Elements of Surgery. Robert Liston

effused in greater or less quantity, according to the degree of curvature.

      The bones of rickety subjects are soft, cellular, and of a brown colour, contain a dark fluid, and are very deficient in earthy matter. As a simple proof of the latter circumstance, it may be mentioned that distortions of the pelvis can be, and often are, accurately imitated by soaking the bones for some time in acid, whereby the earthy matter is extracted. In many instances this component of the bones is almost entirely removed, and soft matter deposited instead; they then consist merely of an extremely thin external osseous shell, covered by thickened periosteum, and containing a pulpy substance resembling fatty matter. During the progress of the disease, the urine deposits, often in great quantity, a white sediment, which, on analysis, is found to be the phosphate of lime. In rickets the head is generally enlarged to a greater or less degree, and the bones of the cranium are thickened and spongy; not unfrequently the intellectual faculties remain acute. In adolescents and adults the limbs seldom become affected; the bones composing the spinal column are the seat of the disease, and, along with the distortion of the spine, the position of the ribs is necessarily altered. Certain rare cases have occurred, in which all the bones of the adult were softened to a very great degree. In one remarkable instance, the patient complained of an annoying sense of tightness in the limb most affected, and, on examination, the softened bone was found greatly depressed at that point, as if a strong ligature had been drawn tightly round it. Mr. Howship, who attended the patient, was so kind as to present me some years ago with a portion of the altered femur, which consists of a fatty-looking substance, and appears to contain little or no earthy matter.13

      

      Though incurvation of the spine occurs in boys, and even in adults, still it is most frequently met with in young females; and in them it is often induced by their having assumed a bad habit by sitting long in one constrained and awkward posture, as in writing or drawing, without, perhaps, the bones being unnaturally soft in the first instance. It often follows affections of the lower limbs, as of the knee or hip-joint; and is also caused by shortening of a limb, which has been negligently or ineffectually treated after fracture during childhood, or by the patient being allowed to continue a custom of standing awkwardly on one leg. In a very remarkable specimen in my possession, the curvature seems to have resulted from the tremendous enlargement and consequent weight of the head. The whole skeleton (head, thorax, pelvis, and extremities) is deformed, flattened, and twisted. This may have arisen more readily in consequence of the atrophy of the bones, and retardation of their growth, produced by the long confinement to bed. The number of ossa triquetra in the lambdoidal suture was unusually great. The patient attained the age of twenty-five. The affection commenced from birth.

      At first, during slight curvature from such causes, the spine can be brought into its original straight position by the voluntary action of its muscles. After some time, however, the curve cannot be remedied by any effort; interstitial absorption of the bodies of the vertebræ towards the concavity of the curve occurs; they become changed in form, and accommodated to their altered position, as shown in the accompanying sketch; the muscles also accommodate themselves to the new position, as do also the various ligaments connected with the spinal column. When the curvature is seated in the dorsal vertebræ it is generally to the right side; this shoulder is raised, and the chest is protruded, whilst the opposite side is depressed and flattened. The clothes hang loose, or fall off on the left side—the patient rests the weight of his body chiefly on the left leg—on stooping the right scapula projects, and, on examination, is found to be nearer to the spinous processes of the vertebræ than the left. The left cavity of the chest is diminished, and the ribs press upon the heart and lungs, causing difficulty of breathing. To preserve the balance of the body, a curvature occurs below the former, and in the opposite direction; and not unfrequently there is a third incurvation situated above the primary one.

      The bones of the pelvis become distorted, and are twisted to one side; or, when the softening is great, and the patient confined to the recumbent position, the introitus of the cavity becomes diminished in the antero-posterior diameter; and, if the patient walk about, the ossa pubis are squeezed together, in consequence of the pressure of the ossa femora against the acetabula. The crests of the ilia are often bent inwards, in consequence of the pressure of steel apparatus injudiciously applied with a view of removing deformity. When the bones become consolidated after such distortion, they present most serious obstacles to parturition; and, most unfortunately, crooked and deformed women possess, it is said, “great aptitude for conception.” When, in such females, the untoward circumstance of pregnancy has occurred, it has been necessary, in some, to have recourse to the Cæsarean operation, and others have been delivered with the greatest difficulty and danger; notwithstanding which, many of these latter have, after recovering from a long and tedious illness, again become pregnant.

      In some cases the softened ribs not only compress the organs of the chest, but are also pressed down upon the abdominal viscera, or even into the pelvis. The symptoms arising from such displacement are at first urgent, as can readily be imagined, and are often treated as inflammatory, to the detriment of the patient.

      After some time, as the state of the patient’s health improves, the bones in some degree regain their original firmness, and the curvatures are rendered permanent. New bone is deposited in the concavity of the curve, at first in irregular masses, but afterwards becoming condensed, and assuming a more regular form, the column is thereby supported and strengthened.

      Bending of the spine backward, with depression of the spinous processes, is extremely rare. But curvature forward, with projection of these processes, is by no means uncommon, and is generally supposed to be caused by caries of the bodies of the vertebræ; in many instances, however, it arises from interstitial absorption only.

      Curvature from caries of the vertebræ, though not so frequent as the curvature from other causes, is met with pretty often. In adults, the curvature from ulcerative absorption is more common than that from softening of the bones. It is attended with the formation of purulent matter, which presents in the loins, at the top of the thigh, or near the anus; the bones may become affected secondarily, though much less frequently, in consequence of the formation and accumulation of purulent matter in their neighbourhood. There is pain in the loins; the patient walks in a stooping posture, and often complains of pain in the knee or thigh. The lower limbs sometimes become paralytic, as also the sphincters and extremities of the hollow viscera; this, however, may arise, without curvature, from softening of, or effusion on, the chord, or diseased thickening of its membranes. In some cases the palsy supervenes slowly; at first the patient has an awkward gait; he lifts his feet high to avoid stumbling, and afterwards puts them down clumsily and suddenly; the foot, in some cases, is extended, so that the patient is unable to plant the sole on the ground. Retention of urine occurs, and is followed by incontinence, with copious deposits.

      In the treatment of Rachitis, the chief indication to be fulfilled is to support and increase the powers of the system; and this may be accomplished by affording the patient a generous diet, keeping the bowels in good order, enjoining gentle exercise and exposure to pure air, by the assiduous use of frictions, and by supporting the softened bones by properly applied and light machinery. Much mischief may be done by clumsy and heavy apparatus which confine the movements of the patient; the muscles are wasted, consequently the spinal column is weakened, the general health is impaired, and the disease is aggravated. Some have recommended the internal administration of the phosphate and muriate of lime, but their efficacy is extremely doubtful. Preparations of iron seem to answer much better in the greater number of cases. In cases of curved spine, apparently arising from bad habit, the patient should be in no degree confined at writing, or drawing, or music; her posture while at work or play ought to be attended to, as well as her mode of walking or standing; and, if awkward, prohibited. Gymnastic exercises of the more gentle kinds ought to be enjoined, such as those with poles and light wooden clubs, the turning of a wheel, the exercise with balls, &c. Carrying weights on the head can only be applicable in certain cases. The shoulders, in some instances, ought to be kept back by means of a light back-board; and in aggravated cases the weight of the shoulders, and sometimes also of the head, must be taken off the spine by a light and well-contrived apparatus.