Manual of Surgery Volume First: General Surgery. Sixth Edition.

by Alexis Thomson; Alexander Miles

Treatment.—The treatment of the disease consists in regulating the diet, improving the surroundings, and preventing deformity. Phosphorus in doses of 100th grain may be given dissolved in cod-liver oil, and preparations of iron and lime may be added with advantage. To avoid those postures which predispose to deformities, the child should lie as much as possible. In the well-to-do classes this is readily accomplished by the aid of a nurse and the use of a perambulator. In hospital out-patients the child is kept off its feet by the use of a light wooden splint applied to the lateral aspect of each lower extremity, and extending from the pelvis to 6 inches beyond the sole.

When deformities are already present, the treatment depends upon whether or not there is any prospect of the bone straightening naturally. Under five years of age this may, as a rule, be confidently expected; the child should be kept off its feet, and the limbs bathed and massaged. In children of five or six and upwards, the prospect of natural straightening is a diminishing one, and it is more satisfactory to correct the deformity by operation. In rickety curvature of the spine, the child should lie on a firm mattress, or, to allow of its being taken into the open air, upon a double Thomas' splint extending from the occiput to the heels; the muscles acting on the trunk should be braced up by massage and appropriate exercises.

Late Rickets or Rachitis Adolescentium is met with at any age from nine to seventeen, and is generally believed to be due to a recrudescence of rickets which had been present in childhood. The disease is not attended with any disturbance of the general health; the pathological changes are the same as in infantile rickets, but are for the most part confined to the ossifying junctions, especially those which are most active during adolescence, for example at the knee-joint. The patient is easily tired, complains of pain in the bones, and, unless care is taken, deformity is liable to ensue. There can be no doubt that adolescent rickets plays an important part in the production of the deformities which occur at or near puberty, especially knock-knee and bow-knee.

Scurvy-Rickets or Infantile Scurvy.—This disease, described by Barlow and Cheadle, is met with in infants under two years who have been brought up upon sterilised or condensed milk and other proprietary foods, and is most common in the well-to-do classes. The hæmorrhages, which are so characteristic of the disease, are usually preceded for some weeks by a cachectic condition, with listlessness and debility and disinclination for movement. Very commonly the child ceases to move one of his lower limbs—pseudo-paralysis—and screams if it is touched; a swelling is found over one of the bones, usually the femur, accompanied by exquisite tenderness; the skin is tense and shiny, and there may be some œdema. These symptoms are due to a sub-periosteal hæmorrhage, and associated with this there may be crepitus from separation of an epiphysis, rarely from fracture of the shaft of the bone. X-ray photographs show enlargement of the bone, the periosteum being raised from the shaft and new bone formed in relation to it. Hæmorrhages also occur into the skin, presenting the appearance of bruises, into the orbit and conjunctiva, and from the mucous membranes.

The treatment consists in correcting the errors in diet. The infant should have a wet nurse or a plentiful supply of cow's milk in its natural state. Anti-scorbutics in the form of orange, lemon, or grape juice, and of potatoes bruised down in milk, may be given.

Osteomalacia.—The term osteomalacia includes a group of conditions, closely allied to rickets, in which the bones of adults become soft and yielding, so that they are unduly liable to bend or break.

One form occurs in pregnant and puerperal women, affecting most commonly the pelvis and lumbar vertebræ, but sometimes the entire skeleton. The lime salts are absorbed, the bones lose their rigidity and bend under the weight of the body and other mechanical influences, with the result that gross deformities are produced, particularly in the pelvis, the lumbar spine, and the hip-joints.

Neuropathic forms occur in certain chronic diseases of the brain and cord; in some cases the bones lose their lime salts and bend, in others they become brittle.

Osteomalacia associated with New Growths in the Skeleton.—When secondary cancer is widely distributed throughout the skeleton, it is associated with softening of the bones, as a result of which they readily bend or break, and after death are easily cut with a knife. In the disease known as multiple myeloma, the interior of the ribs, sternum, and bodies of the vertebræ is occupied by a reddish gelatinous pulp, the structure of which resembles sarcoma; the bones are reduced to a mere shell, and may break on the slightest pressure; the urine contains albumose, a substance resembling albumen but coagulating at a comparatively low temperature (140° F.), and the coagulum is re-dissolved on boiling, and it is readily precipitated by hydrochloric acid (Bence-Jones).

Ostitis Deformans—Paget's Disease of Bone.—This rare disease was first described by Sir James Paget in 1877. In the early stages, the marrow is transformed into a vascular connective tissue; its bone-eating functions are exaggerated, and the framework of the bone becomes rarefied, so that it bends under pressure as in osteomalacia. In course of time, however, new bone is formed in great abundance; it is at first devoid of lime salts, but later becomes calcified, so that the bones regain their rigidity. This formation of new bone is much in excess of the normal, the bones become large and bulky, their surfaces rough and uneven, their texture sclerosed in parts, and the medullary canal is frequently obliterated. These changes are well brought out in X-ray photographs. The curving of the long bones, which is such a striking feature of the disease, may be associated with actual lengthening, and the changes are sometimes remarkably symmetrical ([Fig. 135]). The bones forming the cranium may be enormously thickened, the sutures are obliterated, the distinction into tables and diploë is lost, and, while the general texture is finely porous, there may be areas as dense as ivory ([Fig. 134]).