|dc.description.abstract||Rickets is a general disease of malnutrition widely
prevalent in children, which, were the dietetic, social
and other conditions in early life obtaining anything
like intelligent or ideal, should not exist - or at
least only to a comparatively trivial degree.
The date of its real origination remains hidden in
the misty times of remote antiquity,and it is to the
seventeenth-century observer, Glisson, that we owe the
foundation of our present knowledge of the disease.
The pathology of rickets has been summed up in the
oft-cited aphorism that it is "an exaggerated preparation for ossification and a diminished accomplishment
of it; the osseous anomalies being the most conspicuous
phenomena of the disease. These may affect any of the
bones,but are best known in connection with-the cranium,
the ribs, and the limbs - there being, in the case of
females especially, pelvic deformities which have a very
important bearing on childbirth in after-life. Yet there
is an underlying dyscratic perversion which may also find
expression in various signs and symptoms in connection
with such organs as the brain, lungs,heart, blood, liver,
spleen, and gastrointestinal structures.
The exact etiology of the disease has been,and is
still mooted,though there is general agreement regarding
the numerous and varied conditions which favour its
development,amongst such factors being included heredity,
age, sex, racial peculiarities, climate is and seasonal
factors, local influences, insanitary conditions, exposure
to cold, organopathies, malaria, syphilis, exanthematous or
other acute debilitating affections, parental influences,
a germ, and dietetic errors - the last-mentioned having
attached to them a growing importance.
The disease pursues a characteristic course in the
vast majority of instances, and the symptomatology of
the affection is well recognised.
Various classifications of phenomena have from time
to time been devised and are very convenient for the
purpose of narration.
The osseous symptoms are of prime importance, and
are the outcome of imperfect ossification, abnormal resorption
of osteoid tissue and hyperplasia.
In the case of the head there are alterations in
sìze, shape and fontanelle-closure, with perhaps grooving
and not infrequently craniotabes, which, contrary to what
was formerly supposed is peculiar to neither rickets
nor syphilis. Dental anomalies and facial peculiarities
are often observed.
The chest undergoes certain alterations, principally
in the form of grooves,rosaries and pressure
The pelvic deformities are of much importance in
the case of females,an:l for the reasons described on
The various deformities of the limbs in rickets
make their appearance when the infant attempts to crawl
or walk, the weight of the body on the softened bones
being responsible for the numerous distorsions which
not infrequently arise - e.g. bowleg, knock-knee, and
Marked flabbiness of the muscles and weakening of
the ligamentous structures commonly arise, and find
expression in enlargement of the abdomen, spinal curvatures,
and the like.
The skin may be pale and flabby, and it is important
to note that rickets is more or less of a fat-disease,
even the mother being sometimes deceived by the plump
appearance of the child and only present the latter for
the treatment of gastrointestinal catarrh or other
underlying rachitic condition.
The nervous affections may find expression in such
dangerous complications as convulsions, tetany, and
laryngismus stridulus. Sweating of the head may also
be in evidence.
The tendency to bronchial or other respiratory
lesions in rickets is well known as ever to be guarded
against; bronchopneumonia is a by no means infrequent
cause of death.
The heart may suffer from pressure effects referable
to the distorted ribs, and the circulation in the
blood-vessels is usually sluggish and poor,with anaemia
in a large proportion of cases.
The digestive troubles of rickets are sometimes
difficult to cure. The teeth are late in being erupted,
the coating of the tongue usually indicates the abnormal
conditions obtaining lower down, tonsillitis and
adenoids are common, "pot -belly" and gastrointestinal
catarrh are frequent, and the liver and spleen may undergo
displacement or actual disease.
There are no characteristic urinary symptoms,
though certain observers allege the contrary as regards
the odour and performance of the micturition act.
Cataract is sometimes seen, especially during the
The temperature presents no abnormalities in uncomplicated cases.
Various forms of rickets have been described.The
foetal variety is that seen at bìrth, the deformities
sometimes being of life-long persistence.The congenital
is marked by the tendency to fracture of the long bone
Acute rickets is sometimes of severe and sudden development, there being a multiple epiphysitis or periostitis
of the articular ends of the long bones. It is said not
to be pure rickets, but the latter in association with
some scorbutic taint. Late rickets is characterised by
the tardy appearance of osseous deformities, which are
apt to persist for a longtime. Its exact nature is stil
Various complications, such as bronchitis and other
internal affections,may at any time interrupt the normal.
evolution of rickets and prove a source of great danger
to the child, and in convalescence, too, there are a
number of intercurrent affections which may incapacitate
or kill the patient.
The diagnosis of rickets is not usually difficult
in view of the cardinal symptoms outlined,particularly
the osseous and abdominal ahomalies. But there are
certain indefinite or vague cases which may cause diagnostic
confusion. Amongst simulating affections are
syphilis, tuberculosis, worms, scurvy, chronic hydrocephalus,
craniotabes of syphilitic origination,spinal caries,
osteomalacia, congenital dislocation of the hip, pretinism,
pleurisy, tabes mesenterica, epilepsy, infantile paralysis,
pseudohypertrophic paralysis, diphtheritic paralysis,
Uncomplicated rickets very seldom causes death;it
is therefore mostly of favourable prognosis,provided
the proper prophylactic or actual treatment be of early
institution. The earlier this is done the better. Once the
disease gains a firm hold,there are all sorts of troubles
which may-hamper or terminate the life of the child.
Prevention is better than cure;and prophylactic
measures should be of the most thorough sort and be
directed to the supervision of the father, the mother and
the infant.The entire training of the female child
should have ultimate maternity in view,domestic management being assiduously instilled and an affection for,
and practical interest in,children of all ages encouraged,
with pride in the home appointments and everything which
is likely to concern her future life.
The whole question of infant feeding is of very
great importance in this disease.If properly institute
and effected at the maternal breast,rickets should not
occur, maternal milk being the natural and usually ideal
When it be deficient or unsuitable, a wet-nurse
should be engaged, but under proper precautions as
regards her general health and disposition.
Artificial feeding is apt to be a source of danger
to the infant, and should be undertaken only when absolutely necessary. The food supplied in this way should as
closely as possible in composition approach the breast
It is therefore necessary to be familiar with the
nature, value and uses of the various constituents of
milk, which should receive careful and intelligent study
and application in every case.
Vegetable and malt soups, buttermilk, lactobacilline,
kephir, kumiss, matzoon, dextrinised gruels, egg mixtures,
Ashby's food, peptonised milk, sterilised or pasteurised
milk may be required to meet special indications.
Condensed milk is too rich in sugar and too poor
in fat for general or routine use; it may be allowed for
such occasions as a journey, but it must always be remembered that it is a prolific source of rickets.
Humanised milk may be prepared insuch a way that
the composition is similar to that of the maternal
Walker-Gordon laboratories have been instituted n
various parts of the country for the provision,according
to prescription, of milk modified to the requirements of
the child. These take into consideration particular
needs and have been productive of incalculable good.
Exact percentages are in vogue based on comparative
The number of patent foods is legion. None of them,
however, can take the place of mother's milk, or even
properly modified cow's milk, and are more or less
objectionable in their excessive carbohydrate content
and their deficiency in bone- and tissue-making substances.
In all cases of artificial feeding it is very
important that a proper bottle should be used,and that
it so devised that it can be kept scrupulously clean
and free from the risk of germ infection through
There is a proper way to hold both the bottle and the child during the act of feeding; and on these points
the another should be properly instructed.
During the second year of the child's age mixed feeding may be allowed,but there should be a dietetic
method at this- and all other times. After the second year the food may be of a much more varied character;
and about now one or other of the numerous published diet tables will should be adopted.In this way the child be properly fed and at proper times - care being
taken to meet any special therapeutic indications as
The hygienic treatment of rickets is of vast importance, fresh air, warmth, sunlight, proper clothing, rest, exercise, baths, etc., having a great influence on the prevention and cure of the disease.
Rickets is a disease that cannot be cured with
drugs; in short there is no specific medication.
Cod-liver oil is rather a food than a medicine, and it (or one of its approved substitutes) should be tried
in every suitable case.
Phosphorus has been much recommended, but its ehibition is not always free from risk. The preparations of the metal are, however, not infrequently of great service, particularly the hypophoslahites and the glycerorphosphates.
Iron, arsenic, quinine, strychnine, etc., are tonics
which have their uses in this as in other diseases.
Massage and electricity are of recognised utility
and applicable in a. large proportion of instances.
The alleged beneficial effects of organotherapy in
rickets are still in dispute.
For the rest, as Jacobi puts it, "it is air, air, and
again air!" that is so strongly indicated.
The general treatment of the disease must, however
not be conducted to the entire excision of the control
of the special symptoms and complications - for the
relief of which much can be done with drugs and other
At all times the condition of the gastrointestinal tract must be watched, and any sources of reflex irritaion promptly removed.
The tendency of rachitic children to respiratory
affections must. always be borne in mind and the utmost
care taken to prevent their origination. When once in
evidence, their treatment must be on orthodox lines,
with due regard to the already-existing debilitation
of the patient.
In connection with the nervous system the danger
of death from the rather frequent convulsions must be
remembered and their prevention aimed at by removal of
recognised causes. Tetany requires treatment of the
underlying dyscrasia and the disturbed and excitable
condition of the nervous tissue.
Laryngismus stridulus is always a source of keen
anxiety. Prevention is as important as cure. Reflex
irritations must be forthwith removed, and during the
attack antispasmodic measures should be employed, even
to the extent of anaesthesia in certain instances.
Formic acid and the formates are said to have a
markedly beneficial effect upon the muscular asthenia
in this disease obtaihing.
The correction of the once -established deformities
of rickets is the province of the surgeon; it is their
prevention at which the pediatrist aims. Short of operation, -which should never be too hastily performed owing
to the tendency of the disease towards cure under proper
management, -they can be relieved by simple manipulation
of the softened bones, as well as splints and a variety