RACHITIS. 561 



count that persons who have suffered from extensive rachitis usually 

 remain very small, or even dwarf-like. If certain bones only have been 

 rachitic, while others have escaped, a marked disproportion remains 

 after the disease has subsided, from the irregular growth of the bones. 

 The shortness of the extremities has much less effect on the general 

 health than the distortion of the thorax or the rachitic pelvis, which 

 are also due to the slow growth of the thoracic and pelvic bones after 

 rachitis. Since the sutures and fontanelles of the skull remain open 

 for a long time, and since, until the sutures are closed, the growing 

 brain does not permit any distortion of the skull, the growth of the 

 skull is not arrested, and we often find persons, formerly rachitic, very 

 much deformed, having a small face surmounted by a large head, out 

 of all proportion to the misshapen body. 



SYMPTOMS AND COURSE. Rachitis occurring during the first 

 months of life is so often preceded by chronic intestinal catarrh, with 

 stools at first green and mucous, subsequently copious and watery, 

 that it appears almost justifiable to regard this form of chronic intes- 

 tinal catarrh, the " diarrhoea ablactatorum," " yeasty diarrhoea of chil- 

 dren," among the prodromata of rachitis. But the fact, that numerous 

 cases of this chronic intestinal catarrh do not pass on to rachitis, but 

 sometimes remain uncomplicated, sometimes induce other disturbances 

 of nutrition, renders this view doubtful, as well as that of Stiebel, ac- 

 cording to which, " cacotrophia " is the first, muscular atrophy the 

 second, and disease of the bones the third stage of rachitis. If, after 

 the above state has lasted for a time, we cannot find any changes in 

 the bones during life or on autopsy, there is hardly any proof that the 

 disease is rachitis. The first symptom, showing that rachitis has suc- 

 ceeded the diarrhoea and consequent marasmus, is the pain that the 

 children unmistakably suffer when they attempt to move their limbs, 

 or when they are moved by any one. Stiebel very truthfully describes 

 how children, whose greatest pleasure had been to kick out their legs 

 and put their toes in the mouth, then lie quiet, with their thin legs held 

 straight out, as if afraid to move ; how they cry at every motion, and even 

 begin to whimper for fear of being taken out of the bed when persons, 

 that they had formerly loved, approach them. These symptoms are 

 succeeded by enlargement of the epiphyses which is most noticeable 

 at joints not thickly covered by soft parts, or normally very prominent 

 as the knee and elbow are, and in the lower epiphyses of the radius and 

 ulna, as well as at the point of union of the ribs with their cartilages. 



If rachitis begin in the manner above described, from diarrhoea ab- 

 lactatorum, that is, if it begin when the child has not yet attempted to 

 walk, it often escapes any distortion of the extremities, even if the dis- 

 ease last for years. This shows clearly that the curvatures and partial 



