THE MUSCLES OF RHACHITICAL INFANTS * 
By A. Jacobi, M. D., 
Clinical Professor of Diseases of Children in Columbia College, New York. 
THE muscles of the newly born and of the infant are feeble. 
The total weight of the muscles of the newly born, com- 
pared with that of the adult, is one to forty, while the rela- 
tion of the skeleton is but one to twenty-six. After a while only the 
dynamometric effect of the child’s muscles will increase. Mainly is 
that so after the sixth year. But even then it is only temporary and 
not persistent. Nor is their sustaining and persistent strength satis- 
factory. The frequency of traumatic joint inflammation in infancy 
and early childhood results from the incompetency of muscular re- 
sistance. Falls are very frequent. Squinting is common in small 
children, simply because their muscles of accommodation and motion 
are insufficient. Scoliosis is frequent even in infants and children 
not suffering from or affected by any ailment. Growing pains are 
often muscular only, and the result of over-exertion. 
This is much more evident in those suffering from rhachitis. 
What has been called rhachitical pseudo-paralysis by Berg and 
others is but a confirmation of the fact that the muscular structure 
is insufficient. This condition may be universal or only a certain 
class or combination of muscles are the principal sufferers. Stra- 
bismus is particularly perceptible in rhachitical infants. With it is 
occasionally combined, or there is found isolated in some instances, 
nystagmus, which being in such cases the result of the insufficient 
accommodation is mostly noticed to be bilateral. In many of these 
exclusively muscular cases there is a motion of the head in the same 
or opposite direction. An instructive case of the kind was published 
by Cable some years ago. Scoliosis is very common in rhachitical 
children and those who have been so. 
It is true that rhachitical children are apt to be very strong after 
recovery, but the pressure that children are subjected to in our 
schools, and the expensiveness of fresh air in large cities, and the 
exposure to indoor life more than one-half or more of the year in 
our climate allow but little Easter resurrection to our rhachitis 
smitten little ones. Resurrection is preached only, and from the 
pulpits only. Habitual scoliosis of the very young, up to the 
tenth year, is almost exclusively muscular, mostly dorsal, or some- 
times lumbar, with the convexity usually to the left. Not being 
able here to follow up the cases of school children with 
* Part of a paper read before the Pediatric,the NeW'Yor^3tca.demY of Medicine. 
I V* W'ii e-c V I 2 
PEDIATRICS. 
their left arm (shoulder forward) on the table, clothing amassed 
under one gluteus, and defective sight, I refer only to what we see 
in rhachitical babies, particularly when carried on one arm only. 
More than healthy babies they grow scoliotic. Even when sitting in 
their chair, not supported by their own strength, they topple over 
in one direction or the other. Even before scoliosis occurs there is 
a general flabbiness of the muscles, which prevents free sitting alto- 
gether and causes an apparent or actual kyphosis. The latter is 
easily distinguished from a spondylitis kyphosis, inasmuch as it does 
not exhibit the same angular shape. As long as no bones partici- 
pate in the deformity the diagnosis can easily be made between 
that caused by weakness and that resulting from actual bone disease. 
By raising the baby’s heels and hips, while the chest and chin are 
supported, the apparent curvature depending on the weakened 
muscles will instantly disappear and lordosis rather than kyphosis 
will be observed. 
The feebleness of the infant’s muscles when intensified by 
rhachitical malnutrition is evidenced by nothing better than the 
symptoms connected with the insufficiency of intestinal muscular 
tissue in early life, which is exemplified in different ways. 
One of the reasons why, for instance, renal disorders are not at 
all uncommon in the intestinal diseases of early life (the others be- 
ing as I have shown but lately in a paper on “ Nephritis of the Newly 
Born,” New York Journal, January, 1896, the disproportion of the 
large renal arteries and the small capillaries, and the large size of 
the intestinal vessels and villi) is the feebleness of the intestinal 
muscle in the young, which is less capable of expelling decomposing 
faeces and toxines. This feebleness of the muscles shows itself, 
however, still more frequently in another symptom, which is quite 
common in rhachitical children, and even pathognomonic for early 
rhachitis. Take an infant born at full term, with good weight, 
breast fed and apparently well and increasing in weight The bowels 
are reported to have been regular for four, six or eight weeks, then 
they become costive. There is no apparent change, the baby does 
not appear to be sick, is perhaps a little quieter and paler. Even 
the early cranial changes of rhachitis are sometimes not so percept- 
ible as to be positive evidence of that disease. But this constipation 
is. Go on with the same feeding, air and other surroundings being 
the same, and more symptoms of rhachitis will soon develop. 
In order to be certain of your diagnosis of rhachitis from this 
symptom, every other cause of constipation ought to be capable of 
exclusion ; for instance, chronic colitis and peritonitis, deficient or PEDIATRICS. 
3 
viscid mucus, local atrophy of the intestinal muscle, or stricture of 
the intestine, perhaps even cystic tumor, though they be excessively 
rare. The apparent constipation which results from insufficient 
feeding, either intentional or not, and resulting in starvation ; the 
super-abundance of casein in milk, of starch in artificial food ; the 
relative absence of sugar ; hardened faeces in the colon ; hydro- 
cephalus and other causes of defective innervation. Exclude also 
the drying up of the intestinal contents by excessive perspiration 
during the hot summer months, in hot rooms, under heavy clothing, 
or by diabetes insipidus. After excluding all these possible causes 
of constipation you will not fail to make your diagnosis of rhachitis, 
which will possibly be confirmed by other symptoms of rhachitis if 
you wait a short while, or rather, and that I prefer, by the effect of 
anti-rhachitical treatment. 
The differential diagnosis is also to be made from the form of 
constipation which I have termed congenital constipation in the 
same article, Journal of Obstetrics, iB6O, in which I discussed rha- 
chitical constipation. In annual lectures and occasional papers, even 
in a discourse before the Eleventh International Congress, I have 
referred to the same subject because of its scientific and practical 
importance. It was not heeded much until some years ago, when 
foreign publications took up the subject; for instance, Marfan in an 
essay published in Arch. Gen. de Med. a few years ago. The facts 
are briefly as follows : 
The embryological intestine is formed in separate divisions. 
There is no ascending colon before the fourth or fifth month of 
foetal life. In the newly born it is very short. In spite of this the 
large intestine of the mature foetus is longer in proportion than that 
of the adult. In the new-born it is three times, in the adult only 
twice as long as the body. This is the same proportion that is 
found for the small intestine, this being twelve times as long as the 
body in the newly born, eight times as long in the adult. 
The ascending colon being very short the surplus of length be- 
longs to the descending colon, especially to the sigmoid flexure. As 
the pelvis is very narrow, the great length of the lower part of the 
large intestine causes multiple flexures instead of the single sigmoid 
flexure of the adult, consequently now and then two or three flexures 
may be found overlapping and compressing each other. One of 
them is quite often found in the right side of the pelvis, and not at 
all as an anomaly, as Cruveilhier and Sappey thought. Huguier 
found it in that location so often that he proposed to operate for 
artificial anus on the right side in small infants. 4 
PEDIATRICS. 
This great length of the colon and the multiplicity of its flexures 
retard the movement of the intestinal contents, facilitate the absorp- 
tion of fluids and render the faeces solid. Time and again have I 
been compelled to manually remove hardened faeces from the recta of 
babies otherwise normal, and fed exclusively on normal breast milk. 
The principal points of the differential diagnosis are consequently 
furnished by the time at which under the same apparently favorable 
circumstances constipation begins—in the “congenital” form at 
birth, in the rhachitical in the second or third month. 
Under the ponderous heading of myasthenia gravis pseudo- 
paralytica Jolly describes in the Berl. Kl. Woch., No. i, 1895, the 
case of a boy of fourteen whose voluntary muscles exhibited an un- 
usual degree of exhaustibility. All of the extremities suffered, so 
did the eyes, the neck, the cheeks, the lips. Voluntary action and 
electrical irritability had the same effect on them ; that is, when the 
former was exhausted the latter was lowered. In a similar case, 
however, Mosso found that when voluntary action had exhausted 
the muscles electrical irritability was not lost. In this condition 
there is neither atrophy nor hypertrophy, and no local disease like 
that in juvenile muscular dystrophy. This peculiar condition is 
rather a contrast to myotony or to the tonic contraction produced 
in muscles by veratna, physostigmin or digitoxin. It may be com- 
pared with the effect of curare. This makes it not improbable that 
we have to deal here with the results of some chemical alteration in 
the muscles. Still, both Mosso and Benedict found similar condi- 
tions in central disorders. The former goes so far as to speak of a 
bulbar paralysis not attended with any anatomical lesions. 
In several instances many years ago I subjected rhachitical 
children of the second year who could walk to the Faradic and gal- 
vanic currents. It appeared to me that when they were tired, the 
electrical current had to be increased. But such patients at that 
early age are not favorable subjects for experimentation. 
The treatment in every such case should begin with rest and 
with exercise gradually increased. Hydro-therapeutic measures, 
from warm bathing to cold friction, are indicated. Massage will 
improve the circulation, and chemism, and arsenic and phosphorus 
will probably improve the general tissue building. Veratria, phy- 
sostigmin, digitoxin in small doses and given frequently may be able 
to restore or produce the normal tone in the feeble muscles. 
A syphilitic pseudo-paralysis of the upper extremities was de- 
scribed by Bednar nearly half a century ago (Diseases of the Nnvly 
Born, vol. iv,p. 227). In sixty-eight cases of hereditary syphilis he PEDIATRICS. 
5 
met with it sixteen times in the upper extremities, once in the lower, 
and twice in all of them. He explained it by muscular relaxation of 
peripheral, not central, origin, and saw it getting better with tume- 
faction of the bones, under the prolonged use of mercury. Published on the Ist and 15th of the Month, $2.00 or 8 Shillings a Year. 
PEDIATRICS 
An Illustrated Semi-Monthly Devoted to the 
Diseases of Infants and Children. 
OWNER: 
DILLON BROWN, M. D. 
NEWYORK. 
editor ; 
GEORGE CARPENTER, M. D. 
LONDON, 
EDITORIAL STAFF: 
MEDICINE. 
Angel Money, M. D., Sydney, Australia. For- 
merly Assistant Physician to the University College 
Hospital, and to the Great Ormond Street Hospital 
for Sick Children, London. 
A. Jacobi, M. !>., New York. Clinical Professor of 
Diseases of Children in Columbia College. 
J. Lewis Smith, M. 1)., New York, Emeritus Pro- 
fessor of Diseases of Children in Bellevue Hospital 
Medical College; Visiting Physician to the Found- 
ling Hospital and the Infant Asylum, etc. 
Frederick Forchheimer, M. 1)., Cincinnati. Ex- 
President of the American Pediatric Society, and 
Professor of Diseases of Children in the Medical Col- 
lege of Ohio. 
Duniel Colqulionn, M. D., Dunedin. New Zea- 
land, Examiner in Medicine at the University. 
SURGERY. 
Henry It. Wharton, M. D., Philadelphia, Sur- 
geon to the Children’s and the Presbyterian Hospi- 
Fred'eric S. Eve, F. R. C. S., Eng.. London. Sur- 
geon to the London Hospital and to the Evelina Hos- 
pital for Childr en. 
Lambert 11. Oriusby, M. D., F.R.C. S. 1,, Dub- 
lin, Surgeon Meath Hospital and Rational Chil- 
dren's Hospital. 
C. P. B. Clubbe, M. R. C. S„ Sydney, Aus- 
tralia, Senior Surgeon to the Hospital for Sick 
Children. 
D. Leith Napier, M. D„ Adelaide. New' South 
Wales. Senior Surgeon and Gyncecologist to the 
Adelaide General Hospital. 
Albert Martin, M. I).. Wellington, New Zea- 
land, Surgeon to the Wellington General Hospital. 
ORTHOPEDICS. 
Henry Ling Taylor, M. D., New York. Assistant 
to the Hospital for Ruptured and Crippled. 
Frederic R. Fisher, F, K.C.S., Eng., London, 
Senior Surgeon to the National Orthopedic Hospital, 
and late Surgeon to the Victoria Hospital for Chil- 
d)en. 
THERAPEUTICS. 
Reynold W. Wilcox, M. D., New’ 1 ork, Pro- 
fessor of Therapeutics in the Post-Graduate Medi- 
cal School and Physician to St. Mark’s Hospital, 
John Thomson, M. D., Edinburgh, Extra Phy- 
sician Royal Hospital for Sick Children, and Lec- 
turer on Diseases of Children, Edinburgh School of 
Medicine. . . 
Dawson Williams, M. D.. Loudon, Physician to 
the East London Hospital for Children. 
TERATOLOGY. 
Egbert 11. Grandin, M. D.. New York, Ex Presi- 
dent of the County Medical Society; Consulting Ob- 
stetric Surgeon to the Maternity Hospital, and 
Gynecologist to the French Hospital. 
J. W. Ballantyne, M.D., Edinburgh. Lecturer on 
the Diseases of Infancy and Childhood, Minto 
House; and Physician for Diseases of Children, 
Cowgate Dispensary. 
GASTRO ENTERIC DISEASES. 
Morris Manges. M.D., New York, Physician to 
3Tount Sinai Hospital and Editor of “Ewald’s 
Diseases of the Stomach." 
J. Boas, M. D., Berlin, Editor of the “ Archtv fur 
Verdauungs krankheiten.” 
TROPICAL DISEASES. 
Surgeon Lieutenant-Colonel 1.M.5., Charles 
H. Jon her t, M. 8., F. R. C. S., Calcutta, 
India, Professor of Midwifery and Obstetric Phy- 
sician, Medical College of Calcutta. 
Surgeon-Major 11. P. Birch, Quetta, India. 
GENITO-IJRINARY DISEASES. 
Frederic Russell Sturgis, M. D., New York, 
Visiting Surgeon to the City Hospital. 
G. A. Wright, M. B. (Ixon., F. R. C. S., Man- 
Chester, Senior Assistant Surgeon to the Man- 
chester Royal Infirmary, and Surgeon to the Hospi- 
tal for Children, Pendlebury. 
Fnncourt Barnes, M.1)., London, Consulting Phy- 
sician to the British Lying in Hospital. 
NEUROLOGY. 
Joseph Collins, M. D„ New York, Physician to 
the Hospital for Nervous Diseases. 
James Taylor, M. I)., London, Senior Assistant 
Physician to the National Hospital for the Para- 
lyzed, and Physician to the North Eastern Hospital 
for Children. 
MATERIA MEDICA. 
Henry H. Rushy, M. D., New York, Professor of 
Materia Medica and Botany in the College of Phar- 
macy, 
LARYNGOLOGY AND OTOLOGY. 
Win. C. Glasgow, M. D., St. Louis, Prof essor of 
Laryngology in the Missouri Medical College. 
Arthur H. Chen tie, F.R.C. S., Loudon, Surgeon 
to the Royal Ear Hospital and Aural Department 
of King’s College Hospital, 
Max Tliorner,. M. D., Cincinnati, Professor of 
Laryngology and Otology, Cincinnati College of 
Medicine and Surgery; and Aurist and Laryn- 
gologist to the Cincinnati Hospital. 
Peter Mcßride. M.D., Edinburgh, Aural Surgeon 
and Laryngologist, Royal Infirmary; and Lecturer 
on the Diseases of the Ear and Throat, Edinburgh 
School of Medicine. 
DERMATOLOGY. 
James Ncvins Hyde, M. D., Chicago, Professor 
of Skin and Venereal Diseases in Rush Medical 
College. 
Leslie Phillips, M. D., Birmingham, England, 
Surgeon Birmingham and Midland Skin and Lock 
Hospital. 
OPHTHALMOLOGY. 
My les Standish, M. 1)., Boston. Ophthalmic Sur- 
geon to Carney Hospital and to Massachusetts 
Charity Eye and Ear Infirmary. 
William Arthur Brailey, M. D., London, Ophth- 
thalmic Surgeon to Evelina Hospital for Children 
and Guy’s Hospital, 
PATHOLOGY AND BACTERIOLOGY. 
Henry A shby, M. D., Manchester, England, Phy- 
sician Manchester General Hospital for Children; 
and Lecturer on Diseases of Children, Owens Col- 
lege. 
Alfred Lingard, M.D., India, Muktesar, Kumaun 
Hills, N. W. P., Imperial Bacteriologist. 
PHYSIOLOGY. 
C. S. Sherrington, M. D., F. R. S., Liverpool, 
England, Holt Professor of Physiology, University 
College. 
PSYCHOLOGY. 
T. Telford Smith, M. D., Lancaster, England, 
Resident Medical Superintendent, Royal Albert 
Asylum. 
Lightner Witmer, Ph, D., Philadelphia, Pro- 
fessor of Psychology in the University of Pennsyl- 
vania. 
SEND FOR SAMPLE COPY. Address PEDIATRICS. 
M 32 Broadway, New York, or 85 Great Titchfield St., W. London, or Clarence St., Sydney, Australia, 
or J. C. Juta & Co., Cape Town, South Africa.