The obscure but unmistakable relations existing between rickets and the status lymphaticus will be referred to in Chapter XIV.
The osseous lesions of rickets differ from those seen in osteomalacia, since in the latter the softened tissue is practically decalcified bone, while in the former case most of the affected tissue has never gone so far as genuine bone formation, but is arrested in its perverted state.
The result of rickety changes in the skeleton is a thickening of the shafts of the long bones, of the outer table of flat ones, of the epiphyseal extremities of shafts, and frequently a stunting of their development, so that they do not attain their normal length. The periosteum is also affected in rickets, with the result that when the changes occur, mostly subperiosteally, there are warpings and curvings of the bone shafts, while so long as the disturbance is epiphyseal more or less abrupt curvatures and angular deformities will be produced as the result of muscle action. So marked are the changes in some instances that it has been stated that bones may even lose three-fourths of their calcium salts. When rachitic bones are so soft as to be easily cut with a knife, marked deformities occur as the result of muscular activity. (See [Plate XI].)
In the extremities we see bow-legs, knock-knees, clubbing of the ends of the long bones, bending of the neck of the femur, flat-foot, club-foot, etc.; while the clubbing of the bone ends also may be well marked in the bones of the upper extremity, where, however, marked deformity is less common, because the upper extremity does not bear the weight of the growing body. In the skull the bones remain soft and yielding to pressure, with a tendency to return to their original membranous condition, and this is the condition comprised under the term craniotabes rachitica. The fontanelles always remain open for an undue time; the sutures are broad and membranous. The bones of the face grow less rapidly, giving to the face a disproportionately small size; dentition is delayed and the teeth decay easily. The upper incisors often project far over the lower.
In the thorax there are enlargements of the sternal ends of the ribs, causing a row of nodules referred to as the rachitic rosary. The ribs tend to sink in, the sternum to be protruded forward, and the deformity known as pigeon-breast becomes often pronounced. Curvatures of the spinal column, especially kyphosis, are common, and distinct degrees of lateral curvature are frequently begun as rachitic deformities, to be magnified by perverted muscle action as the child grows older. In the pelvis the innominate bones approach each other, causing the pelvic cavity to become contracted, or the sacral promontory projects too far, or in various other ways the normal pelvic diameters are so far compromised that rachitic deformities of the pelvis constitute the most common and serious obstacles to normal labor in adult women, and are frequently the cause of major obstetric operations.
While the rachitic changes in the osseous system are the most distinctive and easily recognized, numerous other organs and tissues of the body are more or less seriously compromised. Ventricular dilatation, leading to chronic hydrocephalus, is one of the common results of rachitis of the skull, which may be followed by convulsions and terminate fatally. Porencephalon and cerebral sclerosis may also ensue. Disturbances of digestion are common in rickety children—the liver may decrease in size or become much enlarged; the spleen often enlarges, sometimes to enormous dimensions. In various other parts of the body there are the same expressions of malnutrition as are met with in tuberculous disease. Rickety children perspire easily, particularly at night, when the head will often be found bathed in perspiration. They are fretful and irritable, as a rule, and difficult to control. A child with protuberant belly, due to enlargement of liver and spleen, as well as to crowding of pelvic organs, with relaxation of abdominal walls, and a contracted and distorted thorax, the skull flattened on the top, clubbed bone ends, a history of resting badly at night and sweating profusely, constitute a clinical picture of rachitis so marked that it can be recognized at a glance. Between this picture in its worst forms and the slightest deviation from the ideal type there may be met all degrees in manifestations of rickets in the children of the rich or the poor, while in adults may often be seen evidences of that which prevailed during early childhood. In order that all these features may be made out the child should be stripped and examined from head to foot.
Laryngismus stridulus is a frequent accompaniment. It may be followed by general convulsions and tetany. (See [Chapter XIV].) While rickets may be a very acute disease, it is as a rule chronic, and children dying essentially from this disease die rather from cerebral or other manifestations which may be regarded as in some degree accidental. Scurvy and other nutritive disturbances may be associated with rickets.
Treatment.
—The treatment for the condition consists mainly in proper nutrition. Mothers’ milk is certainly preferable to any other, and should be demanded. If feeding must be artificial, it should be in accordance with the best precepts of modern therapeutics. Cod-liver-oil emulsions are of advantage; compound syrup of the hypophosphites is a remedy of great virtue. Minute doses of phosphorus seem to be of value—1 Mg. pro die. It is a mistake to let rickety children begin to walk or even to creep too early. They should be kept upon the back in their cribs.
The modern opotherapy of rickets includes the employment of thyroid and pituitary extracts. The dose should be graduated to the age of the patient, based upon 30 Cg. for an adult, and given thrice daily. This will not preclude the necessity for a careful regulation of diet, etc., but will constitute a valuable adjunct in treatment.