Causation

Rickets is a disease of malnutrition. The fault may lie in a hereditary weakness of the digestive organs, or the influence of some disease, but the majority of cases are directly caused by improper or insufficient food. This food may be the breast milk of a mother or wet nurse, who is herself enfeebled by chronic disease, by oft-repeated pregnancies, or whose mammary secretion is modified by dietetic errors - loss of sleep, emotional or neurotic disorders, or the milk supply may simply be insufficient from too long-continued nursing or the intervention of pregnancy, or some other factor. The poor, for reasons of economy, often suckle their children for too long a period - in fact, until they are two years of age - but even before weaning them they allow them to go to the table and share in the general diet of fried fish, pickles, potatoes, pork, raw fruits, beer, etc. Children treated in this manner are especially prone to develop rickets. In all doubtful cases the milk of the mother or nurse should be analysed before weaning, and an effort should be made to improve its quality.

If the child is already weaned, the cause of the rhachitic condition may be a poorly selected diet, such as a patent " baby food," with insufficient fat and earthy salts and excess of starch.

Rickets has been experimentally produced by Cheadle, Guerin, and others in young animals by depriving them of animal fats and earthy salts. It is caused by withholding all lime salts from the food (Voit), but especially calcium phosphate, and young, growing animals failing to receive a fresh supply absorb lime salts from bones already ossified for the benefit of the newer ones, and thus all the bones become soft. Baginsky found that this process is exaggerated in young animals by the presence of lactic acid in the food, and Wegner proved that phosphorus has a similar effect. Forster has calculated from the lime ordinarily present in milk that an infant four months of age receives a gramme each day. Indigestion lessens hydrochloric-acid secretion and increases lactic-acid formation, and lessens absorption of lime salts.

Starchy and saccharine foods not only contain little or none of the necessary lime, but easily undergo lactic-acid fermentation, which it has just been shown intensifies the rhachitic processes.

Bottle-fed infants are very subject to rickets, especially if the milk be sterilised, and breast-fed infants may become rhachitic if the milk is watery, of low specific gravity, too poor or too rich in fat or in lactose.

Prophylaxis

The best prophylactic against rickets is nursing through the first year by a healthy mother or a carefully selected wet nurse. It is a very common practice in this country for mothers to wean their babies too early, and without a physician's advice to resort to one of the much-advertised patent infant foods, with the result above described.

Dietetic Treatment

The dietetic treatment of rhachitis in a weanling must consist, first of all, in supplying good fresh cow's milk modified to resemble as closely as possible the best mother's milk. It is highly important that the milk should contain sufficient fat, and it must be modified accordingly by the addition of cream or oil. (See Modified Milk, p. 90).

If the child must be bottle fed, the milk should be carefully Pasteurised in order to diminish the liability of its fermentation in the alimentary canal, and among the poor, who cannot afford to purchase prepared milk in this way, the milk as soon as purchased should be heated, and a few grains of bicarbonate of sodium may be added to it. A plug of previously baked cotton should be used in the bottle in place of a cork. When given, the milk should be diluted with barley water, or, if constipation is present, with oatmeal water. These waters are made by boiling a tablespoonful of pearl barley or of good oatmeal in a pint of water until the meal is completely softened. A little salt is then added, and the mass is strained through a fine cloth. It is advisable also to add milk sugar. The proportion of milk for the diluent should be half and half for the first six weeks of infancy; after this the proportion is to be gradually increased, and when six months of age it should be given three parts milk and one part diluent.

The quantity of milk is to be continuously increased, and at the ninth month it may be in the proportion of four to one, and at the end of the year dilution is no longer required.

Very young infants who are fed by artificial means should not be given any farinaceous food. In the first two or three months of infant life the saliva - from deficiency in ptyalin - is incapable of digesting starch, and starch is also poorly digested by the pancreatic juice in the intestine. Starch, therefore, acts as a foreign body and a gastro-intestinal irritant, and passes through the alimentary canal unaltered.

It is advisable in all rickety children to restrict the giving of farinaceous foods until some time after the period when they are often allowed, and, as a rule, children having rickets should not be fed any starchy food until after the twelfth or fourteenth month. They need fats much more than starches or sugars.

There are some apparent exceptions to this where infants become seemingly robust while fed upon amylaceous foods at a very early period, but they are less healthy as they grow older or exhibit malnutrition or some constitutional weakness. Such exceptions by no means controvert the value of the rule in general, as above stated. When starchy food is given to young infants it should always be predigested with diastase or " malted".

Preparations of condensed milk which contain large quantities of sugar are sometimes given to infants by mothers, and they produce a prompt increase in weight, but the appearance in these cases is deceptive, and the muscles and other tissues are less firm and strong than they should be. This is proved by the fact that children erroneously fed in this way succumb far more easily to various diseases of infancy, especially to diarrhoeal troubles, which they may acquire later on. After the first year a little of some malted or pre-digested form of starchy food may be added to the milk.

Whenever amylaceous food is mixed with the milk it should be previously converted, as far as possible, into dextrin or glucose, and it should be added rather with the object of mechanically preventing the formation of coagulae of casein than with the idea of feeding the infant upon a substance which its digestive organs are not yet fitted to act upon. J. Lewis Smith says: " If a heaping teaspoonful of barley flour be boiled in twenty-five teaspoonfuls of water, and when it is lukewarm ten or fifteen drops of diastase be added to it, the gruel in a few minutes becomes much thinner from the digestion of starch, and it is a useful adjuvant to the milk employed in the nursery, especially for infants over the age of six months." At this time or later a little albuminous food in the form of mutton or chicken broth or the expressed juice of rare roast beef or beefsteak.

After a year or fourteen months the diet should consist of cow's milk, cream, beef juice squeezed from a fresh steak, and broths, and stale bread crumbs in milk may be added. Later still, the child may take scraped beef or a raw beef sandwich made with thin layers or bread and butter with meat pulp between them. Beef tea, mutton, and chicken broths are good. Fresh fruit juice, especially orange juice, is excellent. A little sweet currant jelly added to the meat will improve its flavour for older children who object to taking it. When a year and a half old the child may be given eggs, either beaten with milk and sweetened or soft-cooked. If attacks of diarrhoea supervene, it will be well to stop the meat broths temporarily and put the child for a few days on a diet of koumiss, zoolak, or pancreatinised milk. In some cases maltine is found to agree well with rhachitic children, and if diarrhoea does not exist they should be given pure Norwegian cod-liver oil three times a day in doses of a few drops for a young infant, up to a teaspoonful for a child a year or two old. Older children should have abundant fat, in the form of fresh butter on bread, or cream upon stewed fruit or baked apples.

Fothergill wrote: " The liquid fat of fried bacon is most digestible, and the child should be allowed to dip its bread in it or have it crumbed into the fluid fat." Or it may occasionally be given a piece of bacon to suck.

The fat of bone marrow might be used for the same purpose.

Inunctions of two or three teaspoonfuls of olive oil may be given daily over the legs and abdomen.

Rhachitic children, on account of their poor nutrition, usually have a deficient number of teeth or their teeth are imperfect or quickly decay. It is therefore important that when they have passed the first dentition food should always be given them in a state of fine subdivision, otherwise it will be bolted without mastication and gastro-intestinal disorder will result. Meat should be thoroughly hashed or pounded in a mortar, and solid meat should never be given the child to masticate until it is over two years of age. Potatoes should only be given baked in a soft and mealy form.

Some breast-fed infants may become rickety, while others badly fed by artificial means may not, and the extraordinary instances of toleration of improper food which one constantly finds among the children of the ignorant poor, at times severely test one's faith in dietetic rules, but much allowance must be made for the constitution of individuals and for race characteristics. The subsequent history of wrongly fed children often points directly to original faults in diet which have affected the general nutrition of the body, although the immediate effect of such errors may not have been apparent.

Aids To Dietetic Treatment

Rhachitic babies, as well as older children, should be weighed at regular intervals as an important guide for their correct feeding.

In rickets more or less gastric catarrh is commonly present, which interferes with normal digestion and absorption, and appropriate medicinal remedies should be employed to regulate this condition when necessary. There is often excessive acidity in the stomach which must be neutralised by sodium bicarbonate. The hygienic treatment of the children in conjunction with dietetic measures is of the utmost importance. Rickety children must practically live outdoors in all seasonable weather, and it is better for them to remain out in fresh, cold air than to be kept at home in a damp, dark, overheated, and badly ventilated tenement. They should be frequently bathed in order to keep the skin in as good condition as possible, and prevent the occurrence of skin diseases, which are a common accompaniment of malnutrition. They should be kept quiet and not worried, and if they are weak and feeble, great care should be exercised in handling them and in placing them in proper positions upon beds which are firm but not hard, in order to prevent the weakened bones from becoming deformed by pressure.