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dc.contributor.authorMeredith, Evaen
dc.date.accessioned2019-02-15T14:36:52Z
dc.date.available2019-02-15T14:36:52Z
dc.date.issued1911en
dc.identifier.urihttp://hdl.handle.net/1842/35311
dc.description.abstracten
dc.description.abstractRickets 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 effects. The pelvic deformities are of much importance in the case of females,an:l for the reasons described on page 58. 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 flat-foot. 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 teething period. 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 in dispute. 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, and paraplegia. 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 supply. 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 milk. 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 secretion. 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 standards. 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 neglect. 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 they arise. 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 means. 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 orthopaedic appliances.en
dc.publisherThe University of Edinburghen
dc.relation.ispartofAnnexe Thesis Digitisation Project 2019 Block 22en
dc.relation.isreferencedbyen
dc.titleRicketsen
dc.typeThesis or Dissertationen
dc.type.qualificationlevelDoctoralen
dc.type.qualificationnameMD Doctor of Medicineen


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