734 CAUSES OF DEATH IN RICKETS. that which occurs in enchondromata-a pathological, not a physiological occurrence.* The tissue thus changed presents an ivorylike density and hardness so as to become susceptible of a high polish. It is in the long bones, and especially in the seat of an old fracture, or at the concavity of the arch into which they have bent when softened, that the petrifaction of the bone matter is most remarkable; though it is by no means confined to those situations, but is observable, though in a less degree, in the flat bones, and is sometimes strikingly marked in those of the skull. I have already described the evidences of general ill health and of imperfect nutrition which are characteristic of riekets, and it sometimes happens that the child dies with no definite disease, but apparently as the result of the aggravation of all these symptoms. In such cases there is usually a considerable degree of albuminoid infiltration of the liver, spleen, and lymphatic glands, and the degree to which the latter are sometimes distinctly enlarged gave rise to the opinion which once prevailed as to the essential identity of scrofula and rickets. The condition of the glands in the two cases is, however, entirely different; and instead of there being any real connection, there is rather a condition of antagonism between tubercle and scrofula on the one hand, and rickets on the other. In the majority of instances, death is not due to the mere intensity of the rickety cachexia, but to the supervention of some intercurrent disease. I have already alluded to the connection between spasin of the glottis and that imperfect ossification of the skull which is one of the early indications of rickets; and rickety children are not seldom carried off either by distinct laryngeal spasm, or by some other form of those convulsions which, where teething is tardily and ill accomplished, often attend upon it. When the disease comes on in very early infancy too, it is by no means unusual to find it associated with a slow form of chronic hydrocephalus, which develops itself during the general febrile disturbance of the system. The effusion of fluid in these cases is never very considerable, but the head assumes the regular hydrocephalic form, while the general deformity of the skeleton is often so trivial that, unless the patient's history is carefully enquired into, the relation of the hydrocephalus to rickets may be altogether overlooked. It will be learned, however, that the symptoms had no acute onset, but supervened very gradually, that they did not * Professor Kölliker took the former view, while Trousseau, op. cit. vol. iii. p. 472, and more distinctly, because based on independent microscopical examination, Dr. Jenner, take the latter; see his Lecture in Med. Times, March 17, 1860, p. 261. TREATMENT OF RICKETS. 735 come on until the fifth or sixth month at the earliest, and that the enlargement of the skull was preceded by profuse sweats about the head. Children in whom this condition exists appear to suffer much, their emaciation is usually very great, and their digestive functions are very ill performed. For the most part they sink under some attack of intercurrent diarrhoea, or are carried off at last by convulsions at an early stage of the process of dentition. Bronchitis, however, is the great enemy of the rickety child. The malformed chest is, as you know, the evidence, and the cause as well as the consequence, of the imperfect performance of respiration, while an emphysematous state of the lungs due to the same cause is habitual in every instance of considerable thoracic deformity. It suffices for a comparatively slight attack of bronchitis to interfere with the entrance of air into the tubes, for large portions of lung at once to become collapsed, and for death to follow suddenly and unexpectedly on what in any other child would have been a comparatively slight attack of catarrh or influenza. The treatment of rickets need not detain us long, for, notwithstanding the importance of the disease, the principles to be borne in mind alike for its prevention and its cure are abundantly simple. Bad air and defective ventilation are its two great causes; and causes which among the poor it is often difficult, sometimes impossible, to remove. Even among the comparatively wealthy these causes of rickets are not infrequently met with. The nurseries are overcrowded; the infant is laid in a deep cot, wrapped up over-warmly in blankets, and left to breathe for hours the atmosphere which is enclosed within the curtains or the sides of the cot; and which, moreover, is not seldom rendered still more impure by a want of the most sedulous attention to cleanliness on the part of the nurse. If to this be added the attempt to bring up the child entirely, or in great measure, on artificial food, we have at once the two conditions combined which are most certain to generate rickets. Remove them; nourish the infant at the breast of a healthy nurse; place it in a large room, and in a cot which admits the air to pass freely over the child; let there be most careful attention. to cleanliness; and improvement will become almost immediately apparent. If the disease be advanced, combine with all these precautions country or, still better, sea air, and even where marked deformity has already taken place, amendment will be sure to follow. 736 TREATMENT OF RICKETS. As the child grows older, and other food than the mother's or nurse's milk becomes necessary, let too exclusively farinaceous food be avoided. Beef tea at the age of eight or nine months, and a little underdone meat at fifteen or twenty months, are always desirable, while milk should always form an important part of the diet. There is no specific for rickets-nothing which furnishes ready to hand, in a way in which it can be appropriated, the earthy matters in which the bones are deficient; and the notion that phosphate of lime supplied in large quantities to the child would directly promote its cure is but an unphysiological fallacy. Iron and cod liver oil are the two great remedies on which, in this as well as in other cachectic diseases, we mainly rely. Their continuous employment, however, requires that attention be specially paid to the state of the digestive organs; but the simpler aperients, as rhubarb and magnesia, or castor oil, or syrup of senna, are to be preferred to the mercurial preparations which are so often employed without due occasion. It would be needlessly to occupy your time were I to speak of the management of all those complications to which, as I have already said, the main danger of rickets is due. The diarrhoea, the laryngismus, and the bronchitis are to be treated in accordance with the principles which I have already laid down. One point, however, is always to be borne in mind, that whereas rickets is a disease of debility, a cachexia, all its complications must be treated with a full recognition of this fact. Depletion and antiphlogistics are out of place; a tonic plan of treatment should in all cases be adopted. LECTURE XLII. FEVERS-chiefly belong to the class of Exanthemata. Mistakes with reference to simple fever in childhood-its identity with fever in the adult. INFANTILE REMittent Fever, identical with TYPHOID FEVER, which is a fitter name, occurs in two degrees-symptoms of its milder form-of its severer form-signs of convalescence-modes of death.-Diagnosis.--Treatment. INTERMITTENT FEVER OR AGUE-peculiarities characterising it in childhood. WE come now to the last part of this course of lectures; namely, to the study of the febrile diseases incidental to infancy and childhood. They belong, for the most part, to the class of the Exanthemata-diseases characterised, as you know, by very wellmarked symptoms, by a very definite course, and by usually occurring only once in a person's life. These peculiarities have always obtained for them the notice of practitioners of medicine, and few of the affections of early life have been watched so closely, or described with so much accuracy, as small-pox, measles, and scarlatina. Hence it will be unnecessary to occupy so much of your time with their investigation as we have devoted to the study of other diseases which, though not so important, have yet been less carefully or less completely described. While the well-marked and unvarying features of the eruptive fevers, however, have forced those diseases on the attention of all observers, the more fluctuating characters of continued fever have been so masked by the differences between youth and age, that the affection as it occurs in early life was long almost entirely overlooked, and its nature was, in many respects, still longer misapprehended. Many, indeed, even of the older writers on medicine, have spoken of fevers as occurring among children at all ages; but under this name they confounded together several diseases in which febrile disturbance was merely the effect of the constitution sympathising with some local disorder. This mistake was committed with especial frequency in the case of various affections of the abdominal viscera; many of which are attended by a considerable degree of sympathetic fever, while their symptoms, in other respects, are often so obscure that the imperfect diagnosis of former days 738 INFANTILE REMITTENT-IDENTICAL WITH TYPHOID FEVER. failed to discover their exact nature. As medical knowledge increased, many of these disorders were referred to their proper place; but, nevertheless, the descriptions given of the so-called remittent fever, worm fever, and hectic fever of children, present little of a definite character, and are evidently the result of a blending together of the symptoms of various affections. The disease described under these different names was supposed to be a symptomatic fever, excited by gastric or intestinal disorder, and limited in the period of its occurrence to early life; while the absence of the well-marked shivering which usually attends the onset of fever in the adult, the rarity of any efflorescence on the surface of the body, and the comparatively low rate of mortality which it occasions, led persons altogether to overlook the close connection between it and the continued fever of the adult. It was not to be wondered at that the identity of continued fever at different periods of life should escape observation, so long as the various types of the disease in the adult, though separated by essential differences, were yet confounded together. The recognition of the distinctive character of typhus and typhoid fevers was a necessary step towards this object; and this once taken, the analogy between the latter affection in the adult, and remittent fever in the child, could not long remain unnoticed. To M. Rilliet we are indebted for a most elaborate enquiry into this subject, which shows so close a resemblance to subsist between the two diseases, as must, I think, remove all doubt with reference to their identity. They both occur independently of any cause which we are able to detect, the occasional influence of contagion alone excepted; they both run a definite course, and have the same duration, while both, though generally affecting isolated individuals, have also their seasons of epidemic prevalence. Though varying in severity, so that in some cases confinement to bed for a few days is scarcely necessary, while in other cases the patient hardly escapes with his life, yet medicine has not been able to cut short the course even of their mildest forms. And, lastly, though the local affections associated with both vary much in different cases, yet in every instance we meet with that assemblage of symptoms which makes up our idea of fever. Or if, from the examination of the symptoms during life, we pass to the enquiry into the traces left by the disease on the bodies of those to whom it proves fatal, we shall find still further evidence of the close relation that subsists between * De la Fièvre Typhoïde chez les Enfants: Thèse de la Faculté, 1840; and Traité des Maladies des Enfants, vol. ii. p. 663. |