DEFINITION.- A from of general malnutrition which is specially characterized by peculiar changes in the bones, by which they are increased in thickness, especially at their ends; moreover, they become softened so that they are peculiarly apt to bend. It is essentially a disease of childhood, and seldom occurs before the sixth, or after the eighteenth month. 

CAUSES.- Rickets is proximately induced by improper food, and especially in relation to a deficiency of the appropriate vitamine. (See Scurvy.) Anything, however, which interfered with developed and nutrition favours its occurrence. Want of sunlight, impure air, confinement, and lack of exercise, are important factors. (The Glasgow School of Pathologists attach more importance to confinement and lack of exercise than to any dietetic failure and their experiments are very convincing.) Prolonged lactation, and suckling the child during pregnancy, are accessory influences in some cases. Like scurvy, rickets may be found in the families of the wealthy under perfect hygienic conditions. It is most common in children fed on condensed milk, the various proprietary foods and food rich in starches. 


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Rickets


SYMPTOMS.- The disease comes on insidiously about the period of dentition, before the child begins to walk. Mild grades of it are often overlooked. In many cases digestive disturbances precede the appearance of the characteristic lesions, and the nutrition of the child is markedly impaired. 

There are there general symptoms of great importance. First, a diffuse soreness of the body so that the child cries when an attempt is make to move it, and prefers to keep perfectly still. Secondly slight fever (100 degree to 101.5 degree F.), with nocturnal restlessness, and a tendency to throw off the bedclothes. This may be partly due to the fact that the general sensitiveness is such that even their weight may be distressing. Thirdly, profuse sweating, particularly about the heat and neck, so that in the morning the pillow is found soaked with perspiration. 

Notwithstanding that rachitic children are sometimes unusually fat, the flesh is soft and flabby, the skin is pale, the bowels act irregularly, the motions are offensive, and the appetite is often ravenous. The cutting of the teeth is delayed, and if the child has already begun to walk, it now cases to do so, sits all in a heap, suggesting to the anxious mother that the back is growing out. The child is weak, languid, peevish, and restless. 

Before long the ends of the long bones become enlarged. This is most easily observed at the junction of the ribs with their cartilages (rachitic rosary), but the wrists, ankles and other joints are very often affected. The bones also become softer and more or less thickened throughout. If the disease is unchecked deformities follow. Thus, the limbs may become bowed, the ribs may be drawn in anteriorly, thrusting the breast-bone forward (pigeon-breast); the spine may be variously curved. The head is large, out of all proportion to the face; the forehead is high, square, and projecting, and the closure of the fontanelles is delayed. The abdomen is large and distended (pot-belly). 


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X-Ray rickets lower limbs.


As the disease progresses, the child becomes shrunken and old- looking, the digestive functions are increasingly disturbed, the bowels are most irregular, and the nervous system acquires a peculiar excitability, and liability to grave complications are common enough, and often prove fatal, but as a rule the affection is amenable to treatment, if not too long delayed. Spasm of the larynx and convulsions occasionally cause death. 

TREATMENT.- The better the conditions of the mother during pregnancy, the less likelihood is there of the development of rickets in the child. Rapidly repeated pregnancies and suckling of a child during pregnancy, seem important factors in the production of the disease. 

The diet claims foremost attention in the treatment of rickets, and many cases may be cured entirely by qualitative adjustment of the food. Fresh cow's milk diluted with barley-water according to child's age and digestive capacity, with added protein and fat in the shape of meat juices and cream, is the food which is most generally suitable. Care should be taken to examine the condition of the stools, and if curds are present the child is taking too much milk, or it is insufficiently diluted. Starchy food should be altogether avoided by rachitic infants under one year old. With older children, on the other hand, the milk diet may be supplemented by eggs. The principle of producing a sufficiently of protein and fatty food must not be lost sight of. ( Note that while butter contains the needful Vitamine margarine does not.) Green vegetables and salads are desirable. 

Abundance of fresh air, sunlight, and cleanliness of surroundings, rank only next in importance to diet. 

The child should be bathed daily in warm water. Careful friction with sweet oil is very advantageous, and if properly performed allays rather than aggravates the sensitiveness. 

Care should be taken to prevent deformity. The child should not be allowed to walk, and for this purpose splints applied so as to extend beyond the feet are very effective. 

Cod-liver oil, in doses of from half to one teaspoonful, is very advantageous. 

Treatment must be thorough, and if commenced early the best results may be expected; for although one of the most common of children's diseases, it is yet one most easily arrested. 

Phosphoric Acid.- Rickety affections of the bones, with pains in the limbs, and Diarrhoea. 

Calc-C.- In fat children of soft flabby tissues; profuse perspiration about the head, which may be sour smelling; often wake up screaming in the night. 

Silicea.- Corrects the perspiration about the head, especially if offensive, and upper portion of the chest, and the sensitiveness before described; it also controls the tendency to the increased growth of cartilage. 

Calc.-Phos.- In many cases of Rickets this salt is of great utility, and if the child is fed by the breast, both the mother and child will be benefited by the medicine. Phosphate of lime has the power not merely to correct deficient consolidation of the bone, but equally to correct the consentaneous unnatural growth and malnutrition of the soft tissues of the body. 

Asaf., Phos., and Sulph. are also recommended. 

75.- Infants' Scurvy-Barlow's disease (Scurvy Rickets). 

DEFINITION.- A from of scurvy met with in infants, which from its occasional association with rickets, and from the resemblance association with rickets, and from the resemblance of some of its symptoms to those of rickets, has been mistaken for that disease, and called acute rickets. It is a true scurvy, and results from exclusive feeding on proprietary foods, condensed milk, or milk submitted to prolonged sterilisation-in short, any food deficient in vitamines. 

SYMPTOMS.- The disease develops rather quickly, the child becoming pale, and very fretful, crying whenever move or pressed, owing to tenderness of the bones. Examination of the latter reveals ill-defined swellings, more often towards their extremities. Fractures sometimes happen, and more rarely, a protrusion of the eyeball occurs from similar swellings in the orbit.

Before dentition the gums are unaffected, but otherwise they are swollen, spongy, and readily bleed. Bruise-like patches are common. The urine may be slightly bloody. The appetite is usually fair, and as a rule there is no vomiting or nausea. 

In young children with difficulty in moving the lower limbs this condition should be suspected. 

The characteristic lesion is a sub-periosteal haemorrhage occurring without any inflammatory manifestations. 

TREATMENT.- The essential feature of treatment consists in supplying fresh food in the form of fresh milk, sieved potato, fresh meat-juice, and a tablespoonful (in divided doses) of orange or grape-juice daily. 

Recovery is usually prompt and satisfactory. 

MEDICINES.- Practically the same as for Rickets (q.v.) and Bry., Merc., Arn.