RACHITIS. 5(53 



points from the above description, when the disease occurs in older 

 children. In them the symptoms of chronic intestinal catarrh, and 

 general emaciation, do not usually precede the symptoms of rachitis ; 

 the children often have, apparently, normal digestion, and are well 

 nourished when the disease develops. Nor do they usually suffej 

 the pain that is induced in smaller children by all active and passive 

 movements. They only complain of pain when they make a misstep, 

 and easily become fatigued. Finally, when the children attacked by 

 rachitis are two or three years old, or older, the ribs and vertebrae 

 escape in the commencement, and the extremities first become de- 

 formed. They are affected with curvatures, and partial fractures, 

 whose direction is not always the same. Sometimes they form an 

 increase of the normal curvature of the bones ; sometimes they are in 

 the opposite direction, variations whose cause is unknown. Not un- 

 frequently the thighs are bent outward, the legs inward ; the children 

 acquire a clumsy, waddling gait. It is generally a long time, often 

 many years, before the disease extends to the whole skeleton. Then 

 we notice frequently, but not always, as Gruerin asserts, that the dis- 

 ease extends with a certain regularity ; first, the bones of the legs, 

 then of the thighs, later those of the forearms, of the arm, and lastly 

 those of the trunk, are attacked. Even when we succeed in arresting 

 the disease at an early stage, the small size, the misshapen limbs, as 

 well as slight curvatures remaining in the lower extremities, remind us 

 through life of the rachitis that occurred during childhood ; in severe 

 cases very unsightly curvatures and shortenings of the bones remain, 

 which not unfrequently impair the functions of the body. 



TREATMENT. In cases where the rachitis develops from chronic 

 intestinal catarrh and marasmus, the causal indications require the 

 treatment described in Vol. I. We there remarked that it was diffi- 

 cult to arrest the active process of decomposition going on in the intes- 

 tinal canal of children, which induces the diarrhoea, and we must con- 

 sider the want of success in the treatment of this diarrhoea as the chief 

 cause of the tardy and imperfect results of treatment in rachitis. If 

 we succeed in curing the intestinal catarrh speedily and completely, 

 and in improving the nutrition of the child, the rachitic symptoms, in- 

 duced by these disturbances, also generally disappear in a short time ; 

 and, if the disease be recognized early, the children escape any per- 

 manent results of the rachitis. In the treatment of irritative diarrhoea, 

 if it be accompanied by rachitis, in view of the diminished deposit of 

 chalky salts in the tissues, it is customary to prefer carbonate of lime, 

 in the form of prepared chalk, to the carbonates of potash and soda, 

 which are generally used. In other cases, where the disease occurs 

 without our being able to discover chronic intestinal catarrh, or other 



