=Definition.=—A constitutional disease of children, characterized
by impaired nutrition and changes in the growing bones, causing
deformities. The physical growth is disturbed and the bone deformity is
due to an over growth of cartilages and delayed calcification.
=Etiology= and =Pathology=.—Rickets may occur in the new-born, but it
rarely begins before the child is six months old. It is a disease of
the first and second years of life. Heredity is probably not a factor
but certain races, especially the Negro and Italian, have a tendency to
be rickety. The disease is much more common in the large cities than
in rural districts; also it is more common in Europe than America. The
disease is most frequently met with among the ill-fed and badly housed
poor of the large cities, though it is not rare to find it among the
well-to-do. Lesions to the digestive organs predispose. Breast-fed
children seldom have the disorder. Improper or insufficient food (a
diet too low in fats and proteins) bad air, want of sunlight, prolonged
lactation, exposure to cold and dampness are predisposing factors.
=Pathologically=, the most marked changes are seen in the long
bones and the ribs. The cartilage between the epiphysis and shaft
is thickened and is soft and irregular in outline. Underneath the
periosteum the tissue is spongy. Microscopic examination shows
an increase of proliferation of the cartilage cells with scanty
calcification. The bones are soft and there is a diminution in the
calcareous salts. In a word ossification is delayed and the bones
are not perfectly developed. In the cranium the frontal and parietal
eminences are prominent, while the top of the head and the occiput are
flattened, giving the head a square appearance. The fontanelles remain
open until the second or third year of life. The ribs become affected
very early. At the point where the ribs join the costal cartilages,
bulging occurs, forming the so-called “rachitic rosary.” The normal
shape of the chest walls is markedly changed. Just outside the junction
of the ribs with the cartilages, the ribs fall in, producing a shallow
depression, while the sternum and cartilages are pushed forward. The
bones of the leg may be distorted. The normal curves of the spine are
occasionally disturbed. The liver and spleen are often increased in
size.
=Symptoms.=—The =onset= is slow. In many cases digestive disturbances,
with their usual effect upon the nutrition, precede the appearance of
the characteristic lesions. The child is irritable and restless, and
there is usually slight fever and profuse sweats. The child is often
languid, pale and feeble. The lymph gland are enlarged. The tissues are
soft and flabby and skeletal changes begin to make their appearance.
Among the first are changes in the ribs and head, already described
under pathology. Changes sometimes occur in the bones of the face,
particularly the maxillæ. Dentition is delayed. The spinal column is
frequently curved antero-posteriorly or laterally. The long bones are
curved and their extremities become thickened. The pelvis is distorted
and twisted and in women this may seriously complicate labor. “Chicken
breast” and “bow legs” are common, as well as muscular weakness, and
the child walks late. The abdomen is large and prominent, due to
flatulency and to the enlargement of the liver and spleen.
=Diagnosis= and =Prognosis=.—By observing the symptoms, diagnosis is
not difficult. Prognosis should be guarded, owing to danger from other
diseases; still, on the whole, prognosis is fairly favorable.
=Treatment.=—Rickets being a disease of malnutrition due to weakness
of the digestive organs, improper food, or to influences of disease,
the treatment must be principally following hygienic rules and good
dieting. The child under six months, if not nursed satisfactorily by
the mother, should be given diluted cow’s milk. Salts may be obtained
from barley gruel and whole wheat. Diluting the milk with barley water
is highly recommended. Fresh meat juice and cream are invaluable. If
curds are found in the stools, the digestion is not perfect and is
usually due to overfeeding the child. The child should be out doors as
much as possible. Fresh air is a necessity. The worst air outside is
better than the best air of the house as far as purity is concerned.
Protect the child carefully with warm clothes, and when sitting or
walking the child should be supported. Baths will be found beneficial.
In the older child, beef juice, light meats, yolks of eggs, green
vegetables and fruits may be given. Lessen the amount of carbohydrates.
Careful osteopathic treatment of the various affected tissues of the
child will aid a great deal in correcting deformities. Attention
to the lesions found will also aid in increasing the nutrition to
the involved tissues as well as correcting digestive disturbances.
This, also, is of distinct benefit in improving the assimilation
of lime salts. Possibly treatment of the “nutritional” centers,
(fourth dorsal and fourth lumbar) would be effectual. Carefully guard
against complications of the nervous and respiratory systems. After
ossification the deformities may be corrected by the orthopedic
surgeon, though in the young child considerable can be accomplished
by repeated attempts at straightening by bending and molding the long
bones. All those conditions which predispose to rickets should receive
attention; chief among these is the care of the nutrition of the mother
during pregnancy. Nursing should be regulated, and possibly future
pregnancies discouraged.