Rickets.
[Vitamin D deficiency.]
Synonyms:—Rachitis; rachitismus.
Definition:—A constitutional disease of childhood, due to faults of nutrition, characterized by defects in growth and general development, and in the excessive development of the organic structure of the bones, especially of the ends of the long bones, which are soft from deficiency of lime salts. There is also faulty development or malformation of the muscles, tendons and cartilages.
Etiology:—An inherited impairment of the vitality, unhygienic surroundings, filth and poor food are the main causes of this disorder. Children whose parents are dissipated in habit, or who are afflicted with syphilis or tuberculosis, are especially liable to have the disease. It occurs also with those who have what has been known in the past as a scrofulous diathesis, now recognized as a phase of tubercular development. There are cases with good surroundings, who have excellent care, with whom there is some serious impairment of the vitality which influences the nutritive functions, resulting in malnutrition, from which this disease may develop. By far the larger proportion of cases are found among the poor of large cities, who are crowded together in poorly ventilated houses, which are damp, dark and uncleanly, and where there is no opportunity for exercise in the open air and sunshine. In our own city the Polish Jews and Italians seem to be especially liable to this disorder. It can also be traced to inability on the part of the mother to impart sufficient vital force to the fetus or to sustain the infant after birth, from the poor quality of her milk. It is very difficult to adjust artificial diet to this class of cases, and thus prevent the development of the disease. As stated, the condition occurs in early childhood, and is occasionally observed to be congenital. It may not appear, however, until the end of the second or during the third year, and is seldom found after puberty, although the results of the disease will continue through life.
All things considered, there is little doubt but that dietetic faults are most to blame for the development of the disorder.
Symptomatology:—These patients have the appearance of poor health for some little time before disease of the bones is apparent; the child ceases to grow, loses flesh, is peevish, irritable, and keeps up an almost incessant fretful crying. It is unable to properly appropriate its food and seems to be constantly hungry; there are digestive disturbances, more or less marked, which consist of pain, nausea and vomiting, and of sour, fermiented or undigested food, and diarrhea with acid stools. There is some fever, which is erratic and irregular in character, but is seldom high; the head is hot, and the child is always restless. Its sleep is greatly disturbed. It has night sweats, more or less profuse; sometimes it sweats only on the head and neck, and the perspiration has an unpleasant odor.
Later it will be observed that the child screams or cries out suddenly when it is moved, and finally it will be discovered that the pain is in one joint only, and is caused by any movement or handling of that joint, which is extremely sensitive. Still later, enlargement of the joint will become apparent. The disease, however soon extends to other joints; there is an enlargement of the ribs at their junction with the cartilages. These enlargements assume the form of nodules or beads, and the condition is described as beading of the ribs. Later the condyles of the femur, the wrist bones and ankles will become affected, and later the bones of the head. There is a bulging often of the frontal bones, which produces a peculiar square, prominent forehead. The breast bone becomes involved, and so changes its form as to materially alter the shape of the chest, resulting in that condition which is described as pigeon breast. This impairs the shape, development and utility of the lungs, and thus interferes with the proper oxygenation of the blood, and the heart is crowded forward and slightly displaced. The growth and development of the teeth is greatly delayed and the teeth decay early. The child is feeble, listless, seldom interested in amusements of childhood, and soon develops pot-belly.
They are occasionally anemic, but this is not a constant condition. There is slow and imperfect development of the mental faculties in many of these cases, or epilepsy or tetany may occur, and later chorea may develop. Spasmodic croup is not of uncommon occurrence with these patients, and this condition contributes to the deformity of the chest. As the child advances in age and undertakes to walk, it will be found that the long bones have not the stiffness or rigidity with which to support the weight of the body, and they will gradually become bent, resulting in bow-legs or knock-knees, club-foot or other deformities. There may be also curvatures of the spine or spinal necrosis, or deformities of the pelvis may occur.
Many of these conditions are not characteristic of rickets alone, and their presence does not confirm a diagnosis of this condition.
Diagnosis:—The diagnosis depends upon the general failure of the child's health, upon mal-nutrition, its general puny appearance, and later, upon the presence of soreness and pain in the joints, with gradual enlargement and deformity.
Prognosis:—But few of these cases die from this disease. Taken early, they are quite amenable to treatment, and should be treated with confidence and assurance. But with the best of treatment, permanent deformity is common.
Treatment:—As consulting physician I have observed that it is an almost universal fault with practitioners to express much doubt, to talk hesitatingly and disparagingly of an ultimate cure, and to exhibit a lack of confidence in their own ability to handle this class of disorders. There is nothing that contributes more positively to an ultimate cure than to cause the parent to feel absolutely positive that the attending physician will advise measures which will ultimately cure these patients if persisted in, provided the parent co-operates perfectly in carrying out every detail of the treatment as advised.
The first attention must be paid to the stomach. Any disorder there present must be corrected, and the diet must be regulated with the utmost care. If the patient is starving on a full quantity of its mother's milk, it must be at once fed, either in part or entirely, upon pre-digested milk, until the condition of the stomach is corrected, when it may be able to take cow's milk, either of full strength or diluted in the proportion of one part of water to one, two or three parts of milk, to which a little salt is added. I have had good results from a careful selection from among three or four of the best known of the artificially prepared infant's foods. In other cases, where marasmus is pronounced, I have given from five to ten drops of bovinine, every half hour, hour or two hours, with all the water the child desires, and no other food for two or three days, thus giving the stomach an almost complete rest until it is able to digest stronger food. A little sweet cream may then be given, or other simple fats or proteids, avoiding sugars and starches. As favorable results were observed, I have administered a teaspoonful of olive oil every two or three hours, and have used this substance very freely externally. Internally, the phosphate of iron, or the calcium phosphate, or some phosphate which is easy of appropriation, as the sodium phosphate, will be found of much benefit. It is not uncommon for extreme inactivity of the liver to be found present with these cases, and there may be a slight jaundice, the patient passing feces of a light yellow, grayish or clay color, which will float upon water. To these I give twenty grains of the sodium phosphate every two hours for several weeks, unless it should act too freely as a laxative, in which case the dose must be reduced. Others of these patients have done very well on the official compound syrup of the phosphates, or upon a good syrup of the pyrophosphate of iron and calisaya which contains free phosphorus. In other cases I have given an elixir of the glycerophosphates of lime and soda, with hydrastis canadensis and a small quantity of the tincture of nux vomica. I consider phosphorus the essential remedy, and other conditions being properly treated, it will seldom fail to give excellent results. To children five or six years of age, a granule of arsenate of strychnin, which contains the one-one-hundred and thirty-fourth of a grain, may be given three times daily. The specific indications for some of our remedies may appear during the course of the treatment, but remedies of the class above named will be more efficient. Those who have treated this disease with the Schussler remedies believe that to be the most rational treatment, and productive of highly beneficial results.
These patients should have excellent nursing, should receive a sponge bath at a temperature correctly adapted to each patient, with water to which a little salt is added. The tender joints should be protected by the application of cotton wool, and during the progress of the treatment judgment should be exercised to prevent deformity from improper use of the limbs. The child should be kept out in the open air and sunshine as much as possible, even when the weather is quite cool or even cold, and in cool weather it should be properly protected from sudden changes.
I believe that the dieting and care of the mother during the pregnant term has much to do with the nutrition of the child, and where a dyscrasia exists, or where this disease may be anticipated, the mother should be well nourished, and should receive phosphorus or the phosphates freely during the period of gestation. I have observed many cases where the mother seemed to give the strength of her nervous and osseous structures in an excess of phosphates to the child, resulting in rapid decay of the teeth or extreme spinal irritation, amounting almost to symptoms of caries. In one case the draft was so great as to result in insanity. The children were born with an over development of muscular and bony tissue. In other cases where the mother presents these symptoms it is because of insufficient supply, and the child is born rachitic. These cases must be carefully studied, individually, and the conditions met with carefully and correctly adjusted treatment.
