The occiput is to 4. L. O. P. Left Occipito-Posterior. the left and posterior in relation to the left sacro-iliac joint, and the long diameter of the head is in the second oblique. This is by far the least frequent of the positions and most often causes prolonged labor. Just why it is less frequent than the third position is not easy of explanation. The following facts seem to explain the cause: The uterus is generally more on the right side of the abdomen, i. e., to the right of the vertebral column. This leaves the left posterior quadrant of the uterus smaller than any of the others, because of the projection of the vertebral column into it. When the long diameter of the head is in the first oblique the promontory has no effect, and when the long diameter is in the second oblique and the occiput is anterior, i. e., in the R. O. A. position, the promontory does not interfere with the narrow face as it does with the broad occiput in the L. O. P. position. The Position of the Fatal Back.-The position of the fœtal back depends somewhat upon the position of the mother. When the mother is in the dorsal decubitus the back of the fœtus, whatever the position of the occiput at the inlet, tends to he toward the back of the mother because the vertebral column tips the fœtus to the side. The Positions of the Other Presentations. The position of the other presentations will be described under Abnormal Obstetrics. THE X-RAY TREATMENT OF URETHRAL CARUNCLE* By G. H. STOVER, M.D. The X-ray is now so well established as a remedial measure in a large number of pathological states that one who devotes himself exclusively to this line of work would have too many interesting cases for a single paper if he attempted to go over the work done since your last meeting. I therefore consider it more suitable, instead of a general paper, to speak of the treatment of a most intractable condition by a new method; I am not aware that any other radiologist has treated urethral caruncle by the x-ray. *Read before the Rocky Mountain Inter-State Medical Association, September, 1904. This is a most painful and annoying affliction, and one that seems very apt to return after surgical treatment. These extremely sensitive tumors, with a bright red surface, just at the meatus urinarius, are easily recognized, and no other similar condition in this region gives rise to so much pain; by this alone they may be differentiated from other affections of this locality, prolapse of the urethra, etc. The fact that these growths are quite vascular led me to believe that the x-ray, with its well known action in causing an obliterative endarteritis, should be a rational and scientific method of treatment. My first case is that of patient No. 122. The tumor first appeared fifteen years ago, and the original growth and two recurrences have been removed by the knife. When this patient consulted me there was a tumor the size of a finger end, very red and tender and inclined to bleed easily, It was so painful that she could not sit in a chair comfortably. Twenty-five x-ray exposures were given, using a tube of medium low vacuum, at a distance of five inches from the growth, the seances lasting ten minutes each. The size of the growth diminished after the fourth or fifth exposure, and the pain became gradually less. When the patient discontinued treatment she had no more discomfort, the surface did not bleed, and it has taken on the appearance of normal mucous membrane; there was still some thickened tissue present. The other patient was No. 127. The tumor had been removed by the knife some six years previous to her visit to me; it soon recurred and has remained sore ever since, causing a great deal of pain in walking and during urination. Only six exposures were needed; as this sore was quite superficial, a tube of fairly low vacuum was used, at a distance of six inches, with ten minute seances, during a period of about three weeks; after the fourth exposure the patient stated that she had no more pain or soreness. These results are of course very gratifying, but a considerable time must elapse before I will say that they have been cured. CHARCOT'S JOINTS.* By BYRON C. LEAVITT, M.D. Upon January 28th, 1904, I was consulted by a man, aged forty-two, both of whose ankles were swollen, the right knee being also swollen, and in a condition of knock-knee. Until February 1902 he had never had any trouble with his joints. At that time he retired at night as well as usual, and slept well all night. When he awoke his right knee was as large as his head, but was not painful or sensitive to the touch. About three weeks later swelling appeared suddenly in his right ankle, and four weeks after this in the left ankle. This condition had remained ever since the size of the swellings considerably diminishing. There had never been any sensitiveness to touch. sensitiveness to touch. There had been intermit tent painful periods, especially at times of storms or threatening of storm, this being at localized spots, anywhere from the knee to the ankle on the right side, or in the left foot. The history and general appearance excluded osteo- and rheumatoid arthritis. I learned that the diagnosis of sarcoma had been made over a year before I saw him, and a very competent surgeen had then told him that he would have to have an amputation at once, to save his life. As he had lived this length of time with no great change, it was evident that this disease could be eliminated from the diagnosis. I took X-ray pictures of the swollen joints, which I have to show. The condition of knock-knee is evident in the right knee; also the proliferated bony tissue, and the loss of the ligamentous tissue in the ankle joints. This appeared so evidently a case of Charcot's joints that I immediately examined for symptoms of locomotor ataxia, and found Argyll-Robertson pupils, loss of knee-jerk, inability to stand with the eyes closed, a history of shooting pains, and nearly all the typical symptoms of that disease. The patient remained in about the same condition until July of this year, when he suffered much more severe pain in different parts of the body, lost control of his bladder and bowels, and died the last of that month. *Read before Rocky Mountain Inter-State Medical Association, September, 1904. The most trouble was with the knee, and a support for this was advised, but the patient kept neglecting to have it attended to. Excision was not advised because of the tendency of the bones not to unite in this disease. Bradford and Lovett state that in this disease "the cartilage disintegrates, the ends of the bones are exposed and may be rapidly worn away, the synovial membrane and the ligaments thicken and ulcerate. This process may result in spontaneous luxation, in severe cases, synovial effusion may be present, and suppuration may occur. Hypertrophy of the epiphyses may take place as well as the formation of osteophytes, but atrophic changes predominate. The essential character of the affection is the rapid melting away of cartilage and bone. I have written this paper in the form of a report because I was so much interested in the case, and because it seems to me to be sufficiently typical of Charcot's joints to bring out clearly the landmarks of a disease which is but slightly mentioned in textbooks and yet which quite frequently accompanies locomotor ataxia, as well as other diseases of the nervous system. PERNICIOUS ANEMIA, WITH A REPORT OF CASES.* By J. N. HALL, M.D. Denver, Colo. I have recently had the opportunity of studying eight cases of this disease rather closely and believe the results of this study and of the treatment will be of some interest. I an am indebted to my associate, Dr. H. R. McGraw, for much painstaking work in the study of the blood, and to Dr. R. W. Arndt for permission to report two of his cases which I saw with him at the Denver City and County Hospital. Seven of the cases were males between the ages of 30 and 53 and one was a woman of 70. Two were physicians, three were ranchmen, one a laborer, one a smelter-man, while the woman was a housewife. I shall give a brief synopsis of each, with comments upon it. Case 1. A physician of 34 years, from an Eastern state. Tuberculosis of the left apex with hemoptysis five years ago. Full recovery. He had previously lost his right forefinger from septic infection. Three years ago he became anemic, and his blood count at that time showed 1,700,000 reds, 2,000 whites, 37% hemoglobin. HCl. was noted as absent at this time. Without a definite diagnosis he came to New Mexico, and immediately improved, his reds rising to 4,000,000, and his hemoglobin to 70%. He relapsed and came West again a year ago, with some improvement. He was able to work moderately in the intervals. Upon examination I found his temperature running to nearly 100° daily. Reds 3,000,000, hemoglobin 55. Nucleated reds present, marked poikilocytosis; no parasites found in stools. No increase of eosinophiles. Liver slightly enlarged. Teeth sound. Marked venous hum in neck. Notable pulsation in vessels of neck, Soft apical murmur transmitted to left. Heart area not increased. No edema. Urine rather dilute, but contained no albumin nor sugar. The nervous system showed nothing abnormal excepting slight numbness of fingers and toes, which had been present for some months and was evidently not the effect of arsenical medication. *Read before the meeting of the Rocky Mountain Inter-State Medical Association, Denver, September 6, 1904. |