upon the Human System," 1883, 53, and "A Review of the Epidemics That Have Occurred in Southeastern Indiana During the Last Fifty Years, and the Observations on Change of Type in Our Endemic Malarial Diseases," 1885, 104. Every one of these reports was prepared with extreme care and all are valuable. Under the head of "Epidemics," I have referred to the valuable paper of Dr. Sutton, "Remarks on an Epidemic Erysipelas Known by the Popular name of 'Black Tongue,' which prevailed in Ripley and Dearborn Counties, Indiana," Western Lancet, November, 1843. This whole article was reproduced in "Nunneley on Erysipelas," ed. 1844, 95. Various other medical papers, as well as articles on scientific subjects, have been contributed from time to time by Dr. Sutton. For biography see Robson, 293; Stone, 686; Am. Biographical History of Eminent and Self-made Men of the State of Indiana, 1880, Fourth District, 65.

(To be continued.)

OCCIPITO-POSTERIOR POSITIONS.

B. F. KUHN, M.D. ELKHART, IND.

From observation and experience I am led to believe that occipito-posterior positions are more prolific for trouble and anxiety for the obstetrician than any other one abnormal condition that might be named. Not that they are so difficult to manage, but owing to the fact that they are frequently unrecognized, and when the forceps are resorted to, an attempt to deliver the child as a normal case proves futile and often disastrous to both mother and infant.

Requiring, as they frequently do, the use of the forceps, it becomes absolutely necessary that the physician understands the correct mechanism of delivery that he may terminate it with ease and safety rather than have it result in serious injury and perhaps death to the child, and great damage to the birth canal of the mother.

That we may have an understanding of its relative frequency a little review of the following may be advantageous.

Of all labors at full term, about 96 per cent. (96.97, Williams, p. 184) are cases in which the occiput presents. Of these, 70 per cent. are L. O. A., which is considered the normal position. Another 10 per cent. occupy the R. O. A. position and are probably delivered as easily as the former. This leaves 20 per cent. occupying posterior position at the beginning of labor. Of this number, 17 per cent. occupy the R. O. P. and but 3 per cent. the L. O. P. position. This makes 87 per cent. occupying the right oblique diameter and but 13 per cent. occupying the left oblique.

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Of the 20 per cent. occupying posterior positions by far the greater number will rotate to an anterior position and labor terminate normally, but the duration will be longer and the suffering severe owing to the greater rotation required to bring the occiput anterior. In normal anterior positions the head must rotate 1% of a circle, while in posterior positions it must rotate %. Varnier compared a great number of cases and found posterior position prolonged labor on an average of three hours and sixteen minutes in primiparous and one hour and fifty minutes in multiparous women.

There is reason to believe that more than 20 per cent. occupy posterior positions, as rotation. forward may occur before the position is diagnosed. Michaelis of New York found 30 in his last 100 cases. A certain number will fail to

Read at the meeting of the Elkart County Medical Association, held at Nappanee, Ind., Oct. 7, 1910.

rotate anteriorly, but instead will turn backward and will remain persistently in the hollow of the sacrum until delivered or labor is arrested. Even in this position at least the majority of cases will be delivered by the natural forces if given sufficient time. Varnier notes 30 out of 35 cases in which spontaneous delivery occurred. I am at a loss to understand Varnier's statistics on this point unless it was due to most of his cases being premature and small in which it is possible for labor to terminate without aid, as my own observation leads me to believe that but a small number would get through without instrumental assistance. However, we must bear in mind that if left to themselves to either terminate the labor or die in the attempt some seemingly hopeless cases would get through, as Nature will accomplish wonders sometimes.

Obviously the number requiring assistance will depend on the disposition and propensities of the attendant. And where the obstetrician is not skilled in the use of the forceps it probably is best to leave it to Nature and let the woman suffer it out unless it is seen she will die in the attempt. At the present time there is no doubt in my mind that there is a legitimate field for the use of the forceps for no other purpose than to save the mother prolonged suffering, and these occipito-posterior positions will furnish most of the cases of this kind.

Varnier observed posterior rotation in 2 per cent. of cases, West in 3 per cent., Williams in 8.79 per cent., and Edgar in 4 per cent.

Various causes are supposed to play a part in bringing about posterior positions. In the first place the anterior curve of both the spinal column and the anterior abdominal wall holds the uterus in a state of partial flexion and the fetal body with the head flexed and the limbs folded up, having a somewhat semilunar shape, tends naturally to adapt itself to the curve which usually throws the back of the child to the front and the head, settling in the pelvis, assumes one of the oblique diameters. When for any reason the uterus is devoid of the usual curve the child will, of course, be liable to assume some other position.

An excessive amount of liquor amnii is supposed sometimes to play a part in the causation. As to the cause of posterior rotation, imperfect flexion is supposed to play the principal rôle, acting by allowing the anterior part of the head or bregma to first come in contact with the pelvic wall or floor and being rotated forward throws the occiput in the hollow of the sacrum.

A relaxed or lacerated pelvic floor may be the cause, as it fails to furnish the necessary resistance to rotate the occiput forward.

A very roomy pelvis may be the cause by acting in the same way. Again, the fronto-occipital diameter may be so firmly engaged in the oblique diameter of the pelvis that anterior rotation is impossible.

The diagnosis of this condition is sometimes very easy and at others very difficult, and there is no doubt that it is frequently overlooked, the case going on and terminating by anterior rotation without the accoucheur ever suspecting the cause of the protracted labor.

External palpation of the abdomen is very helpful in determining the condition, showing the feet and arms forward and not the back as should be the case. should be the case. The heart-sounds may be heard in the flank on the side corresponding to the back of the child.

The pains in the first stage of labor are frequently irregular and abnormal. By vaginal examination the head may be felt through the fornices, and after dilatation the small fontanelle will be found in the posterior part of the pelvic cavity with the sagittal suture running in the line of an oblique diameter. The presence of the dilating os far back in the pelvis is suggestive, and Michaelis says that one will rarely go astray in diagnosing a posterior position from early rupture of the membranes and the slow dilatation of the os. Notwithstanding all this, there are cases that are very difficult to recognize, for it must be borne in mind that it is not always possible to be absolutely sure which fontanelle we are feeling or know to a certainty the suture we have discovered is the sagittal. With the patient under an anesthetic preparatory to applying the forceps, palpation can be carried out more satisfactorily and the position made out with more certainty. Under the most favorable circumstances, the information to be derived from vaginal touch alone is not more accurate than that obtained by abdominal palpation, and in vertex presentations the fontanelles are not infrequently mistaken for each other, and occasionally breech and face presentations escape differentiation. Moreover, in the latter part of labor, after the formation of a fluid tumor beneath the skin covering the presenting part, detection of the various diagnostic points often becomes impossible. The introduction of the gloved hand into the vagina and passing it alongside the head until the ear or face is palpated will make it certain, and where there is any doubt this should always be done, as it will make the application of the forceps easier and also enable one to know which way rotation should take place.

TREATMENT.

As to the possibility of having the mother carry out any postural treatment during pregnancy that would correct a faulty position there is great doubt, but there seems to be grounds for the belief that posture during labor may be of help. As soon as the condition is recognized the patient should be made to lie on the side towards which the child's back is directed. This is said to favor flexion and cause the occiput to rotate forward. Having the patient kneel at the bedside is said also to favor rotation.

The natural forces aided by posture failing, it devolves on the obstetrician to decide when it is advisable to resort to further measures.

In some cases it is possible by inserting the whole hand into the vagina to grasp the head with the thumb and fingers and rotate the occiput anteriorly. When attempting this maneuver advantage may be taken of the opportunity to pass the hand up back of the head or at the side so as to feel the ear, the neck or the face to determine definitely the exact position.

Rotation with the hand, it will be found, can be carried out in but a very limited number of cases, and when it is found to be impossible the forceps should be applied, and in doing so there are several methods of procedure that are to be considered. First, that usually followed in Germany and Austria of applying the forceps to the sides of the pelvis, irrespective of the head, and making no attempt whatever to rotate the head to an anterior position. Occasionally the head will rotate during delivery, but this is rather unusual. It is said that in the countries where this is the practice the number of episiotomies and severe perineal lacerations are exceedingly large.

The second method consists in applying the forceps as before and attempting to rotate the head at the same time traction is made, the usual practice in America. In this procedure the forceps frequently slip and injure the head or damage the maternal soft parts. In addition to losing their grasp, the forceps are prone to rotate ou the child's head, instead of turning it, and in so doing are very liable to do it injury.

The third method is what is known as Scanzoni's maneuver and consists in the double application of the forceps. The first step consists in applying the forceps to the sides of the child's head, with the curve looking forward or toward the child's face, and in the second application with the curve to the occiput.

Williams of Baltimore is said to be the chief advocate of this procedure in this country, and says that his experience has been so satisfactory that he has ceased to dread occipito-posterior

positions, feeling that when necessary delivery can be readily and safely accomplished.

Edgar advises the pelvic application of the forceps in high cases and bringing them down, then reapplying the forceps and rotating to an anterior position.

The procedure as given by Williams is as follows, applying it to the R. O. P., which, it will be remembered, constitutes over fourfifths of the posterior positions: The right hand is passed into the left posterior segment of the genital tract and the right or posterior ear sought for. Over it the left blade is applied. The left hand is then passed into the right side of the vagina, and over it is introduced the right blade, which is then rotated anteriorly until it comes to lie opposite the blade first introduced.

The forceps are then locked and downward traction is made until the head impinges on the pelvic floor, when a rotary motion is imparted to the forceps by which the occiput is slowly rotated to right transverse, and later on to an oblique anterior position.

The forceps, having become inverted, must be taken off and reapplied in the usual manner to the head, which now occupies a right anterior position when delivery is readily accomplished.

A few practical points should be borne in mind. that will aid very materially in the various steps of this procedure; one is that where difficulty is experienced in introducing the blade of the forceps if the hand is introduced into the vagina the difficulty can readily be determined; another is where the blades refuse to lock a rotation of one or both blades, accompanied by an up-and-down motion, will cause them to adapt themselves to the sides of the head so as to bring the locks in apposition. Another is where one blade cannot be inserted as far as the other, as when an attempt is made to lock them the locks will not meet by about two to two and a half inches. This usually means that one blade is around the occiput and against the neck and should suggest the changing of the blades to a new position. In rotating the head the handles of the forceps. should be given a long sweep so as to avoid bringing the blades in forcible contact with the pelvic wall and so doing the mother serious injury. While making traction the forceps should never be rocked backward and forward, as this will cause the extreme ends of the blades to cut the child's head and will not aid in extraction. In exceptional cases, in which the pelvis is so completely filled that the most thorough examination leaves some doubt as to the exact position, and consequently one is at a loss to know which way to attempt to rotate, I have resorted to a little

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