of the bones, during this period, is most remarkable in the lower extremities, and less so from below upward. M. GUÉRIN states, that his comparisons of the skeletons of rickety subjects with those of the same age and sex who had not been rickety gave the following per centage of reduction in the different bones in the fibula, 26 per cent.; in the tibia, 25; in the femur, 22; in the cubitus, 19; in the humerus, 15; in the clavicle, 9; in the sternum, 8; in the spine, 5; and in the pelvis, 17 per cent.

11. The duration of this stage necessarily varies with the persistence or removal of the causes during treatment, with an early or de

and regimen, and with the local affections which may complicate the disease. In the more rapid states of the complaint this stage may not continue longer than two or three months, while in more chronic forms, and when the complaint has been long neglected, and unfavourable circumstances continue their influences, this period may extend even to several years, the deformity and its attendant symptoms either very slowly increasing or remaining nearstationary.

CHEST, Deformities of.) The flat bones, as those of the shoulder and pelvis, are also sometimes affected. The shoulder-blade is, in a few instances, so deformed as to embarrass more or less the movements of the shoulder; but when the bones of the pelvis are softened, the deformity is of the utmost importance, especially to the female, in after life. The change of form in the pelvis is often remarkable, and is extremely various, the sacrum and pubis being carried either backward or forward, the ilia directed inward or otherwise altered, the lower part of the sacrum pushed upward, and the outlet of the pelvis variously altered in form and diminished in diameter. The progress of delayed recourse to judicious means, with the diet formity is generally from the extremities to the center of the frame, and more especially from below upward, particularly after the first year. 9. The relative proportion of the alteration of the different bones in rickety patients has been stated by M. GUERIN. But it should not be overlooked that, as the bones nearest the centre of the frame are the last affected, or are liable to deformity only at an advanced stage, and in neglected or ill-treated cases, the statistics he has furnished are open to the objections whichly may be urged against the statistics of other diseases; whether the relative proportion, or numerical calculations, be applied to symptoms, or to organic changes, or to remedial results; objections based on the differences of disease owing to varying combinations of predisposing and exciting causes; to endemic and epidemic influences; to seasons and weather, to modes and manners of life, and to numerous circum-ciation increases, the abdomen is more distendstances, to which it is needless here to advert. M. GUÉRIN states that, of 496 cases of rickets, 11 only had swellings of the extremities of the bones without curvature; and of the 485 with curvatures, 59 had at the same time deformity of the thorax, 48 deformity of the spine, 17 enlargement at the same time of the cranium, and 14 only deformity of the upper extremities simultaneously with these alterations.

10. During this stage, the deformity of the bones is not the only change. The alterations mentioned in connexion with the first stage continue during this. The abdomen continues tumid, or increases in size, and is more tympanitic, the limbs more emaciated and flabby; the child more languid and weak; the perspiration free and readily increased; the thirst increased; the pulse quick, small, and weak, with slight hectic symptoms; and pains are complained of in the bones and joints. The bowels are irregular, or loose, and the stools pale or almost devoid of healthy bile. The general emaciation and change in the bones allow the head to appear larger than usual, while it is often only large in proportion to the rest of the body; and while all other parts of the frame, the bones especially, cease to grow, during this stage, the head appears even to enlarge, and the faculties of the brain to be developed, sometimes precociously. The cessation of growth, particularly

* Mental precocity is not, however, always seen; for sometimes the child continues dull, taciturn, or stupid, or even idiotic. These opposite states have been explained by supposing that the openness of the sutures has allowed the circulation and development of the brain to advance at an increased rate, and the faculties of the mind to expand; while the closure of the sutures, and the consequent unyielding state of the cranial bones, have confined and embarrassed the functions of the brain, and occa

12. C. The third stage, or period of restoration, or that attended by either a favourable or unfavourable change, is marked by no very sudden alteration from the state above described; it appears gradually, but rarely rapidly, unless some intercurrent disease or local affection supervene; and this is not infrequent.--(a) If the disease does not tend towards recovery, the ema

ed, and the bowels more disordered, while the secretions and excretions are still more morbid than before. The deformity of the bones continue or increase; and ultimately the child is carried off by disease of the lungs or of the abdominal viscera, or several lesions of the thoracic and abdominal organs may coexist in the same case and terminate life, as congestion of the lungs with effusion into the pleura; general bronchitis with gastro-intestinal irritation; lesions in the digestive canals with enlargement of the mesenteric glands; crude tubercular formations in the lungs, with tubercles in the membranes of the brain, and effusion in the ventricles or between the membranes, &c. If the child is not carried off by one or more of these, and continues deformed, without any amendment of the symptoms, the softness of the bones is much diminished, their flexibility is lost, they are more atrophied, and they are more readily broken; the deformity often still increasing. Recovery then rarely takes place; a complication of internal disorders, consequent upon structural changes, and upon a morbid state of the blood, ultimately terminating life.

13. (b) A favourable change from the second stage is evinced at first by the states of the secretions and excretions. The urine assumes a more natural appearance and composition (§ 16); the stools are more healthy, and coloured

sioned the opposite state of the mental powers. But, as far as I have observed, precocity has not always existed in connexion with openness of the sutures, nor stupidity with their closure. Perhaps the chemical pathologists, who attempt to explain all by chemical changes, will ac count for the different phenomena by ascribing them to the state of the blood and to the excess of phosphates in it, during their passage from the bones to the kidneys, by which they are eliminated.

bility, or to disease, when ultimately a fatal termination takes place in the way now stated. 16. D. The urine in rachitis presents more or less change from the healthy state. Generally it is much more abundant than might be expected, considering the free transpiration from the skin. It is commonly pale, but it is sometimes of natural colour. The urea and uric acid are diminished, while the salts are increased. A free acid is sometimes observed, which has been said to be the phosphoric, but this requires farther investigation. The phosphates are more abundant than in health, and more especially than in healthy children; and a considerable sediment of oxalate of lime is not infrequent; and it has been observed that urinary calculi are frequent in rachitic children. As far as my own observation enables me to state, the increase in the fixed salts is most consid

more deeply by bile; the abdomen appears less tumid and less tympanitic; the pulse is less frequent, and pains in the limbs are not so much complained of. The countenance presents more animation, and the hectic or remittent febrile symptoms and thirst subside gradually. The appetite is less capricious and more natural; and, with the continuance of these changes, the flesh becomes firmer, and voluntary motion is made with greater activity. The growth of the limbs, which had been suspended until now, proceeds with remarkable vigour; the bones are gradually restored, and, if the deformity is not very great, it disappears by degrees; the curvatures are either diminished or altogether removed; the swellings of the epiphyses of the bones subside, and ossification proceeds with great rapidity, the affected bones acquiring greater density and strength than usual. The muscles also acquire a more powerful develop-erable during the advance of the first stage, ment, so that persons who have been rickety in childhood have afterward become remarkable for strength.

14. (c) During recovery an excessive ossific action often occurs, more especially in the parts which had been swollen and softened during the stage of deformity. Not only are the sound bones more dense, but, in some instances, a state of hyperostosis or extoses more or less numerous, especially near the epiphyses and sutures, is observed. I have seen this occur most remarkably at the terminations of the ribs and commencement of the cartilages, the whole being more or less soldered together, and also with the sternum. Occasionally slight accessions of fever are observed during recovery, and either advance the process of restoration, or are the mere concomitants of the change taking place in the bones and system generally. If the complaint occur in children about the second year of age, or later, although it may be of considerable duration, amendment is generally rapid when it commences; and even when the growth is stunted, and the deformity is still considerable, still the period of puberty may remarkably develop growth and diminish the deformity, especially when the advantages of a favourable change of air and out-door exercise are enjoyed.

and when the deformity begins to appear in the bones: it is less remarkable when the disease is far advanced, and the softening and flexures the greatest. The phosphate of soda and the earthy phosphates are most abundant. In a case examined by MARCHAND (Lehrb. der Phys. Chemic., p. 338), the urine contained much lactic acid and lactates, and a great excess of the earthy phosphates. In a case by Mr. SOLLY (Transact. of Roy. Med. and Chirurg. Soc., &c., vol. xx., p. 448), three or four times the usual amount of phosphate of lime existed in the urine. The exact composition of the urine during the third stage, especially during a return to the healthy state, has not been shown.

17. E. Various complications often occur in the course of this complaint. These may be either of an acute or chronic nature. Rickety children may be the subjects of the usual diseases of childhood, as hooping-cough, measles, scarlet fever, small-pox, &c., or of bronchitis, pneumonia, inflammatory irritation of the digestive canal, enlargement of the spleen, scrofulous enlargement of the glands, tubercular productions in the lungs and other organs, cutaneous eruptions, &c. Most of these are accidents by no means necessarily consequent upon the rickety constitution; but when the disease is far advanced, or is attended by de

tions of the lungs, pulmonary congestion, effusions into the shut cavities, and disorders of the digestive organs, may be favoured by such deformity. The complications now mentioned, which are not specific, and which result not from infection, are often produced by certain of the causes which combine to produce this malady, or by influences to which children in this

15. When the disease is attended by an out-formity of the spine or chest, then the affecward or lateral curvature of the spine, or with flattening of the ribs and protuberance of the sternum (see art. CHEST, Deformities of), recovery is imperfect and protracted, and the more so the greater the deformity arising from the eurvatures of the spine and the flattening or bending inward of the ribs. In these cases the functions of the lungs are impaired, and the more advanced parts of the assimilative pro-state are often exposed, more especially to vacesses are impeded. In many of these cases, especially in those which are the most deformed, and when the spinal curvature is so extreme as to form a dorsal hump, the deformity continues through life, the duration of which it may considerably abridge, by favouring the supervention of congestion of the lungs, or bronchitis, or pneumonia, or even asphyxia, by pressure on the origins of the spinal nerves. In some the curvature diminishes with the restoration of health, aided by suitable treatment and regimen; but in others it increases, sometimes after having been long stationary, owing to some change in the general health, or to de

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rious endemic influences, as a close, cold, and humid air, and injudicious diet. M. GUERSENT remarks that he has seldom found rickety children the subjects of tubercles, although he has observed two thirds of children who have died of other diseases present tubercular formations in some of their organs. M. RUFz also states, that in twenty rickety subjects he found tubercles only in six. There can be no doubt of these complications having the effect of aggravating and accelerating the unfavourable progress of the disease in most cases, the only exceptions being when the eruptive fevers occur in a mild form, and then, in a few cases, they

have appeared to impart a new and favourable | stage, and is found spread out underneath the state of vascular action to the frame. In the periosteum, forming a coat from one to two most severe and advanced cases, other compli- lines in thickness. It is found also between cations than those already mentioned often oc- the lamellæ of the bones, where it may be decur, and, in the weakened state of constitution, tected by its darker color, and between the bone frequently terminate life. These are chiefly and the medullary membrane; but it is abundcolliquative diarrhea; hectic with colliquative ant around the epiphyses. It is also abundant, sweats; congestion of the brain, with or with- and more dense, at the concavities of the flexout effusion, and attended either by coma or ures than at the convexities; and it is found in convulsions, fractures of the long bones on sud- both the long and flat bones. The periosteum den motion, retention of urine, complete or in- is more or less vascular and thickened. complete palsy, chiefly in the form of paraplegia, and loss of one or more of the functions of sense.

hand, either separately or together, both in children and in adults, no other deformity of the bones being present; that either or both deformities may, on the other hand, supervene in the progress of true rickets, and of mollities ossium, or the rickets of adults; and that, when curvatures of the spine are thus associated with true rickets, or with mollities ossium, the bones of the pelvis are generally also deformed or contracted in various directions, more especially when the lower extremities continue much bent and shortened by true rickets, and when the softening occurs in adult age. It is worth no

or in parts resemble the structure of the spleen, or contain, in some instances, tubercles in various stages of development. The heart is often paler than natural, and, in a few instances, has presented incipient organic lesions, especially when the complaint has been of long duration and the deformity of the chest has been considerable. The liver and spleen are often pressed downward by the thoracic deformity; and both organs are sometimes found more or less enlarged-the liver frequently paler than natural. The alimentary canal is generally very much distended by flatus, and the mesenteric glands are more or less enlarg-ticing, also, that the extremities, especially the ed, and occasionally contain crude tubercles. The different series of glands contained in the digestive villous surface are either enlarged or ulcerated, particularly when the disease has been complicated with intestinal disorder. The muscles are generally very flabby, pale, and wasted; the adipose tissue is wasted by absorption; and what remains appears soft and almost fluid. The whole of the structures, visceral and external, present a state of flabbiness or softness.

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lower, not only cease to grow during the disease, but also continue much shorter during life, although they have acquired remarkable strength.

24. B. The prognosis depends not only upon the progress and severity of the complaint, but also upon the combination or persistence of the causes, and upon the effects produced by treatment. If the child be not remarkably debilitated, if the disease be not far advanced, and if the deformity have not invaded the spine, or pelvis, or parietes of the chest, a favourable result may be expected from treatment; but when vital power is much reduced, when the deformity is great, and has extended to the spine, or to the chest, or to the pelvic bones; still more especially when it is complicated with serious visceral disease or lesion, and when the deformity is such as to impede the

fected, and sopor, coma, or convulsions supervene, or when the urinary functions are disordered, then complete recovery should not be expected; and, although life may in many cases be indefinitely prolonged, yet it may be very rapidly terminated, particularly in the latter circumstances. An unfavourable issue is the more likely to occur the earlier in infancy the complaint appears, the more serious the disorders which usher it in, and the more manifest and marked the predisposing causes existing in the parents.

23. ii. DIAGNOSIS AND PROGNOSIS.-A. The Diagnosis of this complaint is sufficiently easy, excepting in the precursory stage, and then it is often as difficult as it is important to detect the approaching mischief. In this stage the complaint may be mistaken for several incipient diseases, especially for tubercles in the lung, for tubercular peritonitis, for tubercular disease of the brain or of the cerebral mem-respiratory functions, or when the head is afbranes, or of the spine. A short time and an attentive observation of the symptoms will soon show whether or not they agree with those described as characterizing the first stage (§ 4, et seq.); and when enlargement of the ends of the long bones, and especially when these become at all deformed, the diagnosis will be manifest. If any mistake should be made, or any difficulty of diagnosis between the incipient states of these maladies should arise, but little evil need result, as the treatment would not be inappropriate to either of them. It is evident from the changes observed in the 25. iii. CAUSES.-A due recognition of the bones, especially those evincing re-ossification, remote causes of rickets is of the utmost imthat the softening of the bones of children, or portance in preventing and in curing the distrue rickets, is, in very essential points, a dis-ease.-A. The predisposing causes are not meretinct disease from the softening of the bones sometimes observed in adults, especially in females, although I have considered it at this place as a species of rickets, from the softening and deformity attending it. This latter, the true osteomalacia, or mollities ossium, is never followed by re-ossification, especially when it is consequent upon chronic or malignant dis-li, cujus parentes laxa et debili conditione coreases, or the puerperal state. Curvatures of poris, otiosi, molles, opipara mensa, cibis pinthe spine supervening in the course of rickets guibus, saccharatis, pauca pane, vinis dulcissishould not be confounded with those curvatures mis, et aqua multa calida, usi, morbis chronicis, caused by tubercular or scrofulous disease of venere, ætate, exhausti, tabi inprimis venerea, the vertebræ on the one hand, or by relaxation et iteratis gonorrhæis, multum obnoxii, effo of the ligaments, &c., on the other. (See art. tam ferme genituram impenderunt generandis SPINE.) Nor should it be overlooked, that the liberis." ( 1482.)-There is much truth in this curvatures of the spine, so frequently observed enumeration of the predisposing causes derivconnected with deformity of the chest, may ex-ed from the parents. In respect of the influist in children as well as in adults, or young persons about the age of puberty, without the least degree of rickety change in the bones; that this curvature, as well as the deformity of the chest and sternum (described in article CHEST, Deformities of), may exist, on the one

ly those which act externally on the child, but those also, and often especially, which are derived from the parents and the nurse-these latter sources, which have been too much overlooked at the present day, but to which BOERHAAVE and his commentator have directed attention: "Maxime autem infestus habetur pro

ence to be ascribed to the exhaustion produced in the parents by chronic diseases, venereal excesses, and age, VAN SWIETEN remarks: "Tales parentes, debiles, morbosos, languidos, infantes gignere, nemo dubitat. Unde inter signa sanitatis optimæ numeratur, si quis

natus sit parentibus sanis, vegetis, plenæ æta- | milk, early weaning, or "bringing up by the tis, rara sed fervida venere utentibus. Lycur- hand," a watery farinaceous diet after weaning, gus qui validis exercitiis firmabat virginum cor- a too exclusive use of vegetables, and the want pora, antequam viris jungerentur, voluit, ut re- of animal diet in cold and damp localities, and cens nupti non cohabitarent, sed clam et fur- the periods of the first and second dentition, tiva quasi venere uterentur tantum, adeoque favour the occurrence of the complaint, esperara et fervida. Talem curam gessit robustæ cially in the constitutionally or hereditarily preet bellicosæ posteritatis. Facile patet, qualis disposed. Indeed, whatever debilitates the proles expectanda sit a decrepitis, uti et ab il-frame not only predisposes to rickets, but also lis, qui, in ipso ætatis vigore, libidine ac per- sometimes more directly develops it. ditissimo vivendi genere exhausti, conjugia am- 29. B. No particular exciting cause can be biunt, dum, ante trigesimum annum jam im- adduced in some cases to account for the apbelles senes, lectissimas virgines turpiter de-pearance of the disease, besides those which I cipiunt." (Vol. v., p. 587.) have enumerated as being occasionally predis26. There can be no doubt that these causes, posing influences. But when these act in comso strongly insisted upon by BOERHAAVE and bination, and when other fortuitous circumVAN SWIETEN, predispose to this disease in the stances aid their operation, they produce a more offspring, by imparting an innate or congenital direct and exciting effect. Probably, however, debility to the infant constitution, although they residence in a cold and damp locality has a still cannot be viewed as imparting a more especial more direct influence in developing rickets, tendency to it than to scrofula, or to other dis- even than those causes already mentioned, aleases of debility to which this is more or less though without their aid this cause may not closely allied. The children of parents who produce this effect. Indeed, the disease is even have married at a premature age, or who have endemic in those places which are cold and indulged in sexual excesses, or who have been damp, and where the poor are insufficiently fed guilty of self-pollution, or who have become de- and clothed. I believe that the abuse of spirbilitated by other causes of exhaustion, as by ituous liquors by either parent is not only a preliving in unhealthy localities, or in the foul air disposing, but also an exciting cause of the of crowded factories, or by sleeping in close or complaint, and that it is more especially such crowded sleeping-chambers, are predisposed to when the vice is indulged in by the mother durthis, among other maladies, which are allied ing the period of lactation. The murderous more or less to each other, as respects their practice of giving narcotics to infants, so notocauses, rather than as regards their forms or riously prevalent among many of the physically seats. Certain of the predisposing causes ex- and morally degraded of the manufacturing popisting in the parents, to which BOERHAAVE im-ulation, may produce a similar effect where it puted a considerable influence, and which probably did, at the time he wrote, and still more so when rickets first became a frequent disease, possess this influence, namely, the taint or constitutional debility consequent upon venereal or gonorrhoeal affections, may not, in the present day, produce this effect upon the offspring in so remarkable a manner as in those times; still I am convinced that they are not without some effect, although I believe that they are more influential in developing a scrofulous diathesis than in predisposing to rickets.

27. The effect of lucorrhea upon the offspring, more particularly as predisposing to rickets, may admit also of doubt; still some of the best medical authorities have insisted upon the influence of this complaint in the parent. SroERCK contends that females who are subject to leucorrhoea are liable to suffer abortion, or to have rickety children. "Monebat, tales mulieres, nisi integre curentur antequam nubant, facile abortiri, si conceperint. Dum felici arte cavebatur abortus ita, ut fœtus ad maturitatem perveniret, notavit sequentia. Tales autem fæmina pariunt plerumque infantes crassos, pingues, robustos, et hi tales manent per plures menses: postea vero emaciuntur, lassi fiunt et membra pendula gerunt; tandem subsequitur pessima rachitis, quæ raro huc usque sanari potuit.”

fails of causing a more rapid extinction of life.

30. C. The proximate cause of the change in the bones, of which rickets is the result, is still unascertained. No satisfactory explanation of the changes which take place in this part of the frame has hitherto been adduced. It has been suggested that a superabundance of acid in the blood may cause the removal of the phosphates from the bones; but there has been no analysis of the blood in this disease, and the existence of an acid, and still less the kind of acid, in the blood have not been shown.* If the change were owing to the state of the blood entirely, it might be expected that the bones would undergo the same amount of softening and of chemical alteration throughout the frame. But this is found not to be the case, for the bones of the lower extremities experience these alterations in a much more marked degree and much earlier than those of the head or trunk. It may, therefore, be inferred that whatever agency the blood may exert must be directed or influenced by the vital or the organic nervous influence, to which the nutrition of the several structures is chiefly to be imputed. We only know that

Although the existence of lactic acid in the blood has not been demonstrated, it may probably exist; for it is not unlikely that this acid is formed in excessive quantity in the digestive canal during the early stages of the disease, owing to the nature of the ingesta and the state of 28. The predispositions referable to the chilthe primary assimilation, and that, being carried into the dren themselves have not been sufficiently in- circulation, it there affects the functions of nutrition, and vestigated. Rickets have been observed in all impairs organic nervous energy, although its accumulation constitutions in the dark, the fair, the delicate, in the blood, in a large or very sensible quantity, will be and the apparently robust; but most frequent prevented by the depurative actions of the skin and kidneys. It may also be remarked, that the formation of lacly in the delicate, in the sickly, in the soft and tic acid in the digestive canal, and its excessive excretion flabby, and in infants with large heads, whose by the emunctories, are phenomena of familiar occur fontanelles remain open, and whose dentitional diseases, during which softening or other changes in the rence in rheumatism, in the puerperal state, and in sever is delayed. Insufficient nourishment, unhealthy bones have sometimes taken place.