capsule and periarticular tissue. This condition is also seen in joints stiffened from disuse. In the osseous form the immobility is due to the extreme bony deformity about the articular surfaces. DISCUSSION. DR. H. C. SHARP, Indianapolis: The study of diseases of joints has occupied much more attention of the profession in recent years than formerly. Formerly we diagnosed practically all of our joint cases as either tubercular joint trouble, or rheumatism, but the x-ray has added materially to our anatomic and pathologic knowledge of the condition of the joints. But the unfortunate thing, after all, is that we have made very little progress in the relief of pain, to cure the disease or prevent deformity. There are about as many different nomenclatures as there are writers upon the subject, but Dr. Reed informed me confidentially that this is the real thing, so we will eliminate all other known nomenclatures in the future. The great trouble in the making of a nomenclature is that while we know the pathology fairly well, and the existing condition of the disease, we are so very short on etiology. Broadly speaking, joint diseases can be divided into infectious and non-infectious, and occasionally it would appear to cover the ground. But it does not answer for all cases, and we have the non-infectious troubles which are caused by trauma or some dyscrasia, such as hemophilia, or some purely functional disease, and then there is the type associated with anatomical changes and deformities, deforming arthritis, which may be secondary to disturbed nutrition, or it may be caused by a neurotic condition, such as tabes. Then another feature of the unfortunate condition of making nomenclature is that you will find a condition in one person that to all appearances is identical with that in another, and in the one it may be due to direct trauma and in the other to a former attack of rheumatic arthritis, or in another case it may be entirely due to some disturbance of metabolism. So it makes it impossible to give a well-defined and satisfactory classification of joint diseases. I think that as far as I have had opportunity to judge, Dr. Reed's classification is about as acceptable as any, but it will be impossible for us to get a perfect classification until we know something more about the etiology of the trouble. DR. H. R. ALLEN, Indianapolis: I want to congratulate Dr. Reed on what has been a tremendous amount of work and a good classification, and on his having these printed forms here. It helps the presentation of any subject if we have an outline we can follow. He has given us the non-tubercular classification. That is a very large subject. I wish he had added to that, however, and given us the percentage of cases, as to how many were of each type as compared with tuber culous joints that we are meeting every day. That would have been a very clever demonstration, as the large part of tuberculosis shows in joint affections. You are all familiar with joints, and those of you who work with them know how many joints come to you tagged "rheumatism." I regard the rheumatic joint as one of the rarest joints known. The word "rheumatism" as applied to joints is merely a medicated swear-word. A doctor, instead of saying "damfino," merely calls it rheumatism. All hip diseases that come to the doctor from the Cincinnati district come with a red flannel bandage tagged "rheumatism." Where a man knows that the gonococcus has been at work in a nice married family, the word helps there. I have had a case recently where a clean married woman three weeks before her baby was born turned over in bed and hurt her knee slightly. It was dislocated laterally and considerably rotated. Neither the father nor the mother knew anything about venereal disease, or so they claimed. The mother admitted on careful examination that she was afraid the baby would lose its eyes from a terrible discharge, but no knowledge of the gonococcus could be extracted. I had another case a week later of so-called rheumatism of one wrist, one elbow and one ankle, favorite sites. The only information given by the patient was a series of mosquito bites. I wish some one would say there is no such thing as rheumatism, and then you would study your joints more carefully. Dr. Reed's effort here has been a general classification, and a very good one for us, because as he reads over his different classifications we are constantly applying it to a knee, a hip, or a shoulder, and it serves because it is incomplete. He has simply generalized on the subject. Each joint has its own peculiar set of injuries and peculiar manifestations. I like to see any member of this society or any other society go into the discussion of joints, because it is the largest subject we have before us, and I know it is the sentiment of every one here to regard this effort as Dr. Reed's "farthest north," and we are going to accept him, although he has not his instruments or his Esquimaux with him to prove it. TUMORS OF THE TONGUE.* We meet with benign as well as malignant growths in the tongue. The former, while not threatening life, may still require removal, because they interfere with mastication, speech and swallowing, as exemplified in the following patient: Peter B., a farmer, unmarried, and Read before the Indiana State Medical Association, at Terre Haute, Oct. 7, 1909. 27 years of age, consulted me Feb. 11, 1905, because of a growth involving the right side of the tongue, extending from a point opposite the first bicuspid tooth, backward almost to the epiglottis. He first detected it some twelve years ago, since which it has slowly enlarged until at the present time it approximates a large walnut in size. It has never bled, caused foul breath nor pained him. Upon inspection, the tumor is seen attached to the tongue muscle by a broad base and so intimately united with it that it is immovable without the tongue following. The surface is without ulceration and smooth, save for several smaller nodules which project from its lateral border, while coursing over the base of the tumor posteriorly are a number of large blood-vessels. To palpation it is hard but elastic. Feb. 15, 1905, patient was admitted to St. Mary's Hospital and operated upon under general anesthesia after the following method: The tongue was drawn forward and the base of the tumor transfixed by two needles. Inside of the needles the growth was engaged in a loop of platinum wire, connected with a cautery battery, the circuit closed, and the fleshy mass slowly severed. Very little hemorrhage followed and healing ensued without complication. There has been no return of the tumor. Microscopical examination disclosed that the growth was largely made up of fibrous tissue, so it is properly termed a fibroma. There is one form of growth that only occurs at the base of the tongue, namely, chronic enlargement of the lingual tonsil. It is most often found in persons who use their voice a great deal, such as public speakers and singers, and gives rise to a feeling as if a foreign substance is lodged in the throat with dry reflex cough. In addition, the voice easily tires and there may be a history of hemorrhage from the enlarged vessels at the base of the tongue. Recognition of enlargement of the lingual tonsil is easy with the laryngoscopic mirror. Other innocent tumors reported as found in the tongue are lipoma, papilloma, chondroma and osteoma. Of vascular growths, we meet with the angioma and the lymphangioma. The former is made up largely of blood-vessels and varies in size from the small congenital nevus to the large pulsating aneurism. The lymphangioma arises through dilatation of the lymphatic spaces and may lead to enormous enlargement of the tongue, a form of macroglossia. The color of these tumors, their soft consistency, and the fact that through compression they are readily diminished in size, but refill as soon as the pressure ceases, renders their diagnosis not difficult. Purely cystic formations may occur in any part of the tongue, but most frequently in the region of the foramen cecum. The dermoid cyst may contain hair and other tissue and develops here as in other parts of the body from embryonal tissue. Of the malignant tumors we find both the sarcoma and the carcinoma. The former, according to Butlin, is rare, and while of the latter great variations as to size, extent of ulceration, hardness or softness and rapidity with which the lymphatic glands are infected, occur, nevertheless but one form of cancer is met with in the tongue, and that squamous epithelioma. The following case is of interest, since it illustrates the progress of the disease and the result following a rather unusual plan of treatment carried out under regular medical supervision: Mr. L. B., well past the fourth decade of life and a resident of a neighboring state, was afflicted with a cancerous growth involving the left side of the tongue and extending well down to its base. The lymphatic glands in the left side of the neck were infected. Patient had consulted eminent surgeons in Chicago, who advised against an operation, because of the extensive nature of the disease. As a last resort, a so-called cancer doctor was invited to apply a paste which he positively assured the patient's family was non-poisonous and made from green herbs gathered from the hills near his home town. Our connection with the case was by request of a brother to the patient, a fellow-practitioner, and to render emergency assistance, should occasion arise therefor. July 1, 1898, after the local use of cocain, the paste was applied to the indurated ulceration, along the side of the tongue, for some fifteen minutes. The application was well borne by the patient and no untoward symptom followed. In the course of ten days a large slough separated, bringing away much diseased tissue. It was found, however, that the tumor had only in part been covered by the paste and that the left tonsil and the left side of the base of the tongue, also infiltrated by it, had gone untreated, and since the cancer doctor had returned to his home in a distant city, by request I undertook the application of the paste to these deeper parts overlooked at the time of the first treatment. Again, a large slough separated without unpleasant symptoms following the escharotic and the diseased surfaces in part underwent granulation. However, some of the external infected lymphatic glands suppurated and were incised, but the deeper progress of the disease continued unarrested and death occurred from exhaustion some five months later. The statement, however, that the paste was made solely from green herbs was not taken literally by any of us, since botany knows of no plant possessing such escharotic properties. The cancer doctor refused to impart to us the names of the plants he employed, and just what he added to them I do not know, but it was most likely chlorid of zinc. Cancer of the tongue occurs most often in persons between 40 and 60 years of age and, according to Moritz Schmidt, the initial lesion may be a blister, vesicle, ulcer, fissure, wart or a nodule embedded in the substance of the tongue. Butlin's experience is that of all the actual beginnings of cancer, the warty-like growth is by far the most frequent, and any warty-like formation on the edge of the tongue, if not destroyed or removed, will, almost without exception, later develop into epithelioma. The least frequent beginning is that as a lump or nodule situated in the depth of the muscle of the tongue. Early glandular involvement is to be expected, either in the floor of the mouth or at the angle of the jaw, or in the neck. The subjective complaint, so long as the growth is circumscribed, may be a feeling of thickness of the tongue, with effort in talking and eating. Pain with increased salivary flow and offensive breath is the rule after ulceration. Hemorrhage may then occur and become dangerous to life. The course of the disease may be stated as from one to three years with death the result of metastatic pneumonia, acute hemorrhage or from exhaustion. Diagnosis.-Local manifestations on the tongue of such infectious diseases as syphilis, tuberculosis and actinomycosis may be mistaken for malignant disease. Primary syphilitic disease of the tongue is to be thought of in young persons; it is rapid in its development and attended by early glandular enlargement, with later secondary cutaneous eruption. An unbroken gumma, when single, is easily confused with epithelioma; when multiple and found on the dorsum of the tongue, the differential diagnosis is more readily made. Careful examination of the patient, as a rule, will disclose evidences of syphilis in other parts of the body, while the administration of large doses of iodid of potash is followed by rapid improvement. The serum test and examination for the spirochete pallida may also aid one in reaching a correct diagnosis. Primary tubercular disease of the tongue is extremely rare, and is to be differentiated from malignant disease by searching for the tubercle bacillus and the reaction to tuberculin. Actinomycosis is not often mistaken for cancer, and the finding of the ray fungus will prevent an error in the diagnosis. It must not be overlooked that epithelioma may develop in an old syphilitic lesion, and it is well in all cases of doubtful diagnosis to excise a small portion of the growth under local anesthesia and have a competent microscopist report upon its pathological histology. Causation. As predisposing causes we may mention heredity, excessive smoking, irritation and wounding of the tongue through defective teeth or defective fillings. One case, in particular, I recall where the patient was most positive his trouble originated through a large amalgam filling in one of the lower molar teeth, constantly rubbing against the side of the tongue. As to the exciting cause of a malignant growth, we know next to nothing. Prognosis. This is bad, especially for cancer, since with our improved operative technic only about 10 per cent. recover. Treatment.-Benign cystic growths may be evacuated, extirpated or snared off when located at the root of the tongue. Vascular tumors may be treated by electrolysis, the cautery or excision. I have had no experience with the old method of treatment by injection of a solution of iron. For solid benign growths, excision with the knife or snare is the operation. A word of protest is in place against the indiscriminate employment of nitrate of silver or other irritative form of treatment in ulcer or wartylike growth of the tongue, since thereby the disease is frequently aggravated rather than improved. If you have decided that the growth is to be removed by destructive agent, use the thermo-cautery or the galvano-cautery from choice. For malignant disease, early excision is the operation of election and one must not hesitate to go well outside of the growth into the healthy tissue in using the knife. The x-ray is not nearly so useful in the treatment of malignant disease of the tongue as in like affections of the skin. It may, however, be carefully applied with advantage during the healing stage after operation. As a preliminary step in partial or complete amputation of the tongue for the prevention of hemorrhage, one should not omit ligation of both of the lingual arteries. This operation in persons with short and very thick neck is a difficult one, and I retain vivid recollection of a case where profuse bleeding followed wounding of the internal jugular vein in the practice of a very able surgeon. Operation upon the tongue alone when the malignant disease is complicated by lymphatic gland enlargement is not sufficient and the enlarged glands should either be removed at the time of making the primary operation or later through a secondary one. DISCUSSION. DR. JOSEPH RILUS EASTMAN, Indianapolis: Dr. Brose has treated of such a very large variety that it will be difficult, it seems to me, for any discussor to follow him over such a large field, and, therefore, perhaps you will excuse me if I select two or three phases of the subject. I was glad to hear Dr. Brose remind us again that syphilitic lesions of the tongue are extremely likely to undergo carcinomatous change. There has been a good deal of confusion upon this point. I have often heard it mooted that syphilis gave a certain immunity against carcinoma. True, we can recall very few cases of carcinoma of the tongue or carcinoma elsewhere which had been implanted upon syphilitic lesions, and, as we look back over our work, we are reminded that it is extremely rare that we find syphilitic lesions and. carcinomatous lesions to exist in the same individual. And yet I submit it only appears to be true. As a matter of fact it is not true. I am sure syphilitic lesions of the tongue are exceedingly likely to become cancerous lesions. I recall asking Koerner, of St. Thomas Hospital, in London, whether he had found carci microscopist, who can section it with a freezing microtome and give you a stained section in 12 to 15 minutes or less time. It is absurd, and it would be laughable if not so tragic, that after all the signs we wait for to tell us a neoplasm is malignant, are the signs of its inoperability, these enlarged glands, these ulcerations, etc. We wait for retraction of the nipple in carcinoma of the breast, for example, which means that the case has passed beyond the help and hope of surgery. We wait for cachexia, or constitutional dyscrasia. The patient is dead then, there is no time for anything. The time for the removal of neoplasms of the tongue, as elsewhere, is before they become malignant. That is conservatism in the truest sense. DR. L. D. BROSE, Evansville (closing):-I want to emphasize the fact that it is necessary for the recovery of your patient to practice early operative interference in these cases. The saddest part of my experience has been to find that most of these cases have been temporized with or treatment has been neglected altogether. RAPID DELIVERY IN ECLAMPSIA.* WALKER SCHELL, M.D. TERRE HAUTE, IND. The term eclampsia is applied to an affection. characterized by convulsions, with more or less complete loss of consciousness. noma of the tongue implanted on previous syphi- CESAREAN SECTION AS A MEANS OF litic lesions. He told me he was perfectly sure of it in at least twelve cases. Now I do not think it wise to temporize with any sort of lesion of the tongue which begins to take the nature of a neoplasm in any way. Syphilitic lesions have the potentialities of malignancy just as a benign adenoma may become malignant by some derangement of the basement membrane or variation of the normal arrangement of the cells and become the adenoma malignum elsewhere, as in the tongue. There are only, perhaps, negative evidences to support such a statement. We know the fibroadenoma means only a few more cells to become a sarcoma, and the sooner we cease to theorize, and realize our clinical observation, and recognize its potentialities for malignancy, and that it is cancer from the beginning, the more surely we will operate them before they become malignant and not afterwards, because, particularly in the case of the tongue with its rich vascularity, if it does become carcinomatous, the operation is practically hopeless. These convulsions may occur before, during or after labor. Convulsions in the pregnant, parturient or lying-in woman occur in rather more than 1 per cent. of all cases, and are therefore sufficiently common to be of practical importance. The lives of both mother and child are in danger in the case of the mother amounting to about 25 per cent., in cases at all grave or where there are several convulsions. The death of the child occurs in about 50 per cent. of cases of maternal eclampsia. Where the convulsions take place before the period of viability of the child, it is of course lost, but in addition to this factor, it must be remembered that many of these mothers are albuminuries and that the grave toxemia also poisons the child. Many of these children perish of convulsions, and the pathological lesions present are frequently similar to those found in women who perish of eclampsia. It is time for us to grasp and utilize the instruction of so reliable a surgeon as Maurice Richardson, of Boston, that all these neoplasms, whether benign or malignant, should be treated as malignant and extirpated. In those benign lesions that come from the use of a clay pipe, or ulcerations that come opposite lost teeth from the use of tobacco, which I have often seen in my own experience, and which I have seen Dr. Charles Mayo treat with the hot soldering iron, or even these warty papilloma which break down through the basement membrane and invade the adjacent tissues, it is easy to excise a small piece under cocain or general anesthesia and submit it to the at Terre Haute, Oct. 8, 1909 Our knowledge of the causation is still very incomplete, and Zweifel has termed it "the disease of theories;" nevertheless, certain changes Read before the Indiana State Medical Association, have been observed, and these are of value in aid- plexy is not uncommon from violent convulsions. ing us in the solution of many problems. The condition of the vessel wall may be caused by toxemia. Carl Braun held that the toxemia in eclampsia gravidarum, parturientium and puerperarium was an evidence of uremia produced by retention of excrementitious elements of the urine. Braun came to the conclusion, in 1857, eclampsia was produced by morbus Brightii and uremic intoxication. His conclusion was based upon the finding in the urine of albumin, fibrin-cylinders, blood, etc. This was substantially the view held by most of the famous writers on obstetrics of that period, and by men of such attainments as Simpson, Dubois, Cazeaux, Litzmann. There can be no doubt as to the frequency of renal changes in eclampsia, but the changes are often slight, the anatomical alterations being too insignificant to explain the grave symptoms pres ent. It is more nearly in accord with present views to ascribe necrobiotic changes of the renal epithelium and the fat degeneration of the glomerulus epithelium to a peculiar toxic substance generated by gravidity. Since 1886 it has been known that in eclampsia there were frequently present hemorrhagic and anemic necrosis of the parenchyma of the liver, due to thrombosis of the small branches of the portal vein. So great are the changes in the liver that some consider the disease an hepatotoxemia. I have in several cases seen evidence of hemorrhagic hepatitis. Blood is frequently diffused under the capsule and the insertion of the ligamentum coronarium. Blood has also frequently been found in the cavum peritonei of children born during convulsions. Thrombosis and apoplexy are very common and indicate the grave nature of lesions of the brain frequently present. The French school, under the impulse imparted by the work of Bouchard, attacks the problem from the side of autointoxications, some claiming increased toxic qualities in the blood serum, others that it is due to metabolic poison left in the system by reason of changes in the liver. It has also been claimed that the fetus itself generated the poisons, which, the mother being unable to excrete, produced in her pathological changes. This view was supported by the observations of a long list of writers, that convulsions usually ceased upon delivery, and in the case that I am about to report the convulsions appeared in the child, showing that it was the victim, if not the producer, of the toxemia which brought on the eclampsia of its mother. Rupture of varix of the cerebral veins has been found as a cause of death in eclampsia, and apo There is also the observation of Schmorl of emboli in the lung capillaries of eclamptics, and these emboli are composed of the syncytioma or even chorionic villi. These observations are not supposed to have much bearing on the pathology of eclampsia, since they are frequently the finding in cases where the labor has been perfectly normal. In a paper read before this society several years ago, I called attention to the fact that the lungs were the favorite ground for metastasis of the malignant chorion epithelioma, or the syncytioma malignum. It is then well known that in gravidity emboli from the fetal tissues of placenta are common. Without going elaborately into the pathology of eclampsia, it is seen that there are many lesions and various anatomical changes, but that possibly none or all of these are the sufficient cause of the disease. There is as yet an unknown poison circulating in the blood, responsible for these lesions and the symptoms to which we have applied the term eclampsia. When the physician stands face to face with convulsions, either in pregnancy or labor, all authorities agree that delivery should be accomplished as soon as measures suitable to the case in hand can be safely applied. Just how this should be accomplished in any given case is a matter of serious judgment, and is determined by the difficulties of effecting delivery. If the labor will end speedily in a natural manner, the obstetrician need not interfere. If the cervix is easily dilated and the labor can be finished by forceps in one or two hours, forceps or version should be operations of choice. When accouchement forcé must be resorted to in order that delivery may be accomplished, we must prepare to defend ourselves from criticisms. Charpentier has furnished us statistics showing a mortality of 40.74 after accouchement forcé, and some authors have reported a death rate as high as 66 per cent. after dilatations and incisions of the cervix. Brutal dilatation of a firm and rigid cervix furnishes a high mortality, approaching 50 per cent. The delay in these cases is so great that the child is almost always lost. When the manual dilatation can be accomplished after the method suggested by Dr. Philander A. Harris, in a reasonable time and with moderate force, rapid delivery may be accomplished by this means. Dührssen's deep incisions and his so-called vaginal Cesarean section will be rejected by most obstetricians as more dangerous |