favorable, but they change according to the degree and locality of the
affection and the age of the patient. Generally there is neither fever
nor rapid exhaustion. But the process lasts for months and even years.
In favorable cases, when recovery takes place the teeth will grow
faster, the bones become firmer, the epiphyses will diminish in
relative size, the bowels become regular. But the length of the bones
is, and remains, reduced, and the head remains large as compared with
the length of the body. Not only are the bones of normal firmness, but
the compact substance undergoes a process of hardening called
eburnation by Guérin. The internal organs also become very active,
perhaps because the total amount of blood has to supply only a body
less extended in length. Nor does the brain suffer after complete
recovery has taken place. On the contrary, it appears that the somewhat
more than normal vascular dilatation, which under unfavorable
circumstances leads to effusion, is {158} frequently apt to nourish the
organ of intellect up to a higher standard. In all cases of rachitis,
however, the curvatures of the extremities will not disappear
altogether, while mild ones, it is true, are hardly recognizable in
advanced age. Curvature of the ribs and of the vertebral column,
however, will remain, and interfere with the expansion and the normal
functions of the lungs and heart. In regard to the lungs, it appears
that in many cases they do not find sufficient space to expand. As far
as the heart is concerned, it touches the flattened, no longer
elliptic, chest-wall over a larger surface, and is very apt to give
rise to the suspicion of enlargement in consequence of extended dulness
on percussion. The rachitic pelvis is well known to the obstetrician
for the difficulties it gives rise to during parturition.
Thus, the prognosis would, as a general thing, be sufficiently
favorable if it were not for the number of complications or severe
symptoms. The chronic catarrh of the lungs accompanying rachitis, the
enlargement of the tracheal and bronchial glands and the lymphatic
glands in general, are apt to lead to inflammatory disease of the
lungs, which, after having returned several times, leads to
infiltration of the lungs with caseous deposits, and not infrequently
results in phthisis. The nervous symptoms accompanying craniotabes may
prove very dangerous. Spasm of the larynx and laryngismus stridulus may
prove fatal in a single attack by suffocation, or general convulsion
may set in during an attack of laryngismus or without it, in which the
child may perish. Therefore the prognosis in every case of laryngismus
and in every case of craniotabes has to be very guarded. It is my rule
to wait from six to eight weeks before giving expression to a decided
prognosis, because during that time medicinal and dietetic treatment
will probably have resulted in such an improvement of the symptoms and
condition as to render the prognosis more favorable. Under no
circumstances, however, ought we to lose sight of the fact that, though
rachitis may disappear, the causes leading to it may still linger on.
Defective nutrition, diseases of the lungs, and intestinal affections
which gave rise to or accompanied rachitis will complicate the
prognosis, though rachitis itself, as far as the bones were concerned,
be no longer in existence.
TREATMENT.--To meet the cause of a disease by preventive measures is
the main object and duty of the physician. He thus either obviates a
malady or relieves and shortens it. Now, if the original disposition to
rachitis, as has been suggested, is to be looked for in early
intra-uterine life, when the blood-vessels begin to form and to
develop, we know of no treatment directed to the pregnant woman or
uterus which promises any favorable result. But the more we recognize
an anatomical cause of the chronic disorder, the more we can appreciate
the influence upon the child of previous rachitis in the mother, and
are justified in emphasizing the necessity on the part of the woman to
be healthy when she gets married, and to remain so while she is
pregnant. After the child is born the most frequent cause of rachitis
is found within the diet or the digestion of the patient. To attend to
the former is in almost every instance equal to preventing disorders of
the latter; for most of the digestive disturbances during infancy and
childhood are the direct consequences of errors in diet. It is,
however, impossible to write an essay on infant diet in connection with
our subject. I have elaborated the subject in my {159} _Infant Diet_
(2d ed. 1876), in the first volume of Buck's _Hygiene_, and of C.
Gerhardt's _Handbuch d. Kinderk._ (2d ed. 1882). Still, the importance
of the subject requires that some points should be given, be they ever
so aphoristic.
The best food for an infant, under ordinary circumstances, is the milk
of its mother. The best substitute for the mother is a wet-nurse.
Woman's milk ought not to be dispensed with when there is the slightest
opportunity to obtain it, particularly when the family history is not
good and nutritive disorders are known to exist, or to have existed, in
any of its members. When it cannot be had, artificial food must take
its place, and it is in the selection of it where most mistakes are
constantly made. This much is certain, that without animal's milk no
infant can or ought to be brought up; as ass's milk can be had only
exceptionally, and dog's milk, which has been said to cure rachitis, is
still less available, the milk of either goat or cow must be utilized.
The former ought not to be selected if the latter is within reach,
mainly for the reason that it contains, besides other objectionable
features which it possesses in common with cow's milk, an enormous
percentage of fat. Cow's milk differs in this from woman's milk, that
it contains more fat, more casein, more potassium, and less sugar than
the latter, and that its very casein is not only different in quantity,
but also in chemical properties. Even the reaction of the two milks is
not the same, woman's milk being always alkaline, cow's milk often
either neutral or amphoteric, and liable to acidulate within a short
time. Thus, the dilution of cow's milk with water alone yields no
equivalent at all of woman's milk, though the dilution be large enough
to reduce the amount of casein in the mixture to the requisite
percentage of one, and one only, in a hundred. The addition of sugar
(loaf-sugar) and of table-salt, and sometimes alkali (bicarbonate of
sodium or lime-water, according to special circumstances), is the least
that can be insisted upon. Besides, the cow's milk must be boiled to
prevent its turning sour too rapidly, and this process may be repeated
to advantage several times in the course of the day. Instead of water,
some glutinous substance must be used for the purpose of diluting cow's
milk. As its casein coagulates in hard, bulky curds, while woman's milk
coagulates in small and soft flakes, some substance ought to be
selected which keeps its casein in suspension and prevents it from
curdling in firm and large masses. Such substances are gum-arabic,
gelatin, and the farinacea. Of the latter, all such must be avoided
which contain a large percentage of amylum. The younger the baby, the
less is it in a fit condition to digest starch; thus arrowroot, rice,
and potatoes ought to be shunned. The very best of all farinacea to be
used in diluting cow's milk are barley and oatmeal. A thin decoction of
either contains a great deal of both nutritious and glutinous elements,
the former to be employed under ordinary circumstances, the latter to
take its place where there is, on the part of the baby, an unusual
tendency to constipation. The decoction may be made of from one to
three teaspoonfuls of either in a pint of water; boil with a little
salt, and stir, from twelve to twenty minutes, and strain through a
coarse cloth. It ought to be thin and transparent. Then mix with cow's
milk in different proportions according to the age of the baby. Four
parts of the decoction, quite thin, and one of milk (always with
loaf-sugar), for a newly-born, equal parts for an infant of six months,
{160} and gradual changes between these two periods, will be found
satisfactory. Whenever there is a prevalence of curd in the passage the
percentage in the food of cow's milk must be reduced, and now and then
such medicinal correctives resorted to as will improve a disturbed
digestion. Care ought to be taken lest for the newly-born or quite
young the preparations of barley offered for sale contain too much
starch. The whiter they are, the more unfit for the use of the very
young, for the centre of the grain contains the white and soft amylum
in preference to the nitrogenous substances which are found near the
husk. Thus, it is safest to grind, on one's own coffee-grinder, the
whole barley, but little deprived of its husk, and thus secure the most
nutritious part of the grain, which is thrown out by the manufacturer
of the ornamental and tidy packages offered for sale. But very few
cases will ever occur in which the mixtures I recommend will not be
tolerated. In a few of them, in very young infants, the composition
recommended by Meigs[19] has proved successful. It consists of three
parts of a solution of milk-sugar (drachm xvij-3/4 in pint j of water),
two parts of cream, two of lime-water, and one part of milk. For each
feeding he recommends three tablespoonfuls of the sugar solution, two
of lime-water, two of cream, and one of milk: mix and warm. The baby
may take all of it, or one-half, or three-fourths.
[Footnote 19: In _Med. News_, Nov. 28, 1882.]
The recommendations given above are based on a long experience, and the
simplicity, cheapness, and facility of preparation of the articles. The
substitutes offered for sale under the title of infant foods are in
part worthless, all of them expensive when compared with the simple
articles recommended by me, and not recognizable as to their uniformity
and compounds. But no matter how appropriate my mixture may be, it is
always for the young infant to be considered as a makeshift. It is to
be used as a representative of mother's milk only when this cannot be
had. Therefore it is better to alternate with breast-milk when this is
secreted in but an insufficient quantity. Some good breast-milk is
better than none at all; but with this proviso, that it _is_ good.
There are some milks either too watery or too dense and white. The
former will produce diarrhoea, the latter hard and dense curd. The
former may be improved by feeding and strengthening an anæmic and
overworked mother; the latter, by giving the baby, before each nursing,
a tablespoonful of a mixture of barley-water and lime-water, or, when
it produces constipation, lime-water and thoroughly sweetened
oatmeal-water. The cases in which breast-milk, such as can be had, is
not digested by the infant are rare, but they will occur. In them the
proper substitute will yield a better result than mother's milk; for
mother's milk will not always be a boon, and must then be dispensed
with. Particularly is this so when it is too old. Weaning ought to take
place when the first group or the first two groups of teeth have made
their appearance. After that time mother's milk is no longer the proper
food, and instead of preventing indigestion and sickness it is a
frequent cause of them and of rachitis. Instead of muscle, it will then
give fat, and the large fontanels and big head, the paleness of the
rotund cheeks, the flabbiness of the soft abdomen and thighs, will tell
the story of rachitical disease slowly engendered by the persistent
employment of an improper article of food. I cannot insist too often on
this, that rachitis may develop with increasing weight, {161} and that
the use of the scales alone is no means of ascertaining the healthy
condition of a baby. As much harm, therefore, can be done by weaning
too late as by so doing too early or too abruptly.
At that early age we treat of here, digestive disorders are more
frequently the results of improper diet than of a primary gastric
disturbance. But when the latter is once established it furnishes its
own indications. A frequent occurrence, together with a general gastric
catarrh, is the presence of fat acids in the stomach, such as an
improper amount of lactic, acetic, butyric, etc. acids. Before
digestion can be anything like normal they must be neutralized. For
that purpose calcined magnesia, carbonate and bicarbonate of sodium,
prepared chalk, and lime-water have been found useful. The latter, as
it contains but a trifle of lime, in order to neutralize must be given
in larger doses than is usually done; a tablespoonful contains but a
quarter of a grain of lime. And all of the alkalies must not be given
in the food only, but also between meals. For when given in the former
way alone it neutralizes the abnormal and injurious acids, together
with the normal digestive secretion, the lactic and muriatic. Not
infrequently, when the infants have suffered for some time, general
anæmia will set in, and result in diminishing the normal secretions of
the mucous membranes (and glands). In those cases which do not produce
their own gastric juice in sufficient quantity or quality pepsin and
muriatic acid may be given to advantage. In these cases the plan
suggested by me is particularly favorable--viz. to add a fair amount of
chloride of sodium (one-half to one drachm daily) to the infant's food.
Also that of I. Rudisch referred to by me previously,[20] who mixes one
part of dilute muriatic acid with two hundred and fifty of water and
five hundred of milk, and then boils (one-half teaspoonful of dil. mur.
acid, one pint of water, one quart of milk). Again, there are the cases
in which wine and the bitter tinctures, which are known to increase the
secretion of gastric juice, render valuable service. The addition of
bismuth to any of the proposed plans is quite welcome. As a
disinfectant and a mild cover on sore and eroded mucous membranes it
has an equally good effect.
[Footnote 20: _Am. Jour. Obstet._, July, 1879.]
Under the head of roborants we subsume such substances, either dietetic
or remedial, which are known or believed to add to the ingredients of
the organism in a form not requiring a great deal of change. Rachitical
infants require them at an early period. Meat-soups, mainly of beef,
and of mutton in complications with diarrhoea, ought to be given at
once when the diagnosis of rachitis becomes clear or probable. Any mode
of preparation will prove beneficial; the best way, however, is to
utilize the method used by Liebig in making what he called beef-tea. A
quarter of a pound of beef or more, tender and lean, cut up finely, is
mixed with a cup or a tumbler of water and from five to seven drops of
dilute muriatic acid. Allow it to stand two hours and macerate, while
stirring up now and then. This beef-tea can be much improved upon by
boiling it a few minutes. It may be given by itself or mixed with
sweetened and salted barley-water or the usual mess of barley-water and
milk which the infant has been taking before. Older infants,
particularly those suffering from diarrhoea, take a teaspoonful of raw
beef, cut very fine, several times a day. It ought not to be forgotten,
however, {162} that the danger of developing tænia medio-canellata from
eating raw beef is rather great. Peptonized beef preparations are
valuable in urgent cases.
Iron must not be given during any attack of catarrhal or inflammatory
fever. The carbonate (cum saccharo) combines very well with bismuth; a
grain three times a day, or less, will answer well. The citrate of iron
and quinine (a few grains daily) can be given a long time in
succession. The syrup of the iodide of iron (three times a day as many
drops as the baby has months up to eight or ten), in sweetened water or
in sherry or malaga, or in cod-liver oil, acts very favorably when the
case is, as so frequently, complicated with glandular swelling.
Cod-liver oil, one-half to one teaspoonful or more, three times a day,
is a trusted roborant in rachitis, and will remain so. Animal oils are
so much more homogeneous to the animal mucous membrane than vegetable
oil that they have but little of the purgative effect observed when the
latter are given. The former are readily absorbed, and thus permit the
nitrogenous ingesta to remain in store for the formation of new tissue,
but still affect the intestinal canal sufficiently to counteract
constipation. As the latter is an early symptom in a peculiarly
dangerous form of rachitis, cod-liver oil ought to be given in time (in
craniotabes). Diarrhoea is but seldom produced by it; if so, the
addition of a grain or two of bismuth or a few doses of phosphate of
lime (one to four grains each) daily, may suffice to render the
movements more normal. There are but few cases which will not tolerate
cod-liver oil at all. The pure cod-liver oil--no mixtures, no
emulsions--ought to be given; the large quantities of lime added to it
in the nostrums of the wholesale apothecaries embarrass digestion and
bring on distressing cases of constipation. These mixtures have been
prepared and are eulogized on the plea of their furnishing to the bones
the wanting phosphate of lime. The bones, however, as we have seen
before, are not grateful enough to accept the service offered. But only
a certain amount of phosphate of lime is useful in rachitis and in
digestive disturbances. In small doses it neutralizes acids like other
alkalies; its phosphoric acid combines with sodium very easily, and
gives rise to the formation of glyco-phosphoric acid, which is of very
great importance in the digestive qualities of the upper portion of the
small intestines.
Plain malt extracts will be well tolerated by some older children. The
preparations which are mixed with a goodly part of the pharmacopoeia by
generous manufacturers are to be condemned.
Craniotabes requires some special care in regard to the head. The
pillow ought to be soft, but not hot; no feather pillow is permitted.
The copious perspiration of the scalp requires that it should be kept
cool, the perspiration wiped off frequently to avoid its condensing
into water, and the flattening side of the head may be imbedded in a
pillow with a corresponding depression. Copious perspiration indicates
the frequent washing with vinegar and water (1:5-6). The muscular
debility commands great caution. The baby must not be carried on the
arm, but on a pillow which supports both back and head, or in a little
carriage. No sitting must be allowed until the back will no longer bend
to an unusual degree. No walking must be encouraged at any time. The
patients will walk when their time has come. The bones are so fragile
that great care {163} is needed sometimes not to fracture or to infract
them and to avoid periosteal pain in lifting. The skin must undergo
some training by gradually accustoming the little patient to cool
water. It can be readily, but gradually, reduced to 70° for a bath at
any season. The addition of rock- or table-salt to the bath is a
welcome stimulant. And fresh air ought to be granted freely.
Laryngismus stridulus shares the indications for treatment furnished by
craniotabes. The general treatment remains the same. Prominent symptoms
and complications ought to be treated besides; constipation requires
the more attention the more convulsive attacks of any description may
arise from reflex action. The general nervous irritability may be
relieved by bromide of potassium, sodium, or ammonium. One gramme daily
(15 grains) of either, in three doses, is well tolerated for a long
period. When there are symptoms of an imminent convulsion, or to soothe
the convulsibility which may break out any moment, chloral hydrate,
eight or ten grains in from one hour to four hours, two grains in a
dose, will be convenient. If the stomach refuses or is to be spared,
from four to eight grains may be given in an enema of warm water. A
severe attack of convulsions ought to be checked with inhalations of
chloroform. When a warm bath is to be had, care should be taken that
the child be not tossed about. Hold the baby in a small sheet or a
large napkin, and immerge it thus into the water, raising the head and
cooling it with cold cloths or an ice-bag. Genuine attacks of
laryngismus with well-developed stages--the first paralytic, the second
spasmodic--give but little time for any treatment. The proposition to
apply the electrical current is well meant, but the attack has passed
by, or terminated fatally, or resulted in a general convulsion, before
the apparatus can possibly be in operation. I can imagine, however,
that a Leyden flask kept ready might be used to advantage during the
stage of apnoea for the purpose of bringing on inspiration. Sprinkling
with cold water, beating with a wet towel, shaking by the shoulders,
may certainly contribute to awake respiratory movements. The advice to
wait quietly until the attack has passed by is more easily given than
carried out. Marshall Hall's direction to perform tracheotomy will, I
hope, soon be forgotten.
Nothing is more gratefully appreciated by the little patients than air.
May it never be forgotten that night-air is better than foul air, and
that furnace-air means air greatly modified by injurious additions.
More than twenty years ago I was in occasional attendance upon a male
baby--now a medical man of some promise--with craniotabes and a number
of general convulsions. No treatment would remove, or even relieve, the
attacks, until, without the physician's advice, the father took the
baby into the street in the hardest winter weather. After the first
long absence from his furnace the baby was well of his convulsions, and
the physicians profited by their involuntary experience.
In the same way that salt-bathing is beneficial, so is sea-air. A
summer at the seaside is a great blessing to rachitical children.
Sea-baths have been arranged for them in France (Berx-sur-mer), in
Italy (San Ilario di Nervi, Viarreggio, Livorno, Volti, Fano), in
England (Margate), in Germany (German Sea, by Prof. Beneke), and for
some little time past in the neighborhood of our own large cities.
{164} Complications command great attention in rachitis, particularly
where there is danger from the affection of the nerve-centres, for the
slightest irritation in some distant part of the body may give rise to
an outbreak. Thus, in craniotabes it is desirable to watch even the
gums. Not sharing the etiological superstition which attributes so many
diseases of infancy to dentition, I still know that a slight irritation
of the gums may suffice to exhaust the slim resisting power of the
infant. If there be local swelling and congestion of the gums over a
growing tooth, it may become necessary, or at least advisable, to
lance. An otitis which under ordinary circumstances would give rise to
no symptoms at all besides some inconvenience or slight pain will prove
the source of great danger in a rachitical (craniotabic) infant. The
chronic bronchial catarrh and frequent broncho-pneumonia of such
patients require early attention, for they and the neighboring
lymphatic glands stand too much in the relation of a vicious circle of
cause and effect.