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. Sea-bathing, good air, out-of-door exercise, and attention
to diet, are of material importance. Frequently advantage will result
from the patient’s sleeping on a hard mattress; and, in bad cases, from
lying down, when tired, on an inclined plane.
In great softening, it will be necessary to confine the patient
entirely to the recumbent position, and to support the head and
shoulders by a light and firm machine. The causes, symptoms,
appearances, and treatment of caries of the spine, in its different
regions, with or without curvature, will be afterwards considered.
OF INFLAMMATORY AND OTHER AFFECTIONS OF THE ARTERIAL SYSTEM.
During inflammation of arteries, the actions of the vessels are
accelerated and attended with pain; the internal coat is found to be
of a red colour, from increase of its vascularity, and not from its
being merely tinged with the colouring part of the blood; or it is of a
yellowish hue and rough, from the deposition of lymph on its surface,
whilst the external coat is thickened by the infiltration of serum and
lymph. When bloodvessels are inflamed from mechanical irritation, lymph
is secreted on their internal coat, becomes organised, and obliterates
their calibre; if deficient in nervous influence and circulating fluid
at a particular point, there ulceration of their coats occurs; if
violently injured or completely isolated, their coats mortify; and
these circumstances must all be calculated on in the surgical treatment
of arteries. A universal inflammatory state of the arterial coats is
said to have existed, and its symptoms have been minutely detailed; but
its occurrence seems to be extremely rare, and the treatment is medical.
Inflammation is supposed to precede degeneration of the arterial
coats. As a person advances in life the arteries lose elasticity, and
the heart its balance with them; either the one or the other becomes
dilated, their parietes are thickened, and the valves are altered
in structure; the enlargement of the vessels is generally greatest
towards their origin. The dilatation of arteries, more especially of
the internal ones, is often very great; ultimately the internal coat
gives way, and the external, with the surrounding tissues, yields
in proportion as the blood diffuses itself. The internal tunic is
occasionally burst in consequence of violent and sudden muscular
exertion; and, even when the vessels are pretty limber and sound,
effusion of lymph, and obliteration of the vessel ensue, or, more
frequently, aneurism.
Previously to the rupture of the internal tunic, however, there is,
in most cases, a morbid alteration in the texture of the vessel. The
internal coat becomes dry; its textures is more dense and less elastic,
and consequently more brittle. Morbid matter is deposited between the
middle and internal coats, and this, by stretching the latter still
further, diminishes the elasticity and cohesion of their texture.
The deposit is at first to a slight extent and of soft consistence,
somewhat resembling condensed fatty matter. Afterwards it increases
in quantity and consistence, becoming, instead of soft and yielding,
dense, hard, and incompressible; in short, calcareous.
[Illustration]
Though the morbid deposit is at first confined, as above related, its
limits are afterwards extended; calcareous matter is insinuated, either
in minute particles or in broad laminæ, amongst the fibres of the
middle coat, is also found external to it, and occasionally situated in
the cellular coat. In fine, the various component parts of the parietes
of the vessel degenerate, according to the degree of advancement which
the disease has attained; and such a condition is the predisposing
cause to ulceration of the internal coat, and subsequent effusion of
blood. The steatomatous, ulcerated, earthy degeneration of the proper
coats of an artery, as Scarpa, the celebrated professor of Pavia, has
it, are well exhibited in the accompanying sketch.
During violent and sudden exertions the more brittle parts may burst,
either at a certain point, or throughout the whole circumference of the
artery; and on this such results will supervene as on ulceration of the
internal tunic. Ecchymosis then takes place under the cellular coat,
which becomes thickened, and incorporated with, and strengthened by,
the surrounding tissues; this is the incipient state of an aneurismal
tumour. The effusion of blood, gradually increasing, distends the
cellular coat, forming the cavity into which it is poured, and produces
a tumour of a size proportional to the distensibility of the tunic and
the force of the effusion. Sometimes the external coat is separated
from the others to a considerable extent by the insinuation of blood.
An aneurism, however, may exist from simple dilatation of a portion of
the vessel, gradually increasing, and forming a cavity in which the
blood accumulates. At one time it was supposed that all spontaneous
aneurisms were caused by simple dilatation of the canal; but such an
opinion has been long shown to be incorrect, and the term of true
aneurism is now confined by many to that tumour and accumulation of
blood consequent on the giving way of the internal coat, and situated
externally to the canal of the artery. It is true that dilatation may
occur previously to the giving way of the coats, and thus the two
causes are combined. The dilatation occurs from the calibre of the
artery being considerably diminished, in the first instance, at the
point where its coats have undergone the calcareous degeneration, and
only acts as a predisposing cause to the failure of the coats when
thus diseased. When there is mere dilatation, the tumour is generally
of an oval form; but when the internal coat gives way, a lateral
prominence is formed, and gradually increases in size. The shape of
the true aneurism is various: sometimes the tumour is globular, with a
narrow neck; and, from this being of considerable length, it becomes
difficult, in some situations, as above the clavicle, to ascertain the
particular artery which is the seat of disease, the globular extremity
of the tumour presenting itself at some distance from the vessel with
which its pedicle is connected. This is rare, however. At other times
its form is very irregular, being most prominent at the part where the
accumulation of the blood is least resisted. Pulsation in the tumour
is distinct from the first, and is painful to the patient; and in the
external aneurisms it is so strong as to be perceived by a bystander
at a considerable distance. The tumour is at first compressible, and
completely disappears on firm pressure being applied, either directly
to the sac, or to the artery above, the sac being thereby emptied of
its contents, or prevented from being filled. It may sometimes be
difficult to form an accurate diagnosis, from the circumstance that
tumours, not aneurismal, receive a pulsatory movement from an artery
or from arteries immediately beneath them; such difficulty is obviated
by attention to this simple test—that in an aneurism the pulsation is
felt equally in all directions. Besides, if the tumour is moveable,
it can be partially displaced, so as not to lie immediately over a
large artery, and, if it be not aneurismal, it will then be found to
possess no pulsation; if it be an aneurism, its pulsation will not be
diminished by any change of position.
The blood contained within the aneurismal sac, being comparatively
motionless, coagulates, and the coagulum is attached to the inner
surface; at first it contains red globules, but it afterwards loses
them, and becomes of a pale hue, consisting solely of fibrin. This
coating gradually increases, and attains no small thickness, fresh
portions of fibrin being superadded in concentric laminæ. These layers
are chiefly deposited from the blood within the cavity, but they also
appear to receive addition from lymph being effused by the vessels
proper to the original parietes of the tumour. By such thickening, it
can be easily conceived that the pulsation will be somewhat lessened.
In large aneurisms the accumulation and deposit of fibrin may be much
greater at some points than at others, and hence pulsation may be
rendered “not equal in all directions.” It is not, however, diminished
to any great extent; for absorption of one or more points occurs, and
the coating is again attenuated.
In some rare cases the deposition of fibrin has gone on gradually
accumulating, filled completely the aneurismal cavity, and thus
effected a spontaneous cure, the remaining solid tumour imperceptibly
diminishing by the action of the absorbents. After obliteration of
the aneurismal cavity, the fibrin is generally deposited in so great
quantity as to occupy the calibre of the vessel above and below the
tumour, obstructing the progress of the blood, causing it to flow by
the smaller and collateral branches, and effecting a spontaneous cure,
somewhat similar to that produced by the artificial application of a
ligature. Coagula are seldom formed in the dilated vessel, to whatever
size it may be enlarged, unless there is fissure of the internal
coat; for in no other way can a portion of the blood readily become
stagnant, while the calibre of the vessel remains pervious. There
is in my collection a preparation of dilated aorta, to the coats of
which adheres a large firm coagulum. Occasionally, though rarely, a
dilatation of the internal coats is met with accompanied by thinning of
the external ones. Of this sort of diverticulum, there is also a good
specimen in the collection here alluded to.
A spontaneous cure may also be accomplished from the original aneurism
being compressed by one of a more recent origin, causing ultimate
obliteration of the canal. Of this I recollect one remarkable instance;
the patient was afflicted with an aneurism of the axillary artery,
which had attained a large size, and the cure for the disease in
this situation being then unknown or unattempted, the patient was
considered as lost; but some time after the tumour began to diminish,
and disappeared. The patient died; and the cause of death was found to
be the giving way of an aneurismal tumour of the arteria anonyma, which
was situated so closely to the aneurism of the subclavian as to have
acted as a mechanical compress, causing obliteration of the vessel at
that point.
When a cure has been effected, the vessel is found to be converted into
a dense and impervious cord at the site of the tumour. The canal above
is dilated; the coats are thickened, especially the middle; and from
the thickening and increased action of the fibres, the internal coat
becomes somewhat rugous, the rugæ being in a transverse direction.
The aneurismal tumour in general increases, and approaches the surface,
involving and destroying all the intervening textures. If resisted in
its enlargement by bone, even this is not sufficient to impede its
progress; the bone is absorbed, and perhaps ulcerated, at the point
where it is compressed by the tumour. The osseous is more liable to
destruction from this cause than the cartilaginous tissue, contrary to
what occurs from compression by abscess. Ultimately the sac gives way,
and its contents are discharged either externally, or into an internal
cavity or canal, in consequence of its parietes sloughing from the
compression made by the tumour; and such termination is instantly fatal.
[Illustration]
An aneurism of the descending aorta, in a great measure one from
dilatation, is here represented: the patient also laboured under
popliteal aneurism of one limb, and inguinal of the other. He died
suddenly, in consequence of the giving way of the internal tumour.
The escape of blood into the cellular tissue may even take place to
such an extent as to prove fatal in a few hours. The disease may also
prove fatal by mere compression, as of the trachea, impeding breathing,
and inducing disease of the respiratory organs; or by pressure on the
gullet preventing the passage of food: in the latter case, however, the
dissolution is generally more sudden, in consequence of the compressing
part of the tumour giving way, and the contents being evacuated into
the stomach or mouth. If the aneurism compress a plexus of nerves, or
the spinal chord itself, the anterior part of the vertebræ having been
previously absorbed, paralysis is produced.
In consequence of aneurism, the circulation of blood in the vessel
is obstructed; hence the collateral branches above the tumour become
enlarged, and through them the circulation is continued; by their
anastomosis with collateral branches which arise below the seat of the
tumour, a portion of the fluid is brought back into the canal of the
original artery. The circumstance of collateral enlargement used to be
distinctly enough demonstrated in amputation, one of the old cures for
the disease.
The tumour may be suddenly increased by a portion of the parietes
giving way, and the blood being propelled into the cellular tissue,
which becomes thereby condensed, and supplies the deficiency in the
original sac; diffuse is thus superadded to the true or encysted
aneurism.
The disease is generally accompanied with great pain, the neighbouring
nerves being much stretched by the enlargement of the tumour, as in the
axilla or ham; in these situations also the limb below the aneurism
is much swollen from the compression of the absorbents and veins and
consequent infiltration into the cellular tissue. Diffused aneurism
from wounds, and the other species of the disease, will be afterwards
treated of.
The peculiar degeneration of the coats of the vessels has been already
stated to be the predisposing cause of aneurism; and the disease
may be directly caused by over-excitement of the circulation, or
by an over-exertion of the muscles. It is more frequent in males
than females.[14] In men somewhat advanced in life the arteries get
hard and rigid, whilst at the same time the muscles are strong, the
general health good, and the whole frame stout and active; so that the
patient is capable of violent muscular action, such as the arteries
are ill able to bear, and consequently the internal coat of a vessel
yields, and lays the foundation for an aneurism.[15] The lower limbs
being chiefly subject to such exertions, aneurism in them is most
frequent;[16] and for the same reason it is said to be common in those
who ride much on horseback. Degeneration of the coats of the vessels
in the superior extremity is extremely rare. This is another reason why
spontaneous aneurism seldom assails them.
_Treatment._—In internal aneurism the only indication which can be
followed, with any chance of success, is to favour the occurrence of
a spontaneous cure, by abstracting all stimuli, mental and corporeal,
by enjoining complete rest, by keeping the patient on low diet, and by
repeated bleeding. Thus the force of the circulation is diminished,
and coagulation, it is said, promoted; by this practice aneurisms,
the progress of which defies external means, are occasionally, though
very rarely, cured. Ice and other cold applications to external
aneurisms, or those which have made their way to the surface, have been
recommended to induce coagulation, but their use is not unattended with
danger; for they may, in some stages, so far diminish the vitality of
the coverings as to cause sloughing, and fatal hemorrhage.
In the treatment of aneurisms exterior to the great cavities, important
improvements have been made in modern times. No success can be expected
to follow palliative and temporizing measures, and a cure can result
only from operation. Formerly it was the practice to lay open the
aneurismal tumour, to search for the extremities of the artery opening
into the cavity, and to secure them by a ligature, or close them by
pressure, styptics, or both. In some few instances this method had
permanent success; but in the majority the operation proved wholly
abortive, and not unfrequently fatal. It was necessarily tedious in its
performance, and attended with much danger, the blood being discharged
in great profusion immediately after the opening of the sac, and the
extremities of the vessels being with great difficulty detected and
secured. Besides, the vessels in the immediate neighbourhood of the
tumour having generally undergone the degeneration already mentioned,
were incapable of taking on any healthy action; the application
of ligature on a vessel thus circumstanced could consequently be
productive of no advantage. From this method having almost invariably
proved unsuccessful, practitioners in those days generally preferred
amputation, when the tumour was so situated as to allow it; and when
the disease occupied a situation in the limb so high as to prevent
amputation, the case was deemed incurable, and the patient abandoned
to his fate. But amputation was accompanied with circumstances almost
equally alarming with those attendant on division of the sac: the
hemorrhage was very great; for as a consequence of obstruction to the
free passage of the blood in the aneurismal vessel, the circulation
was chiefly carried on by the collateral anastomosing branches, which
were thereby so much enlarged, as, on their division, to pour out
blood with a profusion resembling that of arteries of the second or
third magnitude. Continued pressure was employed as a less hazardous
method of cure, but was equally inefficacious; and was also attended
with danger, from the risk of sloughing. If the practice ever proved
successful, it was only after a tedious perseverance in its use, and
long confinement of the patient.