It is sometimes stated as regards these foods, condensed milk and starchy preparations, that if deficiency of fat is the source of trouble, this can easily be remedied by adding some cream or butter. This, however, is not sufficient, and there are other drawbacks to such a system. One must recognize the tendencies of the female mind, and one of these is to regard any advertised food as possessing special virtues. The average mother has much more belief in a food that comes out of a tin, with a label extolling its good qualities, than in ordinary dairy milk. She will naturally concentrate her attention on what she believes to be the important article of diet, and will tend to neglect the precautionary additions, of the value of which she knows nothing. Many of the proprietary foods are sold with instructions appended as to the addition of fresh cows' milk. One finds, however, as a matter of experience that as time goes on the amount of fresh milk is not increased, and is possibly lessened, while the amount of the patent food is steadily increased. In the preventive treatment of rickets it is not sufficient to give from a quarter to half a pint of cows' milk daily, along with some other food, but there must be a proper amount of fresh proteins and fats. Again, one constantly meets with cases in which some months previously a medical man had ordered condensed milk or some patent food for a temporary digestive disturbance, and this food had been continued until the symptoms of rickets led the mother to seek medical advice again. It is of the greatest importance that a time limit should always be imposed in the case of such substitute feeding, lest its undue prolongation lead to the production of rickets.

The question is sometimes raised - and it is a very important one - as to whether an infant, nourished entirely at the breast, ever develops rickets. The answer must be in the affirmative, but with qualifications. If a healthy mother, with plenty of good milk, feeds her infant at regular intervals and uses no other food whatever, we may safely assert that the infant will not become rickety during the normal period of lactation. The cases of rickets in breast-fed infants in the writer's experience have occurred as follows : In some cases there has been too frequent feeding, which resulted in the production of a milk deficient in fat, and as regards the infant in gastro-intestinal catarrh. The milk being deficient in fat and the digestion being imperfect, the conditions for the development of rickets were present. In other cases an excessive amount of unconverted starch, either in the form of thick barley-water, or of some proprietary food, was given to the infant in addition to the breast milk. The disturbance of digestion which accompanies the use of improper food may render the assimilation of the best milk impossible. Again, lactation may have been carried on beyond the normal period, and the nutriment supplied has become deficient in fat. In some cases, from too frequent child-bearing, the breast milk after two or three months may be of such inferior quality that rickets develops. Dr. Cheadle has found that if a mother becomes pregnant while suckling, the foetus in utero may flourish, but the infant at the breast may dwindle into a condition of rickets and marasmus. This he ascribes to the diversion of the nourishment from the breast to the foetus. These exceptions in no way affect the general rule that sound breast milk is the best food for infants.

In the case of infants over a year old, the same general causes, namely, a deficient amount of fat and an excessive amount of carbo-hydrate, must be avoided in the preventive treatment of rickets. Carbo-hydrates are cheap and easily prepared, while fatty foods are dear and are not in such common use. Tea, bread, jam, potatoes, and perhaps a "penn'orth of milk" represent a common dietary for young children, and it is one specially conducive to rickets. Such a diet is so deficient in fats and proteins that its unsuitableness is at once apparent. These deficiencies must therefore be avoided.

The Curative Treatment

In an ordinary case of rickets there are two stages in the curative treatment, first to relieve the gastrointestinal disturbance by a spare diet of weak and digestible food, and secondly to cure the constitutional affection by a dietary in which fats and proteins are fully represented.

It is useless to commence with a large amount of fatty food because the already impaired digestion would only be still further weakened. There are usually present intestinal catarrh, a dilated and weakened condition of the wall of the stomach and bowel, and fermentation of the intestinal contents. It is advisable, therefore, to begin with simple plain food in small quantities. An infant of twelve months may be ordered a mixture of milk, lime-water, and thin barley-water in equal proportions, of which 4 1/2 ounces may be taken every three hours during the day. After some days of this dietary, it may be less than a week, or more, according to the conditions present, the strength of the food may be increased by giving equal parts of milk and lime-water. If, on the other hand, the signs of gastro-intestinal fermentation persist, it is advisable to stop all milk for a few days, and to give only weak mutton or chicken soup. This, along with suitable medication directed to the bowel condition, will soon allow of a return to milk. The quantity and strength of the milk mixture are to be gradually increased until the patient is taking a pint of milk and half a pint of barley-water daily.

In the second stage of the treatment a fuller dietary is called for so as to procure proper nutrition and remove the rachitic debility. The fatty element comes first in importance. Fat may be given in the form of cream, butter, dripping, yolk of egg, beef, mutton, or bacon fat, or cod-liver oil, the chief essential being that it is animal fat. Vegetable or mineral oils do not seem to be nearly so efficacious. It may appear at first sight superfluous to give a large fat baby more fat in its diet, but experience has shown that the fatty tissues of a rickety infant, derived as a rule from carbo-hydrates, are merely a burden. Under the use of a diet rich in animal fat these flabby tissues melt away and are replaced by healthy tissues. Further, there is required for the growth and nutrition of most of the organs an abundant supply of fat, and in rachitic babies these organs may be said to be starved in this respect. As a result their function is much impaired and their powers of resistance much lowered. Hence we find that many of the disorders of rachitic infants do not yield readily to an ordinary diet, nor to ordinary medication, but do yield to a full amount of fat in the food. In the employment of fat, therefore, in the treatment of rickets, in order to procure the full effect as speedily as possible, we must not be content with a normal amount of fat, but should push it to the full degree of toleration, as judged by the digestive powers, and the nature of the stools. The form in which the fat is administered is not unimportant, and gravity cream, bacon fat, and cod-liver oil will be found the most suitable for young children. Fresh milk, containing as it does a fine emulsion of fat and a large amount of protein, is to be regarded as the chief article of diet during the whole of the rachitic period. It is of the first importance that it should be whole milk, and uncontaminated by preservatives or sterilized by excessive heating. To a slight extent by boiling and to a marked extent by sterilizing, the fat of milk is altered as regards its digestibility. Probably unboiled milk is more rapidly efficacious in rickets than boiled, and the former should be used whenever the purity of the milk can be relied on. If additional protein food seems called for, it may be given in the form of white of egg or raw meat juice, half to one ounce to be added to the milk daily. The raw meat juice is especially useful when the anaemia of rickets is pronounced. The supply of carbo-hydrate material may be temporarily diminished during the active stage of treatment. Just as the tissues have been described as being starved of animal fat, so they may be said to have been saturated with carbo-hydrates. The history of the previous diet will usually show that clearly. Both the digestion and the system generally will benefit from a strictly limited amount of sugar, bread, and puddings. Hutchison, speaking of the dietetic treatment of rickets, says that "a rickety child must be mainly carnivorous, as rickets might be said to be due to premature vegetarianism." Rickety infants have often a great liking for salt, and this probably implies a demand on the part of the organism. One to two drachms of common salt may be given daily in the milk. It will also be found beneficial to give some fresh fruit, such as orange or grape juice, and a small quantity of mashed potato occasionally. These will supply the anti-scorbutic elements, which have often been markedly deficient in the previous diet. This addition is specially called for in all cases where tenderness of the limbs is present.