Ramsbotham's Atlas of Midwifery. The rickety distortions of the pelvis are probably never met with unaccompanied by spinal curvature; though the latter may occur without materially influencing the pelvic diameters. SPINAL CURVATURES. To one variety of spinal curvatures we have already alluded, that in which there is a projection inwards of the lumbar vertebræ-lordosis. This, however, is not ordinarily a primary affection of the spine, but one secondary to a curvature that has formed higher in the column, and, owing to the sigmoid form of the normal spine, calls for a compensating inclination in the opposite direction, which will necessarily take place where there is a natural tendency forwards. It may also result secondarily from obliquities of the pelvis and coxalgia, which would, however, act differently from the last-named lesion, inasmuch as they would induce a lateral deviation, as well as a projection forwards; in so far, therefore, we differ from Mr. Shaw's views, who states that rickets have no share in producing lateral curvature in females. The main primary curvature of the spine belonging to rachitis, and the one that is more im The Principles and Practice of Obstetric Medicine and Surgery, &c., by Francis H. Ramsbotham, M. D., London, 1841. portant than any other, on account of the frequency of its occurrence, as well as on account of the misery it inflicts upon the patient, and the great deformity produced, is kyphosis, also known as the angular curvature, Pott's malady, or the hump-back. This is almost invariably the result of inflammation and caries of the bodies of one or more of the dorsal vertebræ, or of their intervertebral substances, causing a collapse of several vertebræ, and consequent backward projection of their spines, and an approximation of the corresponding ribs. This disease universally commences early in life; previous to, or about the period of, second dentition. A backward curvature occurs later in life as the result of senile atrophy of the bodies of the vertebræ, which has nothing in common with the angular curvature of rachitis. Lateral curvature of the spine, or scholiosis, is rarely of a rickety character-it may be primary or secondary; and presents an illustration of the law of compensation, equally with the curvatures previously considered. To avoid returning to the subject of spinal curvatures, we add the following remarks on this deformity. The primary curve generally occurs in the dorsal, while the compensating curvature, in the opposite direction, is found in the lumbar region; and as the former is most frequently to the right, the latter, as a legitimate consequence, is most often to the left side. This distortion chiefly affects the female sex, and may be brought on by irregular muscular contraction, or by deficient action of the muscles of one side of the trunk, whether owing to want of exercise, or actual disease, such as pleurisy, or a paralytic affection. When the deformity results from rickets, the primary curvature will probably be found to have taken place in the lumbar region, while the dorsal is secondarily affected. The various malformations of the spine, which we have considered, are not always isolated; but may be complicated with one another, as they are associated with deformities of other parts of the skeleton. That the thorax should be implicated whenever the dorsal vertebræ of the spinal column are affected, may be inferred from the relation the latter bears to the cavity, as well as to the ribs and the sternum combining to form it. The most common malformation of the thorax consists in a flattening of the sides, with a projection of the sternum, and a swelling of the sternal ends of the ribs; this gives rise to the so-called pigeon-breast. It is very frequently, but not necessarily, associated with angular curv ature of the spine; for, in some cases of this disease, the ribs are raised and not flattened, and the lower end of the sternum, instead of being forced out, is actually drawn in, owing to the ribs not being lengthened, and the thorax, in consequence, assumes a more globular form. The thorax, in all cases of rickety distortion, approaches the pelvis unduly, and the abdominal cavity will thus be diminished. A depression of the sternum is very common in rickety subjects; the whole length of the bone being marked by a more or less deep furrow, while the ribs are curved outwards. In both cases just mentioned, the sternum does not deviate from the mesial line; a displacement of this bone, as well as of the thoracic parietes, accompanies lateral curvature of the spine; in this case, to employ the description of Rokitansky, the thorax seems displaced in the opposite direction to the convexity of the dorsal curve, and the whole, or more commonly the lower end only of the sternum, swerves from the mesial line in the same direction; the axis of the thorax itself inclines towards the convex side of the dorsal curve. One consequence of this deviation is, that that half of the thorax which is on the convex side of the curve is lower than the other, and approaches the pelvis; when there is considerable curvature, the false ribs touch the ilium, or even project into the iliac fossa. But, in extreme cases of combined lateral and posterior curvature in the lower dorsal region, the thorax assumes the contrary position; the ribs which pass from the concavity of the curve, force the chest to the opposite, the convex side; the sternum diverges in the same direction, and the sunken half of the thorax is that on the concave side of the curve. The ribs are packed closer together on the concave than on the convex side; hence the dimensions of the two lateral halves of the thorax are much altered; the one on the concave side being contracted in its antero-posterior, but enlarged in its lateral diameter, while the reverse is the case on the convex side. The ribs, independently of any morbid change of structure, suffer considerable changes in form and outline in these deformities; becoming more or less flattened, and being more or less turned on their axis, according to the dislocation of the vertebræ. The scapulæ follow the distortion of the spine, and also exhibit other evidence of being the actual seat of textural derangement. The upper extremities present similar distortions to those seen in the lower extremities in very advanced cases of rachitis; the bones are ill developed, flattened, and variously curved, while the epiphyses are enlarged. Dr. Farre' states that he has met cases in which the upper extremities were bent by rickets, when the lower extremities and the rest of the body exhibited no signs of the disease. If any further proof were required that rickets is essentially a constitutional disease of the same family as scrofula and tubercle, and that its phenomena are not the mere result of mechanical pressure, such cases as those of Dr. Farre would afford it; still, it is important not to overlook the physical influence of the weight of the body in promoting distortions, as we thereby obtain a valuable indication for treatment; for, while everything should be done to correct the vitiated state of blood, it is wise at the same time to remove all unnecessary strain or pressure from any part of the frame, and to afford such support to the weaker points as mechanical ingenuity may suggest. Quoted by Mr. Stanley, loc. cit. p. 226. CHAPTER XLIII. ADVENTITIOUS GROWTHS. UNDER this head we shall consider the various enlargements of an homologous character, termed exostoses and osteophytes, and among which we may also class enchondroma, as well as the heterologous growths met with in bone. Bony tumors are commonly treated of as hypertrophies; we adopt our arrangement partly for convenience, and partly because, as we have already stated, there is a broad distinction. between the increase of the normal texture from mere hyper-nutrition, and the grotesque and extravagant forms springing out of various morbid conditions, to which we shall have to advert. Besides, the various forms of so-called hypertrophy are so frequently complicated with other diseased conditions, that it is impossible to determine which group predominates; nor can an arrangement of the tumors of the bone, as Mr. Stanley observes, be founded on the place of their origin, since many of them, identical in nature, arise indifferently from the periosteum, the compact, or the cancellous tissue of bone. ENCHONDROMA. We follow the example of Mr. Stanley, and consider, first, the abnormal production of cartilage in connection with bone; or, as it has been termed, by Professor Müller,' enchondroma. It consists essentially of the same chemical and microscopic elements as true cartilage, and occurs more frequently in bone than in any other physiological tissue of the body; the bones of the fingers and toes being chiefly liable, though the ribs, vertebræ, and sternum are not exempt; and cases are recorded where the skull, the ilium, and the long bones have been attacked. Müller refutes the theory of its belonging to the family of scrofula, and attributes it to a peculiar formative process in bone, in consequence of which the embryonic primitive formation of cartilage takes place, and is kept up without the attainment of consolidation, or the more perfect organization of the products. The enchondroma appears to possess an independent vitality; it is radically cured by amputation, and appears never to enter into combination with any other changes in the bone. The tumor may originate within the cancellous tissue, or on the surface of the bone. The rapidity and extent of its growth varies, but generally it is of slow progress, and does not exceed the size of an Ueber den feineren Bau der Krankhaften Geschwülste, 1838, p. 31. orange. When seated within the bone, the latter gradually expands with the development of the tumor, yet it is unaccompanied by pain or disorganization of the adjoining parts; when external to the bone it exhibits a lobulated arrangement, and is surrounded by a fibrous sheath. The central variety presents a semi-elastic feel, and, on section, the knife passes through a thin crackling shell of bone, and then exhibits a white cartilaginous mass, which is occasionally found to contain some small cells, while, in some tumors there is an interlacement of fibrous tissue, in which the cartilage is imbedded, thus approximating to fibrocartilage. They may be solitary, or occur in large numbers in the same Enchondroma. Portion of the tumor removed from the lumbar vertebræ of a soldier, consisting of nodules of cartilage of various forms, with the microscopic features of fetal cartilage. In the centre of some of the nodules there are small portions of cancellous bone; the centres of others are softened.-St. Bartholomew's Museum, xiv. ii. individual. A remarkable instance is recorded in the Reports of the Pathological Society of London,' of a boy, in whom the slightest blow produced tumors of this kind. At the time of observation, he presented fifteen or sixteen of these swellings, on the fingers and metacarpal bones, one of which had attained the size of an orange, and required removal, solely on account of its bulk. The superficial variety, though microscopically and chemically identical with the central form, is characterized by the absence of an osseous shell; it is met with chiefly in the pelvis, on the cranium and the ribs. Lebert, who confirms the descriptions and all the details of Muller, gives some cases which fell under his own observation, one of which is particularly interesting, as showing the development of the cartilage,' the characters of which were not at once apparent to the naked eye from the highly vascular condition of the tumor. There is, generally, no disposition to ossification, though Rokitansky states that he has observed this metamorphosis in the aggregate variety. The disease is chiefly met with in early life, and appears to be commonly due, as Muller has shown, to mechanical injury interfering with the due development of bone at that period. A case, accompanied by a delineation, in which there was partial ossification, is given in Vogel's Pathological Anatomy.3 1 1848-49, p. 113. 2 Physiologie Pathologique, tom. ii. p. 212. |