2. DISCUSSION OF PHYSIOLOGY AND PATHOLOGY

In spite of much work, and study on the endocrine glands of the body in their occurrence in individuals and in communities where they are prevalent has led to conflicting hypotheses as to their function and their control of metabolism of the body. More thorough and conclusive evidence must be obtained before we can justify positive statements as to their real role in development, selection of function and causation of pathologic changes.

E. C. Kendall's isolation in 1915 of the alpha-iodin crystals and its use in cretinism and myxaedema is a good step in advance. The difficulty in the separation of this substance.

thymus, hypophysis, adrenals, ovaries will be a matter for the future study to decide.

The knowledge attained by the study of thyroidectomized animals, this effect on metabolism, (Means and Aub) and the correlated symptoms and signs in the human subject before and after lobectomy, or the various types of resections add many stepping stones to ultimate solving of the problem of the physiology and pathology of this gland.

The observation in the female who presents more likelihood of an enlarged or changed thyroid on account of her varied physiological career, shows enlarged thyroid during puberty, menstruation, menopause, and pregnancy, demonstrating the need for thyroid activity.

makes progression along this line very slow. An interesting point in the use of the substance in normal individuals bears a relation to thyrotoxicosis of hyperthyroidism, but the peculiar chronic toxicosis cannot be reproduced artificially in the normal individual. The body has ameliorating substances to offset this intoxication produced artificially, manifesting a tolerance. Therefore, not only the excessive secretion of the thyroid causes the symptoms, but also the various substances that it excites in other organs of internal secretion, that give the multiple pathology of a so-called case of hyperthyroidism or Grave's disease. To what extent the thyroid activity may be influenced by other organs in a pathological state as the

It was said by Dr. Charles Mayo that eclampsia resulted in pregnant women in whom there was an hypothyroidism. This is This is an interesting statement if not altogether accurate. The removal of an ovary may excite an attack of hyperthyroidism. All this demonstrates the need of the thyroid in development and metabolism and the interdependence, of the various glands of internal secretion.

3. STUDY AND DISCUSSION OF 583 REGISTRANTS

Any grouping of large numbers of facts and records will add to the sources of supply that eventually bear fruit of ultimate knowledge. Therefore, I wish to present tonight a study of the thyroid occurrences in 583 Registrants of Division No. 2 of Houghton County, Mich

igan. My connection dates from Feb. 23, 1918, and therefore I could only study those that came under my control from the date of my commission as examining physician to the Board. I studied and tabulated the cases that appeared at the registration of June 5th, Aug. 24th, and Sept. 12th, 1918, that were examined by the associated physicians and myself. Most of the registrants I personally saw. Their ages ranged from 18 to 21 and from 32 to 36 years inclusive.

The definition of goiter that I used was "any palpable enlargement of the thyroid gland." The pathology that gives this enlargement, of

or hyperthyroidism is certainly one of the most feared conditions of disease on account of its great danger to the vital organs-as tachycardia with miocardial degeneration, mental and nervous irritability, and exhaustion, exophatholmos, weakness, loss in weight, and the various degenerations of the liver, kidney, and nervous system. The example of a patient at the height of an attack of the Grave's disease is sufficiently alarming to justify more study and care on the part of the physician and surgeon.

Even the so-called simple goiters and adenomatous goiters have the potentiality of thy

3.

1. Simple colloid. 2. Adenomatous. Toxic goiters, which are found hyperplastic. 4. Malignant.

The danger to the individual depends upon the type of goiter, its size, and position. As we know large, colloid and adenomatous masses press upon the adjacent organs of the neck, trachea, oesaphagus, recurrent laryngeal nerve, and large vessels of the neck, causing symptoms of dyspnoea, dysphagia, hoarseness or aphonia) and cyanosis respectively. Thyrotoxicosis

rotoxicosis. From the large amount of material at the Mayo clinic, Plummer drew the conclusion that 20 per cent. of all simple goiters get a goiter heart in fourteen and one-half years. Allan Graham, at the Western Reserve University, discovered that dessicated adenomata (adult and foetal) could produce the same changes as normal thyroid secretions, which gives to the simple goiter the potentiality of toxic goiter.

In my own observation I believe that the high tension produced by the war, amongst young men and also their worrying and nervestrained relatives, whipped up many quiescent

goiters, and also excited the potential simple goiter to activity causing many cases of acute hyperthyroidism with its accompanying symptoms. I have examined and treated several of this type during the last year.

S. P. Beebe, in an article in the Medical Record of February, 1918, corroborates my own observation in this regard. As I have found in a limited number of cases Beebe has described in many camps, that many cases of so-called soldier's heart and so-called "psycopathies" were true cases of hyperthyroidism.

The large numbers of goiters strike one as a very important factor in the study of the man power efficiency, and the possible ultimate effect on posterity. As we know the goiter question rises in Switzerland to a national problem, it is incumbent on us not to disregard the issue when I will show you a percentage in thyroid defects greater in itself than any other defect. We have more goiters in males tabulated than all other defects added together. Quoting from a non-official communication to Major Peterson in August 17, 1918, I stated: "Of the 1918 class of June 5th (all of which were 21 years of age) who were born in this district, practically one-third had an enlarged thyroid gland of some degree some definitely having large cystic, adenomatous, colloid or toxic goiters. Some of these boys have a definite decrease in efficiency from every standpoint-unable to do average mental or physical labor, having decreased mentality, or suffering from dyspnoea or a definite toxic state with the usual symptoms of hyperthyroidism."

More men were disqualified for military service according to the regulations from large and toxic goiters, than from any other defect. For instance, on referring to chart No. 1, you will see that amongst the 583 registrants examined we have 37 goiters (large and toxic), and 20 hernias, 31 total deformities of the bones and joints and 16 heart diseases. (One interesting feature shows the very low percentage of venereal diseases. This is due to the fact that the young men prepared themselves for examination by prevention and treatment, demonstrating the value of propaganda).

Of the total number of disqualifying defects, goiters stood 20.9 per cent. or more than onefifth, total deformities next, at 17.5 per cent., hernia, 11.3 per cent., and heart diseases 9 per cent.

The percentage of toxic goiters will increase in my mind to 8 per cent. to 10 per cent. if we added to those found the men who developed

toxic states later, and, also, more carefully examined heart diseases.

The deleterious effect of goiters was discovered in a small number of families of Morons whose parent or parents had very marked deforming growths of the thyroid.

It appeared in observation of my practice coupled with my tabulated cases that persons were in danger of thyroid enlargement and its associated symptoms when born in this "goiter belt." Also, persons or families who had opportunity for travel and lived in other sections of the country for any length of time each year, were less prone to thyroid difficulties.

On examination of 583 registrants, I found that 177 of that number or 30 per cent. showed a demonstrable enlargement of the thyroid, 140, or 24 per cent. of the total number examined were simple goiters, 23, or 3.9 per cent. were toxic goiters and 14 or 2.4 per cent. were large goiters of the adenomatous, colloid or cystic types of a disqualifying nature. You can readily see that these figures, by comparing the charts Nos. I, II and III, demonstrate without any doubt the importance of the goiters amongst men of our section.

In investigating the places of birth I found that of 155 men of 21 years of age, all but three were born in the section of the goiter belt. Therefore, the presence of a goiter in 95 per cent. of cases of young men marked the place of birth.

The percentage varied with ages on account of the incidence of goiter and also on the numbers examined, but the average would be a just estimate of the actual percentage.

The decreasing percentage as the registrant grew older is due to the fact that a certain proportion of older members of the community may have been born elsewhere, and that they had traveled in non-goiterous districts. Both factors make up for a decreased hypertrophy and hyperplasia of the thyroid, and argues in favor of the popular belief in some local influence from the water supply exiciting the growth.

I believe that 30.3 per cent. is a true proportion of goiters in males judging from the males examined, and that, therefore, chart No. IV, gives us percentages very close to accuracy to the number of goiters in the Upper Peninsula of Michigan and Houghton County, Michigan. Furthermore, the female, as I have said before, is more prone to the thyroid enlargement than the male. It is a known fact that

there are nearly two females to one male with goiters in the section.

I used the word disqualifying to mean cases with large and toxic goiters according to the definition in the Selective Service Regulations.

The figures when developed would be still more startling. Therefore, in Registration Division No. 2 of our County, there are 9,615 goiters with 1,999 of a disqualifying character; in Houghton County 26,694 goiters of which 5,550 are disqualifying types; and in the Upper Peninsula of Michigan there are 98,665, goiters with large and toxic types numbering 20,515.

The economic and social importance of these figures cannot be denied.

BIBLIOGRAPHY.

Ballin: J. M. S. M. S., Page 463, Vol. XLII.
Beebe, S. P.: Med. Record, Feb. 9, 1918.
Bircher: Practical Med. Series 275, Vol. II, 1918.
Dunhill, T. P.: Int. Ab. of Surgery, 321, 1918.
Editorial: Journal A. M. A.. Page 1826, Nov. 30, 1918.
Epler, B. N.: J. M. S. M. S., Feb., 1918.

Graham Allan: Practical Med. Series 294, Vol. I, 1917.
Johnson's Surgery.

Kemp. M. P.: Practical Med. Series 275, Vol. II, 1918. Kocher: Int. Ab. of Surgery, July, 1918.

Mayo Clinics 1914-1915-1916.

Means, J. H. & Aub.. J. C.: Journal A. M. A., July 7, 1917.
Miller, C. S.: N. Y. Med. Journal, Page 1216, 1917.
Osler: Modern Medicine, Page 403, Vol. VI.

Sherrill. J. G.: J. M. S. M. S.. Aug., 1918.
Smith, E. V.: Int. Ab. of Surgery, 229, Oct., 1918.

VERTEBRAL DISEASE AS A CAUSE OF REFERRED PAIN.*

JOHN B. JACKSON, M.D.
KALAMAZOO, MICH.

In the examination of patients often the physician is unable to explain adequately the cause of pain. This symptom of pain is the one most readily recognized by the patient and the one most likely to bring him to the doctor. Examination of the spine will often reveal vertebral diseases as a cause of pain that cannot be accounted for otherwise. Sensory disturbances in diseases of the spine have not received the attention they deserve. Mistakes have been made in diagnosing visceral disease as a cause of the sensory disturbance when the real cause has been a pathological process in the vertebrae that has caused an irritation of the nerve roots. Rogers and Foley, in reporting an analyses of 75 cases of tuberculosis of the spine report that four cases had been considered gastrointestinal, one had been operated for gall-stones, one for appendicitis, one for perinephritic abscess, one had a nephropexy. Blaine and others. have called attention to the fact that renal and *Read before the Kalamazoo Academy of Medicine.

ureteral stone symptoms are often due to a spondylitis. It is apparent that a routine examination of the spine is important in diagnosing obscure lesions especially where pain is an important symptom.

In this discussion I desire to refer briefly to four classes of vertebral lesions, to report a few cases and to exhibit some slides showing these conditions. The four classes of vertebral disease are Pott's disease, malignancy, spondylitis deformans and spondylolisthesis. Tuberculosis of the spine is a frequent and well understood condition. In children it is of such common occurrence that the clinician is on the watch for this condition and seldom overlooks it. In adults the condition is also frequently present. The pathological process is an osteomyelitis usually of the body of the vertebra. By a destructive process the bone is broken. down and the vertebra collapses causing the well known deformity. Pain is often an early symptom. The location of the pain depends upon the point in the cord at which the vertebral disease occurs. The pain may be in the chest or abdomen. Abdominal pain may suggest disease of the stomach, appendix or kid

neys.

Carcinoma of the spine is not a rare disease. It is a metastatic process. The most common sites of the primary growth are the female breast and the uterus. The disease involves the spongy portion of the body of the vertebra. Invasion of the canal takes place rarely. Root pains are of extremely frequent occurrence and are early and troublesome symptoms. When the disease has progressed sufficiently the vertebra collapses as in Pott's disease and deformity and symptoms of cord compression occur. One vertebra alone may be involved, but as a rule the growth invades two or more adjacent vertebra. Root pains following an operation for cancer should always suggest a secondary invasion of the spine.

Spondylitis deformans is of much more frequent occurrence than is commonly appreciated. In this discussion no attempt will be made to classify this process as to etiology or types of rigidity, but all forms of spinal arthritis with bony changes will be grouped together. Prof. Elliot Smith has shown that this disease was very common among the prehistoric Nubian people. Its extreme prevalence is shown by the fact that in one prehistoric cemetery explored every adult body presented more or less extensive signs of its effects. The following brief description of the pathological changes

is abstracted from Llewellyn Jones' I description.

intervertebral discs undergo absorption eater or less extent and in some cases rely replaced by bone. In both the inral and costovertebral articulations not the articular surfaces be firmly welded but the capsules also become ossified. extensive ossification of the spinal ligaments may also take place.”

There are many symptoms of this disease that are due to irritation of the nerve roots. Oppenheim notes the occurrence of brachial, intercostal and crural neuralgia. Pains in the shoulder and arm frequently occur. Many cases of so-called sciatica are due to this process. Intercostal neuralgia and tight gripping pains across the lower thorax are often present. Girdle pains across the abdomen may be persistent and severe. Roentgenologists have often noted the frequency with which patients sent in for an X-ray demonstration of renal calculi were found to have not calculi but arthritic changes in the lumbar spine.

The fourth condition to which I wish briefly to refer is lumbo-sacral dislocation, the so-called spondylisthesis. This condition has recently been called to the attention of the profession by Darling of New York. It is a sliding forward of the fifth lumbar vertebra until it rests upon the anterior surface of the sacrum. If only one side is dislocated there is a twisting with a marked compression of the cauda and a resulting paralysis. Such cases are readily diagnosed by the severity of the symptoms resulting from the compression of the cord. In cases where both sides of the vertebra are dislocated the articular processes rest upon the anterior surface of the sacrum symmetrically and considerable space is left for the cauda. The resulting symptoms may be very mild and the condition may go unrecognized for a long time. Pain in the limbs may be a troublesome symptom. This often may be diagnosed as sciatica, neuralgia and rheumatism.

With this brief reference to these types of spinal disease I wish to report a few cases. I have purposely left out of this discussion any reference to purely traumatic lesions of the vertebrae and other conditions which may be more obvious from a diagnostic standpoint. In conclusion I wish again to call attention to the fact that vertebral disease often may be the cause of pain in various parts of the body and should be more carefully considered in cases where the diagnosis is not evident.

CASE I. Female, age 33. Chief complaints -left lumbar pain, abdominal pain. Family history negative. Has always been well until a little over a year ago. At that time had a serious illness. She had a terrible beating and pain in her back low down. At this time had a great deal of trouble with the bowels-almost an obstruction. Was in bed five weeks and had some fever. had some fever. Gradually improved and was perfectly well until about six months ago. Now has pain in her back and pain and soreness across the abdomen. Of late has noticed a fullness in the left side of the abdomen. Physical examination: Is thirteen pounds below her normal weight, looks well and has a good color. In the left lower quadrant of the abdomen is a mass that is boggy. Dullness over this mass, but not much tenderness. The spines of the lower thoracic vertebra are prominent and there is some discoloration of the skin over them. The blood, urine, and stomach contents are normal. X-ray examination was negative except for a well marked evidence of tuberculosis of the last dorsal and first lumbar vertebrae. Diagnosis: Pott's disease with a psoas abscess.

CASE II. Female, age 56. Housewife. Chief complaint-pain in back and left groin. Has pain in both feet. Six months ago had attack of lumbago. Has had a weakness in back since. A few weeks later a kyphosis was noted by her physician. Two years ago had a radical breast amputation for cancer. There has been no local recurrence. Physical examination: Some deformity of lower thoracic spine. Moderate enlargement of thyroid. Blood-pressure 170/95. Patellar reflexes exaggerated. Blood shows moderate secondary anemia. Urine normal. X-ray shows a marked destruction and compression of the first lumbar vertebra. Diagnosis: Metastatic carcinoma of the first lumbar vertebra.

CASE III. Male, age 40. Occupation, varnish rubber. Chief complaint-thoracic pain. This pain comes on in the evening after a days work. Comes on as a rule when he sits down. Has no cough or dyspnoea. Feels good except for pain through the chest. He was operated three and one-half years ago for appendicitis. Physical examination shows a mitral insufficiency and a mouth with extensive pyorrhoea. Blood-pressure 115/72. The blood showed a moderate secondary anemia and a negative Wassermann. The urine is normal. X-ray examination showed no evidence of thoracic disease except a very moderate cardiac hyper