is due to the attempt to limit the motion of the ribs, and is partly voluntary, but chiefly involuntary. The inspiration is quick, short and diaphragmatic; the breath is held for a moment, and then expired with a grunt or sigh.

Twenty five years ago Dr. L. A. Sayre called attention to this, and said that if such a patient be laid prone across the observer's knees, with the arms hanging on one side, and the legs on the other, and then the knees were gradually separated, the breathing soon became longer and the patient more comfortable. That was because the traction gradually released the muscular spasm, and the sagging downward of the spine relieved the pressure on the diseased surfaces.

With disease in the upper dorsal region, the shoulders are often held stiffly squared, with the head thrown back, and as the patient walks it produces the socalled "military gait."

Pain in these dorsal cases is referred to the sides and front of the chest and abdomen. In young children a history of frequent stomach ache or colic may be the chief complaint, and children are often treated for digestive disturbances for a long time before the real cause of the pain is discovered. Sometimes, too, the child cries out as if in severe pain, suddenly, when lifted. This is due to the motion imparted to the diseased vertebra through the ribs or arms by the act.

Pain is most easily produced by flexion of the spine, so the patient squats down with knees bent, to reach anything on the floor or to tie his shoes, etc.

Lower Dorsal and Lumbar Disease. One of the earliest signs of disease in this region is an exaggeration of the normal lumbar lordosis, combined with a peculiar, sliding, careful gait.

The lumbar spine is very mobile, participating in nearly every motion of the body, so with disease in this area pain is associated with almost every motion, and also with jars transmitted through the legs. Extension, however, is not painful, as it separates the diseased vertebral bodies, so the muscular contraction and rigidity tend to increase extension by increasing the lordosis. For these two reasons, pain and kyphosis do not develop as early in the lumbar as in the dorsal spine, but, for the same reasons, muscular rigidity can be much more easily observed.

A slight lateral deviation of the spine may often be seen in these lumbar cases before the typical angular deformity has developed.

The habit of squatting, spoken of above, is even more marked in lumbar than in dorsal disease. Contraction of the psoas muscle and flexion of the thigh is often seen in lower dorsal or lumbar disease.

It is due to the irritation at the points of origin of the muscle, or to the presence of an abscess burrowing along the muscular sheath, and produces a shortening of the leg and a limp, simulating hip disease.

These cases may be easily differentiated from hip disease by completely flexing the thigh to relax the psoas contraction, when all motions at the hip except extension will be free, while in hip disease they will all be limited.

Patients with lumbar disease often prefer to stand rather than sit, as sitting reduces the lordosis and throws more weight forward upon the bodies of the vertebra.

Pain may be referred to the groin, into the buttocks, down the outer side of the thighs or along the sciatic nerve.

I have under observation a young lady who was treated for over six months by two most excellent general practitioners for rheumatism and sciatica. Finally, a slight lumbar lordosis was discovered, and she was referred to me for that. Examination revealed a lumbar spine so rigid that she could not lace her shoes in any position; there was a small kyphosis developing in the lateral curve, and, in spite of six months' treatment, the sciatic pains still continued. She had a typical lumbar spondylitis.

Tuberculosis or other infections of the sacroiliac joint may simulate spondylitis, but is more apt to be confounded with hip disease. The limitation to forward motion is not so great as in spondylitis, while that to lateral bending is marked. The patient always favors one side by standing on the leg of the nonaffected side, so some lumbar scoliosis is common, but there is almost always pain on pressure over the synchondrosis, either externally or per rectum, and pressing together the two sides of the pelvis is almost invariably painful. Sacroiliac disease is rare in children, while spondylitis is frequent.

Beside these local signs I have mentioned and the universal muscular spasm, there are one or two general symptoms which are usually present very early. Probably the first indication of trouble, if it were carefully noted, is a persistent change in the disposition of the patient. He loses his animation and becomes quiet and subdued. No matter how active and playful he may have been, he no longer cares to romp and play. He prefers to sit down or keep still, often in some peculiar position, that either supports or immobilizes the spine. The mother often notices this change in a child before he complains of pain, and it is probably coincident with the appearance of muscular rigidity.

Another symptom that is often noticed early is night cries. It

does not accompany spondylitis quite so frequently as hip disease, I believe, but when it does occur it is a sure sign of joint trouble somewhere. It is due to the sudden relaxation of the muscular rigidity that has been on guard all day. As the child goes to sleep, the tense muscles relax, there is slight motion of the affected joint, and the pain causes a sharp, startled cry. Instantly the muscles spring on duty again, and by the time the mother reaches the bedside the child is comfortable and can not explain why he cried. This may be repeated with variations several times before quiet, restful sleep is obtained.

When it is difficult to determine the exact situation of the trouble, the test known as Copeland's test, which depends upon the fact that inflamed tissues are hypersensitive to heat, will often aid in localizing the focus. It consists in passing a sponge or test tube filled with hot water along the spine over the transverse processes, when as it passes a certain spot the patient will often notice a distinct sense of pain.

In closing, I want to say that I believe more failures to diagnose spondylitis are due to lack of careful examination than to lack of knowledge, and I feel that I have only been reminding you of signs and symptoms that you know full well. But I do know that diagnoses. of colic, rheumatism, sciatica or injury cover a multitude of errors. When we remember that spondylitis may cause any kind of pain, from headache or earache to sciatica, and when we cultivate a habit of examining the spine for rigidity as carefully as we examine suspicious lungs for tubercle bacilli, the early diagnosis of tuberculous spondylitis will be more frequently made.

PROGNOSIS.

The mortality from tuberculous spondylitis of all forms is about 20 per cent. Omitting all further statistics on the subject, the prognosis of tuberculous spondylitis may be summed up in a few words: (1) The factors concerned in the prognosis are the time at which the diagnosis is made and the treatment begun; (2) individual resistance to the disease; (3) patient's age; (4) patient's environment. These, with the location of the disease in the spine, are the chief points in determining the prognosis. While the usual time for recovery is from three to ten years, it can be markedly lessened by prompt and efficient treatment. As regards deformity, complications, as abscesses and paralysis, the date at which proper treatment is begun is of the greatest importance. Some patients seem to have no individual resistance whatever to tuberculosis, and they grow worse in spite of treatment. Why, I do not know. How much influence

heredity may have in these cases, I do not know. I think environment has more. The prognosis is always worse in adults than in children, both as to mortality and deformity. As to environment, I think if we could send all of our cases of spondylitis into the open air in a dry climate, and give them good food, the time required for recovery would be markedly reduced. Even taking a patient from the unhygienic surroundings of a poor home, and putting him into a light, airy hospital ward, with good food to eat, often works wonders.

As to the situation of the disease, this is also of prognostic importance. Tuberculosis in the cervical spine gets well earlier and with less deformity than in any other part of the body. The reason for this, as regards the deformity, is because the natural curve of the cervical spine is slightly forward, and the bodies of the cervical spine are thin, comparatively. Tuberculosis of the lumbar spine gets well next in order as regards time required, and the deformity is slightly greater than in cervical disease of the spine, but recovery is the rule. Tuberculosis of the dorsal spine requires a longer time for recovery, and the deformity is greater. It is in the mid and upper dorsal cases that we see the extreme deformities, and these are the cases that last for years and require constant supervision.

92 STATE STREET.

GOITRE, WITH REPORT OF A CASE COMPLICATED BY PREGNANCY, LATE TRACHEOTOMY AND DEATH.

BY FRANK H. EDWARDS, M. D., EVANSTON.

Goitre is a pathological nonmalignant enlargement of one or more of the thyroids or parathyroids or both, which may become a dangerous complication of pregnancy. It is possible that a physiological enlargement occurs in all cases of pregnancy and during puberty, but it is not always possible to determine when physiology ends and pathology begins. Prior to 1884 it was not known that the thyroids had any important function, then Schiff found that the removal of thyroids in dogs is almost invariably followed by illness and death. It has also been shown that these results may be obviated by grafting a portion of the gland under the skin or within the peritoneal cavity. The parathyroids exist either within or without the thyroids and may, according to Sharper, extend along the common carotid and have a multiple origin. About all we definitely know concerning the physiology of the thyroids is that they play an important part, of some kind, in the general metabolism of the Evanston Branch of Chicago Medical Society, November, 1903.

body. Bauman has isolated the substance called thyroidin, but what purpose it serves in the organs of the body is unknown.

The histology is better understood; the thyroid consists of a frame work of connective tissue enclosing vesicles which are lined with very low columnar epithelium. The cavities are often filled with a peculiar viscid fluid called colloid, and is a true gland, formed in the embryo like all other glandular structures by an inversion of an epithelial forming layer of the blastoderm. The excretory duct is in early embryonal life obstructed so that it is in later life a ductless gland. The hypertrophy may include all parts of the gland or embrace the alveoli principally, or again we see principally solid masses of cells and besides these we have the true adenomata divided by Wolfer into four forms. The fetal, the gelatinous, the myxomatous and the cylinder cell adenoma, and we may here remember that cyst formation is common to all forms.

The fetal adenoma arising from the embryonic tissue in the gland begins its growth usually at puberty or during the first pregnancy and appears in nodules which vary in size. The adenoma gelatinosum appears in the form of rough uneven tumors, which may comprise the entire gland or be seated only in one portion. The myxomatous adenoma appears in young and old individuals and forms soft and hemorrhagic nodules of variable size. The conditions for its development are found in hemorrhage at pregnancy during menstruation, or labor. The cylinder cell adenoma is rare, composed of vesicles lined by cylindrical cells.

We may leave further matters of speculation as to the physiology and pathology of goitre and assert that pregnancy exerts a marked influence in the development of a pathological enlargement of these bodies that, with their isthmus, is commonly called the thyroid. Of the many thyroid tumors extirpated by Billroth in Vienna many were directly traceable to pregnancy. Honori noted the effect of pregnancy in 1845. Tarnier, Tait and Simpson have also written and others, notably Pinero. Jenks in his article twenty five years ago laid great stress on uterine disorders and reports fourteen cases, all suffering from some pathological condition of the uterus or ovaries. Hippocrates mentions goitre as a protuberance; sometimes painless, some curable and others incurable. Rose pointed out that asphyxia may result from softening of the tracheal cartilages and pressure atrophy caused by the tumor. We know, too, that hemorrhage may occur into the thyroid in the midst of labor, as in the myxomatous adenoma mentioned, the so called thyroid apoplexy.