In this disease the normal curves of the clavicle are pathologically increased; frequently the clavicle is the seat of angular partial fractures which affect chiefly the middle anteriorly convex curve of the bone. The humerus is visibly curved only in severe eases; the convexity of the curve is as a rule outward and somewhat backward. The enlarge ment of the proximal epiphyses causes nothing special to be noted in the living child, but that of the distal ones is quite often easily palpable and in emaciated children is visible. The humerus frequently shows partial or complete fractures, usually about in the middle of its diaphy sis, and later, a marked formation of callus. The length of the upper arms may be shortened as much as one-half, partly through inhibition of the longitudinal growth, partly through bending and angulation.
In the forearm, the enlargement of the epiphyses, especially the distal ones, is the most constant symptom. The diaphyses frequently show a convex curve, the most. prominent part of which usually lies in the distal half of the forearm, and in addition a spiral bend of the radius about the ulna is often found which causes a more or less marked permanent pronation of the hand. The phalanges are frequently thickened and spindle-shaped, causing the fingers to assume the appearance of a string of beads.
Of the rachitic deformities of the infantile pelvis the thicken ing of the iliac crests has the greatest clinical interest. In the femur the distal epiphysis is often markedly thickened, and the bone is bent with the convexity as a rule forward or outward. Par tial fractures are not infrequent here and usually occur in the mid dle of the diaphysis. In the bones of the lower leg the distal epiphy ses as a rule enlarge more mark edly than the proximal ones. Very often partial fractures are found here usually situated in the lower third with their convexity towards the front and outer side. Besides these fractures an out ward rotation of the entire leg oc curs. These cases are often called " saber legs." If genu carom is added to this the so-called "0 legs" are formed, the foot assuin ing on this account in some cases the virus and in others the val gus position. In " legs" the valgus position exists in both the knee and ankle-joints. In the so-called "baker's legs" one of the extrem ities assumes the valgus position while the other remains almost straight.
In rare cases gout rani?n is found on one side and gene ralgum on the other. In their longitudinal growth the lower extremities are more frequently adversely influenced by rachitis than are the upper.
The osseous deformities of rachitis appear in a very definite sequence as to time. Only in exceptional cases can distinct clinical symptoms
referable to the bones be noted before the end of the third month. Until about the seventh month one finds chiefly craniotabes and the "rachitic rosary," which corresponds to the more marked growth of the skull and thorax at. this time. During the second half year craniotabes very frequently increases in extent and intensity. It is especially at this time that thoracic rachitis becomes prominent. The ribs become weak, the rosary often becomes very marked, and the deformity of the thorax begins. Towards the end of the first year we not infrequently find the kyphosis. If the disease begins after the end of the first year cranio tabes usually does not occur. The thoracic changes still appear, but at this time the deformities of the extremities are most marked. In addi tion kyphosis and scoliosis are seen, and, as a late form of the cranial rachitis, the bulging of the frontal and parietal eminences. The deform ities of the extremities are especially marked in those cases in which the children run about in spite of the rachitis. Permanent deformities first appear as a rule towards the end of the second year.
In cases in which rachitis begins in the middle of the first year, and remains active far into the second year, the three different stages can be seen in the same child. They pass from one to another in sequence without sharp demarcation. In such cases the craniotabes usually be gins to diminsh at about the end of the first year, or indeed even earlier, while the disease advances in other parts. While the clinical symptoms referable to the skeleton are gradually developing, the constitutional symptoms, with which the disease began, usually persist. In a large number of cases all the deformities undergo complete resolution after the active disease is cured, but in very severe cases disfiguring secondary deformities remain throughout life. The marked angulations which re sult from faulty union and consolidation of the diseased bones are not capable of complete resolution. Of the greatest importance are those cases in which kyphoscoliosis remains, or in women, well marked pelvic deformities. In less unfavorable cases the after effects consist merely of irregularities of the bony structures, of remains of the "chicken breast" and of anomalies in the position of the teeth. In the mildest of the severe cases one finds in adults, aside from erosions of the teeth, merely an eversion of the costal arch with the presence of Harrison's grooves.