exists of gauging its exact influence upon this organ and on that does not make the risk any the less, and an anæmic child requires attentive treatment.

Treatment. The difficulty lies in getting at what is wrong; too often it is considered sufficient to give a tonic, chiefly iron, and this almost without inquiry. But, before resorting to drugs, investigation must be made of the personal hygiene of the child-its disposition, its food, its sleep, its clothes, its habits, its play, its work, its home, and its environs, etc. Not till all these things have been considered can it be determined whether the requisite treatment should be by quinine, iron, arsenic, or cod-liver oil, or by more food, more air, less work, and so on. If careful inquiry be given to these matters, the treatment will generally suggest itself.

CHAPTER XLVI.

RICKETS AND BONE SOFTENING.

Rickets is one of those diseases for which familiarity often breeds a certain amount of contempt in the student's mind. "Only a case of rickets" is not infrequently his mental attitude in regard to it. It occurs so often, under conditions of home life which it may well-nigh seem hopeless to combat, amongst the poor, the ill-fed, the badly housed of our large towns. Nevertheless, it is a disease of much interest. That it is called Englische Krankheit may well make us study it thoroughly, and to a motive of this sort may be added that it is a cause of heavy infant mortality through bronchitis and its allies, whilst yet it is one of the most preventable of diseases.

Etiology. As with many another disease, so soon as we come to discuss its causes, although the evidence on the main points is unmistakable, there are yet subsidiary elements which, whilst they are less certain, have, sometimes, in the heat of controversy, been allowed to obscure the light we have. Rickets is a diet disease, due to the prolonged administration of indigestible, and for the most part of starchy, food. It has been said, indeed, that rickets can be produced at will by the copious admixture of starch with the milk at a time when the child is unable to digest it. It is hardly so. In the larger number of cases atrophy and the death of the child are brought about by bad feeding. In some, and these also very common, Nature, so to speak, saves the ship from wreck, and the child is left to drag along in the sadly deteriorated condition we know as rickets. This

much all will allow. It is only when we come to discuss the question as to what other influences are at work in the production of the disease that any uncertainty exists. But, for my own part, in matters so difficult of solution, I doubt the necessity of their discussion. It must be admitted that a deteriorated condition of health on the part of the mother, either during gestation, or while suckling the infant, is only too likely to conduce towards-perhaps actually to produce -rickets. I quite believe with Dr. Eustace Smith that unduly prolonged suckling makes for rickets. One can as readily admit the burden of proof surely lies on him who would not do so—that bad air, ill-ventilated rooms, want of cleanliness, are potent abettors of the disease. And syphilis also, in that it produces a much impaired state of nutrition, which often extends over many months, may surely help in the same direction.

These are all questions which will have to be entertained in individual cases. These various elements of bad hygiene will then need to be very carefully appraised, and the directness of success in treatment will no doubt depend much upon whether this be done well or ill. But the general question involved is untouched by them; and rickets remains essentially a diet disease, unless, indeed, such a radical hypothesis be accepted as that of M. Parrot, that rickets is a manifestation of infantile syphilis.

I shall not discuss what may be the etiological formula for rickets in Paris or other large continental towns; it will be sufficient for my purpose to say that in England rickets, as a disease, exists for the most part independently of syphilis, and it is not ameliorated in most cases by mercurials or iodide of potassium.

The arguments in favor of its dietetic origin are, shortly, these. Changes in many respects like it are found in the lower animals kept in confinement and under artificial con

ditions as regards their food. It is a disease of all large towns, more or less-that is to say, in proportion as the population increases, over-crowding occurs and the means of subsistence become more costly; then hand-feeding, and cheaper, less troublesome, and less valuable foods are substituted for milk, and so we have rickets. Although called the English disease, it is by no means confined to this country. It may be seen in most of the large continental cities, and in some is as common as it is with us. Lastly, it is a disease found, to say the least, in overwhelmingly large proportions, in hand-fed infants. Dr. Buchanan Baxter made some most careful inquiries on this point amongst the outpatients at the Evelina Hospital, and the result was that no less than ninety-two per cent. of the whole number had been given farinaceous food before the age of twelve months. The time of life at which the disease is met with forms an important element on this head, and I have analyzed 141 of my own cases, to show the time of life at which the disease

Sixty-eight were boys, seventy-three girls.

Dr. Gee* gives much larger numbers than these. Of 635 cases (365 boys, 270 girls) 32 were under six months, 144 from six to twelve months, 183 from twelve to eighteen months, 133 between eighteen months and two years, 116 in the third year, and 27 in the fourth year. And he further states that thirty per cent. of sick children under two years of age are rickety.

This table only gives the age at which the child was brought for treatment. In most cases the onset of the dis

* On Rickets, "St. Bartholomew's Hospital Reports," vol. iv., p. 69.

ease must have ante-dated the attendance by a considerable period. But it shows well how large a proportion of cases occur from ten months to two and a half years—that is to say, from weaning onwards through the period of dentition.

It may be added here that some authors have contended for the existence (1) of foetal rickets, (2) of rickets at birth (congenital rickets) and (3) of the rickets at the time of life. here spoken of. As to fœtal rickets, most authors consider it to be a form of cretinism; and the existence of congenital rickets is but doubtful, although, as I have said, if exceptional, its occurrence seems possible. All agree that rickets is rare during the first two or three months of life.

I have stated the case thus far somewhat dogmatically; but it must be borne in mind that there is no single fact in connection with rickets which has not been at some time or another, and which is now, disputed by this authority or that. There are some who think the disease a diathetic oneone, that is to say, passed on from parent to child, in large measure independent of and incapable of production by external agencies alone. And some observations of Ritter von Rittershain show that rickety children frequently come of mothers who still bear traces of having suffered from a similar disease. It is also said, and the same author, to some extent, countenances this view, that tubercle is associated with rickets. Trousseau held that the two were mutually exclusive. But there can be no doubt that tuberculosis is not uncommon as a sequel to rickets, although, as Hillier says, the two conditions seldom go on actively at one time.

Others hold, as I have done, that it is dietetic; others, still more rigorously, that it is not only dietetic in a general way, but due to the administration of starch in particular; others, again, lay stress on feeble health in the mother dur