OSTEO-ARTHRITIS OF THE SPINE: SPONDYLITIS 
DEFORMANS. 
BY 
JOEL E. GOLDTHWAIT, M.D., 
BOSTON. 
From the Transactions of the 
American Orthopedic Association. 
1899. OSTEO-ARTHRITIS OF THE SPINE: SPONDYLITIS 
DEFORMANS. 
JOEL E. GOLDTHWAIT, M.D., 
BOSTON. 
The term osteo-arthritis is used to designate the disease of the 
articulations, which is characterized pathologically by a marked 
proliferation of the edges of the articular cartilage, associated with 
an atrophy or degeneration of the cartilage at the points of pressure, 
the two conditions producing an amount of impairment of function 
of the joint varying from the slightest inconvenience to complete 
ankylosis. 
Various terms have been used to designate this condition, some 
of them suggestive of the general process, while others refer only 
to the local manifestation. Of the former, chronic rheumatism, 
arthritis deformans, rheumatoid arthritis, rheumatic gout, dry or 
proliferating arthritis, malum senile, arthrite seche are the most 
commonly met with. Of the latter, the most common are malum 
coxse senilis, referring to the disease as seen in the hip and spon- 
dylitis deformans, or spondylose rhizomelique, representing the 
same process involving the spine. 
It is with reference to this latter manifestation of the disease 
that this paper is concerned, and while some mention of the gen- 
eral process is necessary, it will be only such as would be of value 
in considering the local disease. 
The disease has been described by various writers in journal 
articles, but as yet there has been but slight mention of the sub- 
ject in the works on orthopedic surgery, and most of the literature 
is devoted to the report of individual cases, with but little consid- 
eration of the disease itself. It is for this reason, and also because 
it seems to me, from my observation, that the disease is more com- 2 
OSTEO—ARTHRITIS OF THE SPINE. 
mon than has been supposed, that the subject is offered for discus- 
sion here. 
Bradford,1 in 1883, reported three cases of “ rheumatism of the 
spine,” all in men between thirty and thirty-six years of age. In 
two practically the whole spine was stiff, with ankylosis of the ribs. 
In the other the rigidity of the spine was confined to the dorsal 
region. In the first two cases there was a gonorrhoeal history. In 
all of these cases the spine alone was affected. 
Marie,2 under the term spondylose rhizomelique, reports five cases 
of his own, in one of which there was a distinct gonorrhoeal history. 
One patient was sixty years of age, the others from thirty to forty 
years, and in all some of the other joints—usually the hips or 
shoulders—were affected. 
Striirapell3 reports three cases, and in his book describes the 
type of painless progressive ossification of the spine and hips. 
Mutterer4 reports a case of a man fifty-eight years of age, with 
complete ankylosis of the spine, together with ankylosis of both 
hips and some slight trouble with the knees. 
S. Popoff5 reports a case of a man, twenty-eight years of age, 
in which the process developed very rapidly and was associated 
temporarily with weakness of the legs. This weakness disap- 
peared as the disease became less active. 
Beer6 reports three cases, thirty-nine, forty-seven, and forty 
years of age. In one a history of gonorrhoea is given ;in one the 
hips and shoulder-joints were affected; in another the shoulder 
and hand, and in one there is no mention of the other joints. 
Marie and Astic7 report a case of a man, sixty years of age, with 
trouble with the back of ten years’ duration. The spine is com- 
pletely ankylosed. 
Bechterew8 reports five cases : two women, about fifty years of 
age, in both of which about hali the spine was rigid, with no other 
joints affected. Of the three men, one, a patient thirty-nine years 
1 Annals of Anatomy and Surgery, Brooklyn 1883, vol. vii. p. 6. 
2 Rev. de M6d., 1898, xviii, 285. 
8 Deutsche Zeitschrift f. Nervenhk., 1897, p. 838. 
4 Loc. cit., 1898, Bd. xiv., 1 und 2 Heft. 
5 Neurologisches Centralblatt, Jahrg., No. 7. 
6 Wein. med. Bliitter , 1887, xx. 127 and 128. 
i Presse M6d., 1897, October. 
8 Neurologisches Centralblatt, 1893, p. 426 ; Deutsche Zeitschrift f. Unfallhk, 1897, xi. 326. JOEL E. GOLDTHWAIT. 
3 
of age, had the spine completely ankylosed, with the symptoms of 
nerve pressure, such as areas of anaesthesia and others of hyper- 
sesthesia. Other joints were not affected. Of the other two, one 
had paralysis agitans and the other was insane. In both cases 
the spine was rigid, and there were symptoms suggestive of press- 
ure upon the nerve-roots. The other joints were apparently not 
affected. 
Individual cases are also reported by Fagge,1 Spillman and 
Etienne,2 Gasne,3 Raymond,4 Sanger,5 Stocker,6 Henle,7 Baumler,8 
Davies and Colley,9 Sturge,10 and Pasteur.11 
Of my own cases, ten in all, most of them have been seen in the 
Orthopedic Clinic (for adults) at the Carney Hospital, and the cases 
which have been selected are those which are particularly charac- 
teristic and in which the other joints have been but little if any 
involved.12 
The first case was previously reported by me in the Boston Med- 
ical and Surgical Journal of December 26, 1895, and is here 
reported because of its relation to the other cases. 
Case I. Mrs. McC., fifty-eight years of age, by occupation a 
nurse, had always been well and actively engaged in her work 
until the present sickness. Her family history is good, and she 
never had the least trouble from rheumatism. In July, 1893, she 
was caught in a thunder shower and her clothing was wet through. 
The next morning she complained of pain in the neck, with some 
tenderness in the upper part of the chest. There was no cough or 
expectoration. The pain in the neck increased in severity very 
rapidly, until the slightest motion caused the most intense suffer- 
ing, and because of this she was admitted to the Good Samaritan 
Hospital. The patient entered the hospital in the service of Dr. 
1 Transactions Pathological Society, 1877, xxviii. p. 201. 
2 Rev. de M6d., 1898, xviii. p. 746. 
3 Sera. Med., 1899, p. 78. 4 Loc. cit., 69. 
3 Neurologisches Centralblatt, 1898, xvii. p. 1144. 
6 Clinical Journal, May 9, 1894, p. 35. 
7 Vereinsheilage S. deutschen med. Wochensehrift, 1894, S. 20. 
3 Deutsche Zeitschrift f. Nervenhk., 1898, xii. 
2 Transactions Pathological Society, 1855, p. 359. 
Transactions Clinical Society, 1879, xii. p. 204. n Loc. Cit., 1889, xxii. 298. 
i 2 The pathological specimens are from the Warren Museum at the Harvard Medical School. 4 
OSTE O—A R THRITIS OF THE SPINE. 
Coolidge, and it was through his kindness that I was enabled to 
see her. 
At the time of the first examination she was evidently suffering 
a good deal. The head was held a little to one side, the chin to 
the left, the shoulders drawn up, and all motions were most care- 
fully guarded by muscular contraction. Any attempt at motion 
caused great pain. None of the other joints were in the least in- 
volved, and aside from this local condition the patient seemed well. 
For the first week or two the patient was kept quiet in bed, and 
the various rheumatic remedies freely given with very little if any 
effect. After this a Thomas collar was applied for more complete 
fixation, and following this light-weight extension was used. 
These gave some relief, but neither could be used continuously, 
because of the nervousness of the patient; so that the two appli- 
ances were used alternately, each being worn for a few hours. In 
three or four weeks after the beginning of the attack a swelling 
appeared in the right side of the neck. This was about the size of 
a small lemon, and was apparently connected with the spine. At 
the same time the numbness of the left arm was noticed, with some 
impairment of motion, and this condition continued and increased 
until the arm was almost entirely helpless. The right arm and 
both legs also became involved, never in as marked a degree as 
the left arm, but enough to make motion in bed, unassisted, im- 
possible. At one time there was difficulty in swallowing, and for 
a short period breathing was almost entirely diaphragmatic. 
The patient’s condition remained about the same for two months, 
after which there was a slow but steady improvement, so that at 
the end of the third month she was able to sit up for a short time 
each day, and in December, five months from the onset of the 
trouble, she was able to move about with but little assistance, and 
was taken home. The paralytic symptoms referred to in the right 
arm and legs had by this time practically disappeared, but the left 
arm was still very helpless. The swelling in the neck was prac- 
tically the same as when first noticed. 
The patient was not again seen until thirteen months later, during 
which time, aside from the Thomas collar, no special treatment had 
been carried out. At the time of this examination the improve- 
ment in the patient’s general condition was most marked. She JOEL E. GOLDTHWAIT. 
5 
moved about with perfect ease, and, aside from the stiffness of the 
neck and some impairment in the use of the left arm, she seemed 
well. Extension of the neck was entirely restricted, so that in 
order to raise the chin the whole body was bent backward. Rota- 
tion was also entirely restricted, while flexion was more free, it 
being possible to lower the chin to the chest. On each side of the 
neck, over the transverse processes, was very distinct thickening, 
Fig. 1. 
apparently bony in character. In the left arm all motions were 
limited, especially those in which the shoulder muscles were used. 
The fingers were flexed, apparently due to the contraction of the 
palmar fascia and the flexor tendons. The sensation of the hand 
and arm was normal. 
At the present time the patient’s condition is practically the same 6 
OSTEO —ARTHRITIS OF THE SPINE. 
as at the time of this last Dote. She is able to be about at her work, 
but there has been no change in the condition of the neck or arm. 
Case 11. Mrs. M., seventy years of age, came to the Carney 
Hospital over two years ago. She had considered herself, and had 
been considered by her family, to be well until ten years ago. At 
that time she fell on the floor, striking the lower part of the spine. 
Since then she has had more or less pain in the back, and while 
previously she had carried herself quite erect, she gradually bent 
over both to the front and to the side. Except the spine, the joints 
were not affected. At the time of the examination there was a 
large, rounded kyphosis involving the whole dorsal and lumbar 
spine, together with quite marked lateral deformity. There was 
but little motion in the spine, and no symptoms of paralysis. Fig. 
1 represents her condition at that time. 
Case 111. G. K., a man, twenty-one years of age, a steel pol- 
isher by occupation, came to the Carney Hospital in June, 1897. 
For one year he had been having trouble with the back, with a 
gradual loss of the use of the arms and legs. At the time of the 
first examination the whole spine was bent forward and was rigid. 
None of the other joints were involved. The left arm could not 
be raised to the head, and both legs were very weak. The knee 
reflexes were present, the left being exaggerated. There was marked 
muscular atrophy of both arms and legs. The patient was seen 
by Dr. Bullard, and the diagnosis of osteo-arthritis with pressure 
upon the nerve-roots confirmed. 
Case IV. D. F., a man, twenty-nine years of age, an ordinary 
laborer, came (o the Carney Hospital in September, 1897. Some 
years previous he had an attack of rheumatism when in Ireland, 
which lasted for three weeks. After that he came to this country, 
and for a time u fired” in an engine-room. He used “to sit in 
draughts to get cool.” This brought on another attack of rheuma- 
tism, and he was unable to walk for seven weeks. The patient 
was well after the second attack of rheumatism until a few months 
ago, at which time he had typhoid fever. Soon after he was able 
to be about he noticed pain in the back, and as this increased and 
prevented him from working, he came to the hospital. At that JOEL E. GOLDTHWAIT. 
7 
time the spine was straight except for a slight prominence of the 
eighth, ninth, and tenth dorsal spines. The motions of the whole 
spine were guarded, but those in which the low dorsal vertebrse 
were used were least free. A plaster-of-Paris jacket was applied, 
to prevent an increase of the deformity, and a little later this was 
Fig. 2. 
changed to a leather jacket, which has been worn until the present 
time. There has been some bending forward, as is shown in the 
photograph (Fig, 2), and his spine has gradually aukylosed, so that 
at present it moves as one piece from the pelvis to the lower part 
of the cervical region. The ribs have also become aukylosed, so 
that the respiration is entirely diaphragmatic. His general health 8 
OSTEO-ARTH RITIS OF THE SPINE. 
is good, and, except for an occasional few days of pain in the feet, 
the] other parts of the body have not been involved. 
Case Y. P. 8., a man, twenty-four years of age, came to the 
Carney Hospital in the early part of this year. His previous 
history was good, and there was no history of rheumatism in the 
Fig. 3. 
family. His work was that of a stationary engineer, having charge 
of a hoisting engine, and, being obliged to work in all kinds of 
weather, he was much exposed. Five years ago he noticed pain 
in the back and feet for a time, but has been regularly at work 
until the past year. Since then he has been so weak and tired so 
easily that he could not work. When seen at the hospital the JOEL E. GOLDTHWAIT. 
9 
whole back was arched forward, as shown in Fig. 3, and there was 
complete ankylosis from the pelvis to the mid-cervical region. The 
ribs were also ankylosed, so that the breathing was wholly abdom- 
inal. The other joints were not involved and there were no signs 
of nerve pressure. The chief complaint was pain in the small of 
the back, due, undoubtedly, in part to the active disease and partly 
to the muscular fatigue resulting from the posture. For treatment, 
aside from general remedies, the patient has worn a light spring- 
steel brace with much benefit. 
Case VI. J. S., a man, twenty-five years of age, came to the 
Carney Hospital in March of this year. For occupation he had 
done u firing” in a gas-house, and has considered himself well 
until the past three or four mouths, since which time he had had 
pain in the feet, followed by pain in the hands and spine. At the 
present time the whole spine from the pelvis to the mid-cervical 
region is rigid, and the ribs are also ankylosed, so that the breath- 
ing is wholly abdominal. A few small joints of the hands and 
feet are involved. The spine is fairly erect, there being but little 
of the anterior bending. 
Case VII. G. H., a man, thirty-two years of age, consulted 
me in September, 1898, at the request of Dr. H. W. Cushing, of 
Johns Hopkins Hospital. The patient was a professor in one of 
our large universities. His family history was excellent; he 
had been well previous to January, 1897, when he broke down 
nervously. He went abroad, and soon after this stiffness of the 
neck and shoulders developed, not enough, however, to prevent his 
going about. Soon after this numbness developed in the left arm, 
with marked loss of power, and later the right arm was similarly 
involved, only not so severely. The condition improved slightly, 
and then remained about as it was at the time of the examination. 
At that time there was a moderate rounded curve involving the 
upper dorsal and cervical regions of the spine. This portion of 
the spine was rigid. The shoulders were drooped forward and 
there was marked atrophy of the muscles of the chest, shoulders, 
and upper back. Both shoulder-joints were somewhat involved, 
so that the motions were limited, and there was some thickening 
about the head of the humerus. On attempted motion there was 10 
OSTEO —ARTHRITIS OF THE SPIKE. 
marked spasm of the muscles about the shoulders and upper spine. 
The legs were normal and there was no change in the reflexes. 
There was a distinct loss of power in the left arm, with some 
numbness, and there was a tendency to the same condition on the 
right side. The treatment, which has been almost wholly general, 
has been followed by improvement. 
Case VIII. C. H., a man, sixty-two years of age, was referred 
to me by Dr. George Bancroft, of Natick, in April last. When 
in the Civil War the patient contracted “ rheumatism,” and the 
back has been stiff ever since, so that he has not been able to work 
regularly. The neck has not been involved until the past eight 
months, previous to which time he overworked and broke down. 
Since this time the neck has been painful and has been growing 
worse. When examind the whole lumbar and dorsal spine was 
ankylosed and free from pain. The cervical region could be moved 
but slightly, and this only with great pain. Even the atlas and 
axis were apparently involved, there being but a very few degrees 
of motion of the head in any direction. The ribs moved slightly 
on respiration. The sensation in the right arm was much impaired, 
but the muscular strength remained about the same as the other 
side. The other joints were not involved. A Thomas collar, to 
support the head, gave very marked relief in this case. 
Apparently in this case there have been two separate attacks of 
the disease—one early in life and the other one thirty years later. 
Case IX. M. J. K., a man, thirty-four years of age, by occu- 
pation a currier, was seen by me at the Massachusetts General Hos- 
pital with Dr. John Homans. The patient had been well previous 
to five years ago; at that time he had an attack of pain in the 
shoulder, the left knee, and the right foot. Soon after this he 
noticed that his back was somewhat stiff. Three years ago the 
pain became acute in the right heel, and since then this has caused 
him the most trouble. One year ago he had another attack of the 
so-called rheumatism, in which the neck was affected. He was in 
bed at that time for six mouths, and since then the back has been 
much stiffer, and it has been difficult for him to breathe freely. 
When seen by me he was wrell nourished and developed. The 
spine was straight, and was ankylosed from the pelvis to the JOEL E. GOLDTHWAIT. 
11 
cervical region. The ribs moved but slightly with respiration, 
the breathing being almost entirely abdominal. The other joints 
were in fairly good condition, except the right heel, which was 
Fig. 4. 
painful, and the X-ray picture showed a similar osteo-arthritic 
process. The position of the spine is shown in Fig. 4, and is 
interesting as showing that the rounded back is not necessarily 
characteristic of the disease. 12 
OSTEO —ARTHRITIS OF THE SPINE. 
Case X. Mary S., thirty-five years of age, came to the Carney 
Hospital about three years ago because of trouble with the back 
and neck. The history as given was that a few months previously 
she made a change in the underclothing and took cold. This was 
followed by a sudden pain in the neck, which prevented her from 
being about. At that time the slightest motion of the head was 
extremely painful. Xo other joints were involved. The arms 
for some time could not be used freely, the left one being worse. 
Under general treatment the patient gradually improved, so that 
at the present time, except for the rigidity of the upper dorsal and 
lower half of the cervical spine, she is well. 
In all about thirty-five cases have been reported previously, or 
forty-five cases, including the ten of my own. Beside this there 
have been several reports of pathological specimens, illustrating 
the pathological appearance of the disease entirely apart from the 
clinical history. 
In analyzing such a series of cases certain facts are at once sug- 
gested, but before they can be studied to much advantage they 
must be distinctly differentiated from the other type of rheumatoid 
disease, which is chronic in character and also leads to joint anky- 
losis, but in which there is atrophy of all the joint structures, with 
no tendency to nodular growth or osseous deposit, as is seen in the 
type of disease under consideration. 
Both of these diseases are usually considered together in the text- 
books under the head of arthritis deformans, which accounts for 
the variation in the clinical picture as it is presented by the various 
writers. 
As the cases are seen side by side there cannot be the slightest 
question but that there are two distinct diseases or two very widely 
divergent types of the same disease, and it is because of (his that 
much of the confusion has arisen. 
In a paper published in the British Medical Journal, Bannantyne 
and Vollman have carefully described the two types, and in a 
paper entitled the u Treatment of Joints Disabled by the So-called 
Rheumatoid Diseases,” published by the writer in the Boston 
Medical and Surgical Journal, January 29, 1897, the two types 
were described and illustrated. In that paper the descriptive term JOEL E. GOLDTHWAIT. 
13 
“ arthritis deformans” was used to designate the whole class of 
these so-called rheumatoid diseases. Rheumatoid arthritis was used 
to designate the cases in which joint inflammation and atrophy, 
resulting in ankylosis and marked distortion, were the chief 
features, while osteo-arthritis was the term used for the cases in 
W’hich the nodular deposits about the articulations were the most 
prominent features. 
The importance of this differentiation is mentioned because 
several of the cases which have been published as spondylitis 
deformans are undoubtedly cases of rheumatoid arthritis, and are 
not osteo-arthritis, which explains the discrepancy in the clinical 
picture. 
It is evident, in the first place, in the analysis of the cases, that 
the disease is essentially a disease of adult life, but not necessarily 
a disease of old age, as is often stated. Some of the worst cases 
have developed in the period of late adolescence, while in very 
few has the process started in old age. The disease as it is seen in 
old age is not so definitely localized in the spine, but, as a rule, the 
other joints are more or less involved. 
Another feature which is also noticeable is that there is no one 
cause of definitely recognized etiology to explain the onset. Gon- 
orrhoea has been mentioned as a probable cause in a certain number 
of instances, but in a much larger number this is not suggested as 
a possibility. In the majority of cases the cause seems to be some 
exposure or the rapid change in temperature of the affected part. 
These influences are recognized and accepted as etiological factors 
in similar phenomena in other parts of the body, and their impor- 
tance in spondylitis deformans is probably equally certain. Ex- 
posure to wet or cold, or occupations which necessitate sudden 
changes from heat to cold, such as “ firing” or “ engineering,” are 
the causes most frequently met with. Bechterew suggests trauma 
and heredity as possible causes. Beucke believes the process to be 
due to senile and mechanical causes. 
Most of the other writers, however, either do not express an 
opinion as to etiology or else accept exposure and gonorrhoea as 
most probable. 
Still another thing which is evident is that the disease is not 
peculiar to this generation, and that it also is not peculiar to the 14 
OSTEO —ARTHRITIS OF THE SPINE. 
human race. Bland Sutton reports a specimen illustrating this 
disease in a mummy taken from the pyramids, while Sutton reports 
the disease in oxen and horses, and Bricon mentions a similar con- 
dition in cats. 
Fig. 5. 
Pathologically, the disease consists of a nodular enlargement of 
the edges of the articular cartilages, with the subsequent ossification 
of these nodes and an extension of the process into the ligaments 
which have their origin or insertion near by. With this hyper- 
trophy at the edges of the cartilage the centres or areas of pressure JOEL E. GOLDTHWAIT. 
15 
usually undergo atrophy. In the atrophy the interstitial tissue is 
the last to be absorbed, which explains the granular appearance as 
it is seen at times; but as the process continues this interstitial 
Fig. 6. 
substance is absorbed, and either the two surfaces of bone fuse or 
remain in apposition. lu the other joints in which there is free 
motion the bare surfaces of bone frequently become polished and 
increased in density. 16 
OSTEO ARTHRITIS OF THE SPINE. 
The process in the spine usually begins upon one side anteriorly 
and extends up or down along the anterior lateral ligament. It 
may remain as a comparatively local process involving only a small 
portion of the ligament, as is shown in Figs. 5 and 6, or it may 
cross over to the other side and extend up and down until the 
whole spine is invaded. When this occurs the chief deposit or 
new formation of bone is along the lateral ligament, the change in 
the median line consisting simply of a fusion of the vertebrae, as 
shown in Fig. 7 and also in Fig. 8, in which the lumbar spine had 
become joined to the sacrum. 
Fig. 7. 
At times, even though the hypertrophic change is quite active, 
that which develops from adjoining vertebrae does not fuse, and a 
more or less free joint remains. This is distinctly shown in Fig. 
7 and also in Fig. 9, in which an intermediate joint remains mobile 
(a), even though the osseous deposit has been so extensive as to 
entirely overlap the articulation in front (6). 
As the disease goes on in the ligaments and cartilages the inter- 
vertebral substances atrophy, and if the process is slow the entire 
intervertebral disk may be absorbed before ankylosis takes place. JOEL E. GOLDTHWAIT. 
17 
If this be the case, naturally the back is rounded and the spine 
becomes very much arched, as shown in Fig. 10. If, on the other 
hand, the process is more active the vertebrae may become ankylosed 
before the disk has been absorbed, and, consequently, no deformity 
is produced. If this be the case the disk ultimately is replaced 
Fig. 8. 
by osseous tissue and the ankylosis rendered more complete. The 
condition is shown in Fig. 9. If the process is more active on 
one side than the other it is easy to see that lateral deformities may 
result, and, naturally, this is more commonly seen in the cervical 
region, where the spine has more flexibility. The condition is well 
shown in Fig. 11. 18 
OSTEO—ARTHRITIS OF THE SPINE. 
While these changes are taking place in the anterior portion of 
the spine, similar changes lake place in the ligaments and articula- 
Fig. 9. 
tions at the back, so that the transverse and rarely the spinous pro- 
cesses are affected. It is the disease in these regions that causes 
Fig. 10. 
Fig. 11. 
most of the symptoms of paralysis or disturbed sensation, by 
narrowing the foramina through which the spinal nerves pass. JOEL E. GOLDTHWAIT. 
19 
Clinically, as the disease is seen, the subjective symptoms are 
usually slight in comparison to the actual pathological change, and 
frequently there has been so little trouble with the back, and the 
change has taken place so gradually, that the patient is not con- 
scious of any special limitation, the condition being discovered by 
accident. More often, however, there is considerable pain, which 
is referred to the back, and which is aggravated by change of posi- 
tion. When quiet the pain is so much relieved that the patient 
frequently does not seek treatment until the disease is far advanced, 
or even if treatment is asked, it is often excused without examina- 
tion as a “ touch of rheumatism,” and the therapeutic suggestions 
made accordingly. 
If the disease is seen early, before much actual change has taken 
place, there is usually a definite region in the spine to which the 
pain is referred, and in this region the motions are restricted, at 
first, of course, by muscular spasm, but later by osseous change. 
At this time, when the process is so definitely localized, the portion 
of the spine affected may appear more prominent than normal, 
suggesting the beginning deformity of Pott’s disease, and at this 
time a positive diagnosis may not be possible. The onset is sug- 
gestive, and also the reference of the pain to the back at the exact 
seat of the disease rather than the referred or abdominal pain of 
Pott’s disease, but it may require some weeks before the true nature 
of the process can be determined. Case IY. was at first thought 
to have Pott’s disease, and it was only after seeing him several 
times that the correct diagnosis was made. 
As the ankylosis of the spine takes place the ribs almost invari- 
ably are affected, and the process may prove so extensive that all 
the articulations become ankylosed, and the thorax is perfectly 
rigid. In this case thoracic respiration is, of course, entirely lost 
and the breathing is done wholly by the diaphragm. 
Beside the pain in the back and the limitation of motion, neu- 
ralgic pains in the arms or legs, together with disturbances of sensa- 
tion, numbness or hypersesthesia, are probably the most common 
symptoms. These are, of course, due to pressure upon the nerve 
roots, and, consequently, are not seen until the disease is well 
advanced, or when the onset has been unusually rapid, as in Case 
I. Following these neuralgic pains, when the disease is well 20 
OSTEO —ARTHRITIS OF THE SPINE. 
advanced paralysis may result, the extent of which varies from 
complete inability to use the part to a slight inconvenience. Rarely 
are. the two sides affected equally, or if both sides are affected the 
symptoms have developed at different times. This, together with 
the fact that the paralysis is peripheral in type, is of importance 
in differentiating it from Pott’s paraplegia. 
Occasionally, when the disease is very active, the same osseous 
deposit takes place in the posterior ligament (ligamentum longitu- 
dinum posticum), and may result in enough narrowing of the spinal 
canal to produce symptoms of pressure paralysis exactly similar 
to that seen in connection with Pott’s disease. This is not very 
common, but nevertheless does occur, and must be borne in mind 
in making the diagnosis. Case I. had this type of paralysis in 
connection with the paralysis of the arms, due to the pressure upon 
the nerve-roots. The presence of the two types of paralysis is of 
assistance in determining the diagnosis. 
After the active stage of the disease has passed, with the lessened 
vascularity and natural shrinking of the non-osseous structures, the 
direct pressure upon the spinal cord is usually relieved, and the 
same may be true of the pressure upon the nerve-roots. In my 
own experience, and, so far as I can learn, from the reported cases, 
there is no case in which the symptoms due to the direct pressure 
upon the cord have not been relieved. With the involvement of 
the nerve-roots, while there has always been some improvement, 
in many of the cases the recovery was never complete. 
The deformity, which is so striking at times, has a wide range of 
variation. In the most extreme form the rounded back with the 
protruded head and the flat chest (Fig. 3) is the type usually 
pictured or described. It is evident, however, that the nature or 
extent of the deformity must vary with the seat or extent of the 
disease, and also with the rapidity of its development. In Case 
IX., Fig. 4, the whole dorsal and lumbar spine is ankylosed, with 
scarcely any change in the normal curves. 
The lateral deformity of such an extreme type as is shown 
in Fig. 1 is rarely seen, and probably could only occur late in 
life. It is probably due to osseous deposit and thickening on 
one side of the spine, with atrophy and softening on the other. 
A moderate amount of lateral deformity is not uncommon, and JOEL E. GOLDTHWAIT. 
21 
is almost always present when the disease is in the cervical re- 
gion. 
The treatment of this disease is of more importance than is 
commonly supposed, and is partly medicinal and partly mechan- 
ical. As an early diagnosis is, of course, of the first importance, 
it is at this time, before the deformity has taken place, that the 
most can be accomplished. The disease is probably a trophic 
process, and, consequently, all medicines or methods of treatment 
which debilitate should be most carefully avoided. This naturally 
includes the various so-called rheumatic remedies, all of which are 
depressants, and also the various baths or courses of treatment 
which tend to lower the vitality. The general treatment should 
be wholly nourishing and stimulating. Extra diet, stimulating 
bathing, massage of the unaffected parts, electricity in a mild cur- 
rent, all are of value, and also the dry heat, provided it is not used 
so frequently as to be debilitating, relieves the pain and does much 
good. For medicines, iron, arsenic, and strychnine are the drugs 
which are of the greatest value. Cod-liver oil and alcohol in 
medicinal doses are also useful. For mechanical treatment some 
form of spinal support should be used at once, partly to relieve the 
pain by restricting the motion and partly to prevent the marked 
deformity from developing. Case IV. was under treatment quite 
early in the disease, and, even with the imperfect general care which 
it was possible for him to have, he has been kept from becoming 
more deformed than is shown in his picture (Fig. 2), A plaster-of- 
Paris jacket was used at first, and this was followed by a leather 
jacket, which is still worn. The whole spine has been involved 
and also the articulations with the ribs, and I am sure that without 
treatment the deformity would have been as great as that shown in 
Fig. 3. The position of the chest, with the greater room for respira- 
tion, has had a very definite beneficial effect upon his general health. 
Manipulation of the spine is naturally of little value, and prob- 
ably would result in more harm than good. Attempts have been 
made to forcibly break up the ankylosis,1 but they have been fol- 
lowed, as would be expected, by results which were not satisfactory. 
1 Striimpell. Deutsche Zeitschrift f. Neryenhk., 1897, xi. p. 338.