A treatise of the rickets being a diseas common to children. Wherin (among many other things) is shewed, 1. The essence 2. The causes 3. The signs 4. The remedies of the diseas. Published in Latin by Francis Glisson, George Bate, and Ahasuerus Regemorter; doctors in physick, and fellows of the Colledg of Physitians at London. Translated into English by Phil. Armin.

CHAP. XXI. The Signs of the Rachites, and first the Diag∣nostical Signs. (Book 21)

WE distinguish the Signs of the Diseas into three Chapters. The first containeth those Signs which demonstrate the presence of the Affect, and are called Diagnostical. The se∣cond containeth those that distinguish among themselvs the differences of the Diseas, and these are called, Diacri∣tical, or Discrepant. The third comprehendeth those Signs which presage the event of the Diseas, and they are termed Prognostical. In this Chapter we shall not treat of the first kind.

We divide the Diagnostical Signs into Pathognomo∣nical and Synedreontal. And here the Physical Authors seem to be more strict in the definition of the word Pa∣thognomonical, then the necessity of the nature of the matter doth require. For they wil have it to be Insepa∣rable and (as Logicians speak) Proprium quarto modo, that is, to agree, omni, soli, & semper. Indeed it must be granted, that such an Inseparable Sign, or, Proprium quarto modo, must be according to the most proper sens a Pathognomonical Sign. For whether it be present, or

whether it be absent, it is ever demonstratively signifi∣cant: When it is present it certainly witnesseth the spe∣cies of the present malady, and being absent it sheweth that that species of the Diseas is not present.

But when we truly and seriously consider how seldom such Signs as these occur and of what useless considerati∣on they will prove, the knowledg of them being thus re∣strained; we are induced to think of the amplifying of the usual signification of the word. For although the Ancients to supply this defect, did substitute 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉 in the place of one true Pathognomoni∣col Sign strictly taken, and we our selvs do most willing∣ly accept of, and approve this very same 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉; yet seing that this 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉 doth seldom appear from the begining of the Diseas, and by consequence seldom ob∣taineth the reputation of an Inseparable Sign, it neces∣sarily followeth, that it also can but seldom perform the office of a Sign, quarto modo propriè, and therfore also that this notion is reduced to an extream narrow use. We are compelled therfore that we may fully prevent, or a∣void this inconvenience to extend somwhat higher the signification of a Pathognomonical Sign; yet so, as that we wil abate nothing of the Nature and certitude of the signification.

Therfore we define a Pathognomonical Sign to be somwhat appearing about the Patient, which certainly and infallibly demonstrates the Species of the Diseas, And in this extended sens it may be divided into a Sign Inseparable, or, proprium quarto modo, and a Sign Se∣parable; namely, as being proper only, Modo secundo; to wit, becaus it is competible only to one kind of Disea∣ses, although not always. In like manner the Paththo∣gnomonical Syndrome, or Concours of Symptoms may be divided into two kinds, respectively Analogical to those

aforesaid. For somtimes it beginneth with the Diseas it self, and doth inseparably associate to the very last peri∣od. So the pricking pain of the side, and acute Feaver, the difficulty of breathing, and the cough, if they be taken collectively, they are indeed a Syndrome, but such an one as is always equivalent to one simple Pathogno∣monical Sign of the first kind, and doth inseparably ac∣company a Pleurisie from the first beginning to the very end. But somtimes the Syndrome or concours of Symp∣toms is not compleat and perfect from the begining of the Diseas, yet afterwards it is made perfect by the inter∣vention of the other Signs, and doth infallibly denote, the species of the Diseas. For example, in the smal Pox upon the first begining of the Diseas, the Syndrome, is so incompleat, that it doth not yet certainly determine the species of the Diseas; but afterwards the Pox break∣ing out of the Skin very thick, and tending to matura∣tion, then the Syndrome is finished, and the species of the Diseas is put out of al doubt.

But that a Sign proper to one Diseas alone (although not in the fourth manner) whether it be simple and so∣litary, or compounded of a concours of many together, may suffice, when it is present to make a Sign truly Pa∣thognomonical: It is manifest from hence, becaus, when it is present, it doth as certainly and infallibly denote the species of the Affect, as a Sign doth, which is pro∣per in the fourth manner. For that which agreeth to one species only, when it is present, doth necessarily infer the presence of that species also. Although therfore that a Sign proper in the second manner, be not Inseparable, and where it is absent, doth not determine the absence of the Diseas, as a Sign doth proper in the fourth man∣ner; yet when it is present, it is as we have said of the same valu and certainty. For Physitians do esteem the

dignity of the Sign by the certainty of the signification. For to that purpose they enquire out the signs of a Di∣seas, that they may attain to a certain knowledg therof. Therfore seing that Signs proper in the second manner are equivalent in respect of their certainty, when they present to Signs proper in the fourth manner: we shall here comprehend them under the extended signification of Pathognomonical Signs.

You may say after this manner many after appearing Signs may be reduced to the Pathognomonical and are confounded with them. Be it so, provided that they do infallibly denote the species of the Diseas. For in this respect they are worthy to be severed from the other af∣ter appearing Signs, neither wil any confusion follow hereupon in the method of the semeiotical art, but ra∣ther the valu and dignity of the Signs wil by that means be more plainly and easily observed.

Of the Synedremontal or assident Signs we have no∣thing of moment to say, but wil directly proceed to the Signs themselvs as they are to be reduced into order. Yet no exact method must be expected from us, because for the most part the Signs flow from so many several foun∣tains, that they wil scarce suffer themselvs to be marshal∣led into any accurate order. Wherfore, that they may be constituted which have some affinity among them∣selvs, we have reduced the signs of this Affect to the sub∣sequent Method.

We shal propound therfore

First, The Signs which relate to the Animal actions.

Secondly, Those which have reference to the irregu∣lar Nutrition.

Thirdly, Those that concern the Respiration.

Fourthly, Those that appertain to the Vital Influx.

Fifthly, Certain vagabond and fugitive Signs redu∣cible

to no Classis. Under each of which we shal subjoyn the valu of the Signs.

First the Diagnostical Signs relating to the Animal Actions, are these. The loosness and softness of the parts. The debility and languidness. And finally, the slothful∣ness and stupefaction.

First, A certain laxity and softness, if not a flaccidity of all the first affected parts is usually observed in this Affect. The Skin also is soft and smooth to the touch, the musculous flesh is less rigid and firm; the joynts are easily flexible, and many times unable to sustain the bo∣dy. Wherupon the Body being erected it is bent for∣wards or backwards, or to the right side or to the left.

Secondly, A certain debility, weakness, and enervati∣on befalleth al the parts subservient to motion. This weakness dependeth much upon the laxity, softness, and litherness of the parts aforesaid: for which reason we have placed those Signs before this, as also this before the slothfulness and stupefaction in the next place to be enumerated, which ow much both to the loosness and softness. Moreover, this debility begineth from the ve∣ry first rudiments of the Diseas. For if Children be in∣fested within the first year of their age or therabouts, they go upon their feet later by reason of that weakness, and for the most part they speak before they walk, which amongst us English men, is vulgarly held to be a bad O∣men▪ But if they be afflicted with this Diseas, after they have begun to walk, by degrees they stand more and more feebly upon their legs, and they often stagger as they are going, and stumble upon every slight occasion: neither are they able to sustain themselvs long upon their legs without sitting, or to move and play up and down with an usual alacrity, til they have rested. Lastly, upon a vehement increase of the Diseas they totally lose the

use of their feet; yea, they can scarce sit with an erected posture, and the weak and feeble Neck doth scarcely, or not at al sustain the burthen of the Head.

Thirdly, A kind of slothfulness and numbness doth invade the Joynts presently after the begining of the Diseas, and by little and little is increased, so that day∣ly they are more and more averse from motion. The Yonger Children who are carried about in their Nur∣ses arms, when they are delighted and pleased with any thing do not laugh so heartily, neither do they stir themselvs with so much vigor, and shake and brandish their little Joynts, as if they were desirous to leap out of of their Nurses hands, also when they are angred they do not kick so fiercely, neither do they cry with so much fierceness as those who are in health. Being grown grea∣ter, and committed to their feet, they run up and down with a wayward unchearfulness, they are soon weary, and they love to play rather sitting then standing, neither when they sit, do they erect their body with vigor, but they bend it somtimes forwards, somtimes backwards, and somtimes on either side, seeking som props to lean upon that may gratify their slothfulness. They are not delighted like other Children with the agitation of their bodies, or any violent motion; yea, when the Diseas prevaileth they are avers from all motion of their limbs: crying as they are at any play that is never so little vehe∣ment; and being pleased again with gentle usage and quiet rest. In the interim, unless som other Diseas, Symp∣tom, or caus of sickness doth com between, they are mo∣derate in sleeping and waking, they are ingenious, not stupid, but for the most part of forward wits, unless som other im pediments arise, their countenances are much more composed and severe than their age requireth, as if they were intent and ruminating upon som serious mat∣ter.

These Signs being taken together, unless they result from some evident wariness, or proceed from some pri∣mary affect of the Brain (which indeed hapneth very seldom in this tenderness of age) do constitute a suffici∣ent Pothognomonical Syndrom of the first kind, & where they are present together, they certainly witness the pre∣sence of the Diseas, & when they are absent together they infallibly attest the Essence of this Diseas. But if at any time a wearisomness do bewray any Feaverish, or any other like Signs, they may easily be distinguished from these, both because the reasons of the weariness have gone before, and also because the Signs from thence a∣rising do suddenly break out, and assoon vanish. But in this affect the signs do invade by degrees, and perse∣vere, or else they are dayly more encreased. Now the primary Diseases of the Brain are distinguished by their proper Signs. And thus much of the Signs which re∣late to the Animal Actions.

The Signs which belong to the disproportioned Nourish∣ment of the Parts.

Of how great moment the Alogotrophy, or unequal Nourishment of the Parts is in this affect, we have alrea∣dy shewed; we shall here therfore prosecute those signs which in some great measure depend upon it, and we shall present them as if they were to be beheld at one View.

First, there appeareth the unusual bigness of the Head, and the fulness and lively complexion of the Face, com∣pared with the other parts of the Body. But although this Sign may presuppose some motion of the Diseas be∣fore it shine out, yet is the Diseas so obscure before the appearance of it, that it is accounted in a manner un∣perceivable:

Therfore commonly this Sign sheweth it self more or less from the first beginning, and continu∣eth till the departure of the affect, unless (as we have noted before) the pining of those parts supervene from some other caus.

Secondly, The Fleshy parts, especially those which are full of Muscles beneath the Head which we have li∣sted among the first affected, in the progress of the Diseas are dayly more and more worn away, made thin and lean. This Sign doth not presently shew it self from the begining of the Diseas, becaus it pre-requireth some notable motion of the Diseas before it evidently appeareth; yet in time it most certainly is exposed to the senses, and accompanieth the Diseas to the last step be it either to life or death; excellently demonstrating the motion and degree of the Diseas by its encreas. Moreover this Sign being conjoyned with the former doth at least constitute a Pathognomonical Sign of the second kind, that is such an one as is proper to this Diseas alone; and where they are present together they infallibly denote the presence of this Diseas, although upon their absence they do not equally signifie the ab∣sence of the Diseas.

Thirdly, Certain swellings and knotty excrescences, about some of the joynts are observed in this affect; these are chiefly conspicuous in the Wrests, and somwhat less in the Ankles. The like Tumors also are in the tops of the Ribs where they are conjoyned w^th grizles in the Breast. We have noted abov in our Anatomical Obser∣vations that these tumors are not scituated in the Parts, but in the very Bones; although this consideration doth scarce belong to them as Signs, seing that of themselves they are searce conspicuous. This Sign doth also sup∣pose some kind of motion of the Diseas, neither is it

emergent a Principio principiante, as the Phylosophers phrase it, yet it offers it self as an object to the senses sooner than any considerable extenuation of the parts. But where it is present, it constitutes a Pathognomical Sign of the Second kind, and without dispute witnes∣seth the Species of the Diseas.

Fourthly, Some Bones wax crooked, especially the Bones called the Shank-bone, and the Fibula or the small Bone in the Leg, then afterwards the greater Shank-bone, and the undermost and lesser of the two long Bones of the Elbow, but not so much altogether nor so often; somtimes also the Thigh-bone and the Shoulder-bone. Again, there is somtimes observed a certain shortning of the Bones and a defective growth of them in respect of their longitude. This by chance was omitted above, where we gave the Reason of the Organical faults. Yet this affect doth seem to depend upon the same irregular nourishment; namely so far forth as the nourishment taken in encrcaseth the Bones according to breadth and thickness more than length. From hence it comes to pass that some Children long afflicted with this Diseas become Dwarfs. Hither per∣haps may be referred that folding in the Wrests, the Skin it may be having better nourishment and more growth than the Bones of those parts, wherupon it must needs be contracted in the Wrests into a folding or wrinkledness. Finally, to this place also may belong a certain sticking out of the Bones of the Head, especi∣ally of the Bone of the forehead forwards. For it con∣cerneth the common kind of viciated Figure and the Alogotrophy of the Bones. Yet this in the Bone of the Forehead doth evidently seem to depend upon the free nourishment of that Bone in his circumference, where∣with it is coupled to the Bones of the fore part of the

Head, and constitutes that seam called S••tura Coronalis, which lieth in the foremost parts therof. For herupon it must needs be thrust forwards. And indeed in that place it is plentifully nourished without any difficulty, becaus this Bone in Children is cartilagineous towards that Seam. And this also was pretermitted above where we discoursed of the Organical faultiness, becaus we have but lately observed it.

Fifthly, The Teeth come forth both slowly and with trouble, they grow loos upon every slight occasion, somtimes they wax black, and even fall out by pieces. In their stead new ones come again though late and with much pain. This kind of Sign, as also that which we noted in the former Article, may be referred to the Synedremontal Signs, becaus neither of these is either perpetually present, or if it be present, it doth not un∣doubtedly confirm the presence of Diseas.

Some have imagined that the Bones in this Diseas are transfigurable like wax; But we have never seen it, neither have we received it from any eye witness who was not of suspected credit. Wherfore we reject this Sign as altogether Fabulous.

Sixthly, The Breast in the higher progression of the Diseas, becomes narrow on the sides, and sticking up foreright, so that it may not be unaptly compared to the Keel of a Ship inverted, or the the Breast of a Hen or Capon. For on each side of the middle it riseth up into a point, the sides being as it were pressed down. If any demand whether this Sign be solely apropriated and peculiar to this affect; We answer, That the Breast may be a little encreased in an Atrophy or Phtisick, and less than the other parts of the Body, and so by conse∣quence it may be narrower: but it can scarce so fall out according to the change of the Figure without an

Alogotrophy, namely that which is proper to this Dis∣eas. Wherfore this Sign also when it is present, al∣though the invasion of it be tardy must be reputed a Pa∣thognomonical Sign of the second kind, becaus when it is present, it certainly denoteth the Species of the Dis∣eas, though not on the contrary. And thus much of the Signs which have reference to the unequal nourish∣ment.

The Signs which belong to Respiration.

First, The narrowness and sticking up of the Breast already mentioned must be hither referred, wherof we then discoursed at large.

Secondly, A swelling of the Abdomen, and an exten∣sion of the Hypochondriacal parts, which hindreth the free motion of the Diaphragma downwards, and by consequence doth somwhat interrupt the breathing. Yet it must be noted that the Abdomen and the Hypo∣chondries also in respect of their outward parts appear very lean and extenuated, but inwardly, namly in those parts which are contained in the Cavity of the Abdo∣men, they swell, from whence ariseth this fulness. This swelling proceedeth partly from the windiness of the Stomach and Guts, and partly from the bigness of the Liver and other Bowels. Somtimes also a watry moi∣sture into the Cavity of the Abdomen, introducing an Ascites, joyneth in this conspiracy. This Sign is sel∣dom absent, and yet it must be numbred among the Pathognomonical Signs, becaus it is common to many other Diseases.

Thirdly, A Cough is frequently present in this Af∣fect, as also a difficulty of breathing, and many other faults of the Lungs, as Stoppings, hard Tumors, Impost∣hums,

Inflamations, a Coalesence of them, with the Plura, and the like; Yet these scarce deserve to be recko∣ned among Signs, because of themselvs (whilst the Pa∣tient liveth) they are not sufficiently conspicuous.

Fourthly, Children afflicted with this Diseas are of∣avers from lying upon their Sides either the right or the left, or at least it is troublsom to them; namly, either be∣caus of the Coalesence of the Lungs with the Plura, or by reason of som Tumor on the contrary side, but to lie with their Faces upwards they are very much delighted. And thes signs also being taken together wil not amount to pathognomonical signs of either kind, but syndrecion∣tal only and are common to other Diseases.

Signs belonging to the Vital Influx.

First, The Veins and the Arteries are more slender than ordinary in the first affected parts, and less con∣spicuous than you would expect in a lean Body. But in the Face (respect being had to the gracility aforesaid in the other part) they exceed the just proportion. This perhaps is a pathognomonical sign, although it be diffi∣cult to be observed, and indeed not yet sufficiently sifted by us.

Secondly, The Puls in the Wrests, and the other af∣fected parts is smal & weak, otherwise perhaps it is mo∣derat, unless when a Feaver is present.

Thirdly, A moderate Ligature cast about the Elbow or the Knee, doth not so soon swel and color the part beneath and above the Ligature with Bloud, as it doth in other sound Children of the same age.

Centain vagabond and wandring Signs.

First, An appetite to Meat and Deink that is either moderate, or unduly weak, unless where a Feaver is conjoyned.

Secondly, The Excrements of the Belly and Bladder do commonly resemble theirs that are in health, unless some other Diseas do interdict it.

Thirdly, It is observed, that those which are sick of this diseas do abominat sweet things, as Syrups, and Jun∣kets condited with much Sugar or Honey▪ Perhaps al∣so such things as these are hurtful for them, as also for those which are troubled with the Scurvy, because they thicken the humors.

Fourthly, Some have observed, That they have seen som Children affected with the Rachites, to weigh hea∣vior than others of the same age and stature. If this be so, it must be attributed partly to the facility, and partly to the inequality of the Nutrition of the bony substance in this Affect. For when this weight can scarce be ascri∣bed to the Flesh, which are here extenuated, it seemeth plain that this must be attributed to the bony substance: And seing that the Bones in this Diseas are not yet ob∣served to encreas beyond measure in respect of their lon∣gitude, it followeth plainly, that it must be imputed to the thickness of them which is superfluously augmented. These are also common signs, neither do they merit a more worthy estemation. And thus much for the Di∣agnostical Signs, the Diacritical now follow.