Although, as already indicated, rickets may have its origin (at least in some instances) during intra-uterine life, it is seldom that it can be recognized until several months after birth, and it most commonly attracts attention at about the end of the first year. The symptoms which precede the outward manifestation of the disease are marked disorders of the digestive and alimentary functions. The child’s appetite is diminished, and there is frequent vomiting together with diarrhoea or irregularity of the bowels, the evacuations being clay-coloured and unhealthy. Along with this there is a falling away in flesh. Importance is to be attached, as pointed out by Sir William Jenner, to certain other symptoms present in the early stages, namely, profuse sweating of the head and upper parts of the body, particularly during sleep, with at the same time dry heat of the lower parts and a tendency in the child to kick off all coverings and expose the limbs. At the same time there is great tenderness of the bones, as shown by the pain produced on moving or handling the child. The urine contains a large amount of calcareous salts. Gradually the changes in the shape of the bones become visible, at first chiefly noticed at the ends of the long bones, as in those of the arm, causing enlargements at the wrists, or in the ribs, producing a knobbed appearance at the junction of their ends with the costal cartilages. The bones also from their softened condition tend to become distorted and misshapen, both by the action of the muscles and by the superincumbent weight of the body. Those of the limbs are bent outwards and forwards, and the child becomes “bow-legged” or “in-kneed” often to an extreme degree. The trunk of the body likewise shows various alterations and deformities owing to curvatures of the spine, the flattening of the lateral curves of the ribs, and the projection forwards of the sternum. The cavity of the chest may thus be contracted and the development of the thoracic organs interfered with as well as their functions more or less embarrassed. The pelvis undergoes distortion, which may reduce its capacity to a degree that in the female may afterwards lead to serious difficulties in parturition. The head of the rickety child is large-looking in its upper part, the individual bones of the cranium sometimes remaining long ununited, while the face is small and ill-developed, and the teeth appear late and fall out or decay early. The constitutional conditions of ill-health continue, and the nutrition and development of the child are greatly retarded.

The disease may terminate in recovery, with more or less of deformity and dwarfing, the bones although altered in shape becoming firmly ossified, and this is the common result in the majority of instances. On the other hand, during the progress of the disease, various intercurrent ailments are apt to arise which may cause death, such as the infectious fevers, bronchitis and other pulmonary affections, chronic hydrocephalus, convulsions, laryngismus stri. dulus, &c.

An acute form of rickets of rare occurrence has been described by writers on diseases of children, in which all the symptoms are of more rapid development and progress, the result in many instances being fatal.

The treatment of rickets is necessarily more hygienic than medicinal, and includes such preventive measures as may be exercised by strict attention to personal health and nutrition on the part of mothers, especially where there appears to be any tendency to a rickety development in any members of the family. Very important also is the avoidance of too prolonged nursing, which not only tends directly to favour the development of rickets in the infant nursed, but by its weakening effects upon the mother’s health is calculated to engender the disease in any succeeding children. At the same time it must be admitted that, when the mother is healthy, her milk abundant, and nursing discontinued before the lapse of the first year, there is no better means of preventing the occurrence of rickets than this method of feeding an infant, the disease, as is well known, being far more frequently met with in children brought up by hand. The management of the child exhibiting any tendency to rickets is of great importance, but can only be alluded to in general terms. The digestive disorders characteristic of the setting in of the disease render necessary the greatest care and watchfulness as to diet. Any one system of feeding the infant may at times be found to disagree, and may require to be changed or modified in some particulars. Thus, if the child be not nursed but fed artificially, milk, either fresh or condensed, should be almost the only article of diet for at least the first year, and the chief element for the next. When not digested well, as may at times be shown by its appearance as a curd in the evacuations, it may be diluted with water or lime water, or else discontinued for a short time, carefully-made gruel or barley water being substituted. Many of the so-called “infant’s foods” which are now so extensively used appear to be well adapted for their purpose, but when employed too abundantly and to the exclusion of the due amount of milk are often productive of digestive and intestinal disorders, probably from their containing a greater amount of starchy matter than can be utilized. From the end of the first year light animal soups may occasionally be given with advantage. The medicinal remedies most to be relied on are those which improve the digestive functions and minister to nutrition, and include such agents as the preparations of iron, quinine, and especially cod-liver oil. The administration of lime salts in large quantity has been proposed by some physicians under the idea that in this way the deficient earthy matter might be supplied to the bones. M. Piorry recommended for this purpose powdered fresh bones which contain a large amount of phosphate of lime. No great success can be claimed for this plan, and it is generally recognized that the most useful method of treatment is that which is directed to the feeble assimilative powers, and seeks to supply food of a kind which will be at once readily digested and nutritious. Of no less importance, however, are abundance of fresh air, cleanliness, warm clothing, and attention to the general hygiene of the child and to regularity in all its functions.

When the disease is showing evidence of advancing, it is desirable to restrain the child from walking, as far as possible. But this precaution may be to some extent rendered unnecessary by the use of splints and other apparatus as supports for the limbs and body, enabling the child to move about without the risk of bending and deformity of the bones which otherwise would probably be the result. (J. 0. A.)