Rickets.

Synonyms.—Rachitis; Rachitismus.

Definition.—A disease of early infancy and childhood, characterized by an excessive development of the bony tissues, which are deficient in the lime salts, leaving the osseous tissues soft, which leads to deformities.

Etiology.—The specific cause of rickets is unknown, though we are familiar with many conditions that may be classed as predisposing factors in the disease.

It is found much more frequently in the poorer quarters of all large cities in the north temperate zone, where all the conditions are favorable for impairing vitality, while it is seldom found in the cities of the tropics, no doubt exposure to outdoor air and sunlight neutralizing the effects of poverty.

Unfavorable environments, found in the poor classes of all large cities of the North, must certainly contribute much towards this condition. Housed in damp, dark, poorly ventilated quarters, where pure air and sunshine are unknown quantities, the vitality is impaired, and when we add to these conditions that of poor food, we have a combination that gives rise to malnutrition. These same conditions impair the vitality of the mother, rendering her milk of poor quality, or, if the baby be hand-fed, sweetened condensed milk, or starchy artificial foods mixed with water, set up fermentative processes, whereby lactic acid is generated, the alkalinity of the intestines is diminished, and the assimilation of lime salts prevented.

Race seems to predispose to rickets, the colored and Italian children, especially in the crowded quarters of all large cities, showing a larger per cent of rickets than those of other races.

Tuberculosis and syphilis always impair the vitality of the offspring, and thus favor mal-nutrition; hence it is not uncommon to find rickets in children from tuberculous and syphilitic parents.

Pathology.—The constant and peculiarly characteristic pathological changes are found in the bones, the visceral changes being secondary and generally unimportant.

The long bones and those of the skull are most frequently affected, and give rise to the most common deformities. Thus the bending of the tibia and femur, owing to the weight of the body, is quite common, while the large, square head is characteristic of rickety subjects. Chest deformities also occur, and we have the chicken-breast or pigeon-breast.

The funnel-shaped pelvis is due to enlargement and thickening of the pelvic bones. Distortions of the spinal column also occur, and thickening of the ends of the ribs near the costal cartilages gives rise to a beaded appearance known as the "rachitic rosary."

A rachitic bone, if examined in a fresh condition, is much softer than one in a normal state, and the actively developing centers, as the epiphyses of the long bones and the centers of ossification in the cranial bones, are found to be larger and very vascular. The periosteum is thickened and adheres tenaciously to the surface, and when separated from the bones, irregular masses of pulpy osseous tissue are adhered to the inner surfaces. A portion of bone thus denuded reveals a soft, vascular, spongy tissue.

From fifty to sixty per cent of the calcium salts are removed; hence the bones are lighter and more fragile, and greenstick fractures are common in rickety children.

The cranial bones may have so little of the lime salts present as to leave them soft and parchment-like and when palpated they give a crepitant sound, known as "craniotabes."

After the acute stage has passed, the bone may remain soft and spongy, the interstices containing fatty matter, or a rapid bony formation may take place, leaving the bone hard like ivory.

Enlargement of the liver and spleen may occur, due to fibroid degeneration, while catarrhal inflammation of the gastro-intestinal tract is quite common. Anemia is found in all cases.

Symptoms.—For some time before any visible osseous changes or deformities take place, certain prodromal symptoms appear that may be said to be characteristic. These are gastro-intestinal disturbances, irregular fever, night-sweats, diarrhea, debility, and general evidences of malnutrition. The child is peevish, restless at night, and frequently vomits a sour mass of undigested food. Diarrhea, the stools being excessively acid, may alternate with constipation; profuse perspiration, also acid in character, bathes the head at night, the pillow becoming quite damp and ill-smelling.

The child early shows tenderness about the joints, the soreness becoming general, the child crying when handled. The muscles become weak, flabby, and unable to perform their function; hence what at one time was supposed to be rachitic paralysis, is now known as muscular debility.

The little patient becomes feeble and puny, with prominent abdomen.

Dentition is delayed, and this, together with the symptoms already mentioned, would suggest rickets.

The first evidence of deformities may be seen in the bending of the ribs, with beads or nodules at the junction of the ribs and costal cartilages, or the wrists, ankles, and condyles of the femur may be the first to show evidence of deformity, not infrequently the large fontanels and square-shaped head will be first to attract attention.

The sternum is often thickened and crowded forward, and, the sides of the thorax being compressed, the chest assumes the appearance of a bird's thorax, and is known as pigeon-breasted. As a result of this deformity, the lungs are compressed, are unequal in size and development, and lesions of the respiratory apparatus are quite common. The heart may be crowded to the right and forward, the pulsation being quite visible.

Not infrequently there is a tendency to spasmodic contraction of the muscles of the larynx, giving rise to spasmodic croup, laryngismus stridulus, and severe forms of whooping-cough.

Pelvic deformities, due to pressure upon the bones, and curvature of the spine, are peculiarly unfortunate in the female, as it renders labor in after life either extremely difficult or impossible.

The lower extremities suffer more frequently than other portions of the body, and club-feet, bow-legs, and knock-knees are not uncommon in rickety children.

The frequency of fractures in the fragile bones, and the tendency to imperfect union of the same, or the partial fracture, greenstick fracture, adds to the deformity.

Diagnosis.—This is readily made after the various deformities appear, and certain characteristic symptoms should excite suspicion very early; these are gastro-intestinal lesions, when the child frequently vomits a sour and ill-smelling, undigested meal; has sour diarrheal stools; profuse sweating about the head; tenderness and soreness on being handled; is cross, restless, and peevish, with a disposition to remain passive, and delayed dentition,—these should suggest rickets.

Prognosis.—Where favorable hygienic surroundings can be secured early, and the child can live mostly out of doors, in a climate where there is a maximum of sunshine, and where a nutritious diet can be appropriated and the right remedies selected, a favorable cure may be established, and even deformities be corrected or made to disappear entirely.

Where the deformities are marked, they will of course remain. If the chest be pigeon-shaped, there will be danger from respiratory troubles, and when the pelvis is involved in the female, parturition will be attended with danger.

Treatment.—In the treatment of rickets, as much, if not more, depends upon the hygienic care given than upon medication. The child should not lie upon a feather bed, nor one too hard, a hair mattress being preferred.

If the mother's milk be of a poor quality, the child should be furnished with a wet-nurse, whose milk is of unquestioned quality. Where this is not possible, good cow's milk is preferable to artificial food. The milk should be diluted with barley-water, slightly sweetened with sugar of milk, and only such quantity given as can readily be digested. Later, as much fats and proteids should be furnished as can be appropriated, but a very small amount of carbohydrates are to be allowed.

The child should be sponged daily with salt water, and gently massaged several times each day, to establish a better circulation and relieve painful parts. Olive-oil may be used with benefit in the rubbing. The little patient should be much in the open air and sunshine, even in cold weather, if the air be dry.

Iron, arsenic, and the hypophosphites, in doses suitable to the age of the patient, should be given, and if the stomach will tolerate it, cod-liver oil may be given with advantage.

Such agents as taraxacum, iris, euonymus, phytolacca, stillingia, corydalis, rumex, berberis aquifolium, and such other remedies as influence the blood, will be found useful.

Silica and calcaria carbonica may be given with much benefit. Rickets is a good disease to test the efficacy of the Schussler tissue remedies should the patient fail to improve on the well-known remedies already named.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.