RICKETS.
Whatever view be accepted regarding the pathology or etiology of rickets, all authorities are agreed that the treatment must be mainly dietetic.
Other important agents must not, however, be overlooked in the management of all cases of the disease. These are abundance of open air and as much sunshine as the seasonal conditions permit and suitable clothing to prevent chills.
As regards prophylaxis, the same dietetic provisions which are indicated in the treatment of the established disease are equally successful in its prevention, and to these must be added the necessity of proper feeding and improved hygiene in the case of the mother during pregnancy and lactation. Factors in the production of rickets which are constantly overlooked are the food and care of the cow which produces the milk for the infant's use. The animal requires good food, sunshine and warmth, and as regards the former the practice of feeding milch cows on the refuse grains from the distillery has, in the writer's opinion, much to answer for ; this food is often in a state of incipient putrefaction, and its use causes an abundant secretion of milk with a small amount of cream.
The first duty of the physician, therefore, is to institute a careful inquiry into every detail of feeding and everything connected with the sanitary surroundings of the child, and to have any violation of the laws of health promptly rectified.
A too rigid adherence to some one particular artificial food may be the cause, and a change in this direction may be imperatively necessary. The physician must bear in mind the sometimes marked peculiarities which exist in young children, and any hard and fast lines for feeding must be considerably relaxed. One infant will thrive upon the milk of a cow which will he poison to another and apparently a stronger child. Patience and discrimination in this matter are, thereft re, of the greatest importance at the very outset.
It is too rigidly maintained that the cause of rickets must be due to the absence from the diet of some particular constituent or constituents essential to healthy nutrition. The deficiency has been supposed to be
either in the fats, carbohydrates, salts or proteids, but although the disease is rare except in bottle-fed children it may supervene when the usual substitute—cow's milk—is employed in such a form as to contain the fats, salts and proteids in sufficient amounts. Moreover, the same cow's milk in exactly the same form may be used as the exclusive food of another child who remains healthy. The explanation of these contra dictory results probably lies in the theory that a serious error in the diges tive function is present whereby the necessary constituent (present in suitable proportions in the milk or food) is not being assimilated.
Various opinions have been held, and still are held, upon which of the essentials is wanting. The absence of lime salts, proteid and fats have all in turn been blamed. The solution of the difficulty is not made easier by the knowledge that the milk of a healthy mother contains proteid, fat and salts in such proportions as prevent the possibility of rickets, and that when cow's milk is used instead, with such additions as are necessary to make it identical in composition, rickets supervenes sometimes.
It is maintained that an insufficient amount of fat is absorbed, and this is probably an etiological factor of the disease. Though cow's milk contains quite enough fat for the maintenance of healthy nutrition, the superabundance of proteids in the form of casein taxes the digestive powers of the infant beyond their effective limits,with the result that both fats and proteids are assimilated in insufficient amount.
An obvious and simple expedient would be to dilute the cow's milk till the requisite amount of proteid present in human milk is provided, but when this is so proportioned it will be found that the fat and sugar have fallen below the standard necessary to insure healthy nutrition.