"The opinions generally entertained upon the subject of distorted spine appear to have been, that it has always had its origin in caries of the vertebræ, or in a morbid state of the bone tending to it. Prior, however, to the occurrence of any alteration in the position of the spinal column, except in those cases where it arises from local injury, we find that there is a considerable decrease of muscular power, and a sense of great general lassitude and weariness: the least bodily exertion induces great fatigue, and the patient, even if permitted, is not inclined. to indulge in the sports common to childhood; there is generally derangement of the digestive organs, and an uneasiness which is referred to different parts of the spine. As no particular spot can be pointed out as the seat of disease, these symptoms perhaps are overlooked, till, from the general causes of debility, some part of the muscular structure becomes unable to support the spine in the erect position, and it yields; this perhaps may, in some instances, give rise to unnatural pressure on the parts, and consequently inflammation of the ligaments, absorption of the intervertebral cartilages and caries of the bone; but, that very considerable distortion of the spine, both laterally and anteriorly, may.exist for years without such effects being produced, I have had sufficient demonstration, both from the instances of restoration which I have witnessed, and from inspection of the parts in the dead subject." 25.

The firmness of cartilage will generally be found in proportion to the strength of the muscles. From a number of experiments made by Mr. Wasse, (Philosoph. Trans. vol. xxxiii.) it was ascertained, that there is nearly an inch difference between the height of a body on first rising in the morning, and in the evening. The same writer makes this remark; "all the difference I find between labourers and sedentary people is, that the former are longer in losing their morning height, and sink rather less than the latter."

The greater strength of the intervertebral substance in persons advanced in life, may be assigned as the cause of their exemption from this disorder; Pott having remarked that he had "never seen it at an age beyond forty." Our author thinks, that sufficient importance has not been attached to the influence of the cartilages and ligaments in the production of this disorder. Their relaxation or firmness-increase or decrease of size-power or weakness, will be commensurate with the tone and vigour of the muscular structure. The diminished strength of the ligaments and cartilages is a sequel of muscu lar debility; and, therefore, by giving power to the muscles, an accession of strength is given to the ligaments and intervertebral substance.

"That to muscular debility we may ascribe the first occurrence of the disease, is confirmed by the method of cure, which, however it may differ as to the particular mode of conducting it, is founded on the principle of giving increased action to those muscles of the Vol. III. No. 12.

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spine which have been weakened and extended, and thereby equalising their contractile power with that of their antagonists." 31.

Our author thinks, that spinal distortion, arising from muscular debility, may be distinguished from disease of the bony structure, not only by the mode of its termination, but by the history of the complaint. We shall allow the author to attempt the distinction in his own words.

"In the lateral distortion, the incurvation is commonly gradual and not sudden, and if it occur in the cervical vertebræ there is a second or third curve from the action of the muscles of the spine necessary to preserve the centre of gravity; it is not attended with acute pain, but merely a sense of uneasiness, which may, perhaps, be referred to the fatigue of the muscles connected with the spine. In several cases of long standing that have fallen under my own observation, the patient has never been sensible of any pain or uneasiness in the spinal column or its vicinity, and, except from the alteration in shape, would have been totally unconscious of the approach of the disorder. The length of time which it is in forming is also various, sometimes its progress is slow and insidious, occupying a period of one, two, or three, and in some instances six or seven years or more. Its approaches are for a long time scarcely perceptible, but on the occurrence of any particular disturbance to the constitution, such as febrile indisposition, the spine in the course of one, two, or three months, is found to yield in a greater degree than it had previously done during as many years.

"In the anterior curvature of the spine the curve will also be found very gradual, as it comprehends several of the lower cervical, and the whole of the dorsal and lumbar vertebræ; in some instances it is formed by the dorsal and lumbar only; in these cases likewise the pain is of an obtuse kind, which may probably be referred to the

same cause.

"In caries of the bodies of the vertebræ there is a sudden projection of the part; the relative position of the spinous processes is altered, and they are occasionally separated to a greater distance than could be imagined, without a loss of substance anteriorly; in other instances they only approximate more nearly to each other. The incurvation from within outwards is occasioned by the absorption of the bodies of one or more of the vertebræ. The circumstance of the disease having been preceded by a blow, is, with others, a fair ground for suspicion of caries. The pain, previously to any incurvation taking place from disease of the bone, is more acute than in that arising from weakness, as might be expected from the manner in which inflamma

"Mr. Copeland relates a case in which the intevertebral substance was removed, and the dorsal vertebræ anchylosed, without there having been any elevation of the bent spinous processes, or distortion of the form of the spine; this case however must be deemed of rare occurrence. Copeland's Observations on the Spine, p. 15.”

tion proceeds in parts of a ligamentous, cartilaginous, or bony texture, and it is more confined to the diseased part, and attended with greater febrile indisposition." 36.

Our author considers it a matter of great importance, to distinguish the disease of which he treats from that produced by caries and rickets, "as it is evident, that where any alteration of structure has taken place in the bodies of the vertebræ from the former, or where there is a scrophulous disease in the parts, any attempts to cure the distortion by muscular exercise would, by preventing the natural cure by anchylosis, be highly injurious."

Treatment.-On the first invasion of the disorder the digestive organs ought to be strictly attended to-the diet should consist of plain animal food once a day," of which the pa tient ought to be allowed to eat heartily"-bread and butter, or bread and milk, or tea, for the other meals-passive and active exercise of the spinal and other muscles, as friction, shampooing, percussion, horizontal position, galvanism,&c. -and as active, the excitement of the muscles by volition, or general muscular exercise. These various methods of exciting the warmth of the parts, and promoting a greater flow of blood to them, differ as to effect, only in degree. Their choice and application must be left to the discretion of the practitioner, and they must be regulated by the sensibility of the parts and the state of the disease. The gentler means should be used at first. Shampooing and percussion possess some advantages over friction. These means should be employed for not less than an hour at a time, and repeated twice or thrice in the twenty-four hours-never carrying them the length of exciting pain. As to position, in the anterior curvature of the spine, our author prefers recumbency on the back, although he does not consider it absolutely indispensible. He merely recommends it to be pursued to such an extent as not to be productive of inconvenience to the patient.

"In the lateral incurvation the confinement to a general horizontal posture is all that is requisite, without restricting the patient to any particular position." 43.

The recumbent position, by taking off the superincumbent weight, and thus enabling the parts to regain their former healthy condition, is, our author acknowledges, "a measure of essential importance" in the treatment; and, in many slight cases, may alone be sufficient; but, he thinks, it ought not to be relied on exclusively. When the spine has thus recovered its proper station, the muscles attached to it, and which are

its principal support, are left in an atonic state, and incapable of executing their functions. It is obvious that the best means of giving permanency to the cure, and of preventing a recurrence of the disorder, is by giving additional tone and strength to the muscles in question.

"One of the methods that I employ for this purpose and the detail of which will place the subject in the clearest point of view, is the following a weight appended to a cord is passed over a pulley, and the other extremity, having a strap attached to it, is fastened round the patient's head; the pelvis being fixed, the patient is directed to raise the weight by drawing the head and trunk backwards, and to repeat this effort until fatigue is produced. The frequency of repetition of this exercise of the muscles, and the weight of the body to be raised, must, of course, depend on the patient's strength. After each effort, it is advisable to take rest, by lying down on a couch or sofa, in order that the muscles may not be placed on the stretch and thus prevented from recovering themselves. This mode of exercising the muscles is equally applicable to the anterior curvature of the spine, as to those which take place laterally." 44,

Our author advises a combination of the different means enumerated, as being more efficacious than any one measure however strenuously pursued. He has observed that when the recumbent posture was trusted to alone, a great degree of dyspepsia was often induced, a circumstance that did not occur when action and rest were alternated, which strengthened the digestion as well as the muscular system.

Mr. Ward is no advocate for any mechanical contrivance in correcting the spinal distortion, as he coincides with Mr. Wilson in believing that they injure the bones of the pelvis on which they are made to rest. Seven cases are related illustrative of the methodus medendi above detailed. For these cases we must refer to the work itself.

The second chapter is on Deformity of the Chest. As the bones forming the thorax derive their support from the spinal column, any incurvation of this part will necessarily be accompanied by a corresponding displacement of the ribs and sternum, and the removal of the spinal distortion will usually be followed by an improvement in the form of the chest. But thoracic deformity is not unfrequently found to exist without any derangement of the spine. The general appearance of the chest, in these cases, has procured for it the term chickenbreast.

"It is marked by an apparent projection of the sternum, which seems rather to arise from a loss of the arched form and a flattening of the ribs on each side, than from any unnatural protuberance of the bone itself. Sometimes there is a falling in of the breast bone, producing a preternatural hollow instead of projection of this part of the

chest, in which case the edges of the false ribs are frequently turned in upon the lungs, and the ensiform cartilage can scarcely be felt, and not unfrequently one side of the breast is flattened, while there is a corresponding swelling of the opposite side.

"In weakly and delicate children also, independently of any distortion, there is a greater length of chest from the first to the lowest false rib than in the natural state; the clavicles project forwards, as well as the points of the shoulders, and there is not that depth or capacity of chest from the sternum to the spine which may be observed in perfectly healthy individuals; this is particularly apparent when the patient is viewed sideways." 69.

The diminished capacity of the chest is productive of various complaints, as palpitations, dyspnea, and pulmonic affections. In the treatment our author relies principally on the local means before detailed, with proper attention to diet and the general state of the constitution.

"The method which I have employed with regard to the local means in those cases, where the spine has been exempt from disease, has been that of placing the intercostal muscles and those connected with the anterior part of the chest on the stretch, by placing the patient in a standing position, with the back against a cylindrical piece of wood and the arms extended backwards. By this means an extension of the pectoral muscles is produced, and they are thus brought into full action upon the ribs as well as the muscles of the abdomen which are opponents to them. The position, as well as the condition of the muscles, may be imagined by that of a person in the act of attempting to throw a somerset backwards. While the patient is in this situation he is desired to take deep inspirations. I direct manipulation, and afterwards percussion, to be employed for one or two hours during the day, gradually increasing them in force according to the influence produced on the patient.

"In addition to these means, I usually direct the patient to suspend the body by the arms, and similar modes of exercise, with a view to promote the full action of the pectorales, serrati magni, and postici muscles, &c. on the ribs, to produce the greatest possible extent of elevation of the ribs and sternum, and consequent expansion of the chest." 76.

The 4th chapter is on Contractions of the Limbs. Our author is inclined to view these affections as depending rather on weakness in the extensors than in rigidity or contraction of the flexors of the part bent. The cases of distortion, our author remarks, in which the motion of the limb is not entirely lost, arise generally from inflammation of the joint connected with some internal disorder of the frame, as rheumatism, gout, &c. occasioning deposition of coagulable lymph, or the formation of concretions-at other times, collections of fluid within the cavity of the joint, or abrasion of the cartilages. To these causes may be added spasmodic or para