expressed juice of fresh beef may also be given, and, if the patient is of proper
age, fresh vegetables are valuable adjuncts to treatment.
The anaemia and poor general condition often render advisable the admin-
istration of codliver oil, the syrup of iron iodide, and other tonics; these should
seldom be prescribed before the scorbutic symptoms have disappeared.
Epiphyseal separation necessitates orthopaedic treatment in connection
with the measures above suggested. Fortunately the separations are seldom
Definition. A disease of infantile nutrition characterized chiefly by anom-
alies in the development of the bones and consequent deformities.
.etiology. Rarely the affection is congenital. It occurs far more fre-
quently in cities than in the country and is more common in Europe than in
America. It is particularly frequent in the Italians and negroes of the United
States, probably because the native habitat of these races offers a warmer
climate than ours. It occurs especially amongst the children of the poorer
classes because of the vitiated hygienic conditions in which these unfortunates
are compelled to exist. In Russia it is said to appear commonly in the families
of the well-to-do, the climate of this country, in its northern part at least,
being such as to render free ventilation uncomfortable. Dense crowding
and lack of sunlight seem to be important predisposing causes. An unsuitable
or insufficient diet is the most essential aetiological factor and consequently
the disease is more often observed in artifically fed infants than in those fed
from the breast; it does, however, appear in breast-fed children when the
milk is not of good quality and also when the child is not weaned at a proper
time. Infants fed upon sterilized or condensed milk or upon proprietary
foods are especially prone to the affection which seems here to be due to a
lack of sufficient fat and proteid matter in the dietary, in consequence of
which there is for some reason a defective assimilation of the calcium salts.
Syphilis may co-exist with rickets but the latter is not a manifestation of
the former disease although it may be mpdified by it.
Sex has nothing to do with the incidence of rickets; the disease usually
shows itself between the 6th and 15 th month but the so-called late rickets
may not appear until the loth or 12th year of life.
Pathology. The lesions are chiefly of the osseous system, particularly
the bones of the cranium, the long bones and the ribs. The skull tends
toward the cubical in shape, the vault and occiput being flattened while the
frontal and parietal eminences become more pronounced. The head is
enlarged and the forehead bulging. The closure of the fontanelles is delayed,
even until the third year, the margins of the bones being thickened and soft.
Foci of delayed ossification which yield to pressure may be present in the
parietal or occipital regions.
The epiphyseal cartilages of the long bones are enlarged as a result of the
rapid thickening of the zone of proliferation, which is bluish in color and soft
and spongy. The periosteum is easily detachable revealing a spongy bone
markedly deficient in the lime salts. The bones bend easily, producing
deformities which are particularly evident in the tibiae as a result of the pres-
sure of the body weight or are produced by sitting cross-legged. The femora
also may be bowed outward or forward. The humerus is often bent and the
radius and ulna may be twisted out of shape. Exaggeration of the normal
curves of the clavicle is not infrequent.
The chest is characteristically deformed; a vertical groove may be present
between the 4th and 8th ribs upon its lateral aspects producing the chicken-
breast. Accompanying this deformity the so-called Harrison's groove may be
observed; this is a transverse depression extending from the xiphoid cartilage
toward the axilla. The "rickety rosary" is also frequent. This term is
applied to the bead-like nodules which appear at the junctions of the ribs
with their cartilages.
Spinal curvatures are common, the normal dorsal convexity and the lumbar
lordosis being accentuated. Scoliosis, also, is not rare. Thickening of the
scapulas and the well-known rhachitic deformity of the pelvis are often ob-
served, the iliac bones being distorted, the anteroposterior diameter of the
true pelvis diminished, and the pubic arch narrowed.
The bony deformities are due to the tension of the muscles or to the pres-
sure of the body weight.
Upon chemical analysis the bones in rickets are found to contain a super-
abundance of organic matter and a greatly diminished proportion of the
282 CONSTITUTIONAL DISEASES.
The muscles are small and poorly developed and the abdomen is usually
enlarged and prominent.
Various lesions of the viscera are common. Collapse of the lung may be
present beneath the lateral grooves of the thorax; bronchitis and broncho-
pneumonia are frequent and mild gastric and intestinal catarrh with dilata-
tion may be observed Splenic enlargement (simple hyperplasia) is often
noted and the liver may be increased in size. Enlargements of the lymphatic
glands often occur but are merely an associated lesion.
Symptoms. Many of these have been dealt with in discussing the pathology
of the disease. The onset is usually gradual and as a rule appears before
the 15th month; one of the earliest symptoms is sweating of the head, espe-
cially at night and often so profuse as to wet the pillow; the child sleeps rest-
lessly, and may exhibit a slight febrile movement and digestive disturbances
such as nausea, regurgitation of food, flatulence and constipation. He is
poorly nourished, dentition is delayed and the teeth when they appear are
often poorly formed and decay quickly. Tetany and laryngismus stridulus
are not infrequent and rickets is a very important predisposing cause of
infantile con\'ulsions, these being usually excited by some digestive disorder.
Tenderness over the epiphyses may be present causing the child to cry when
lifted or otherwise distiu-bed.
The first symptom to appear referable to the osseous system is the beading
of the ribs and is a very constant manifestation. In very young infants as an
early symptom soft spots may be observed over the occipital or parietal bones
which crackle somewhat like parchment upon pressure. This condition is
termed cranio-tabes and may occur in congenital syphilis both with and
without rickets. The other bony deformities have been described in the
section devoted to pathology. The fontanelles are late in closing, often
persisting until the child is 2^ years old, the forehead is protuberant and the
face relatively small and of a prematurely aged expression; the veins of the
scalp are often conspicuous and the hair over the occiput is thinned owing
to the friction of the pillow.
The ligaments, especially those of the large joints, are loosened and stretched,
causing the weak ankles, the backward bowed knees and the abnormal mobility
of other articulations which are so often seen in rickets.
The muscles are flabby and small and their consequent weakness causes
walking to be delayed and interferes also with standing and sitting upright.
The lack of power in the ill-developed muscles may be so marked as to render
the differentiation from a true paralysis impossible except by testing the
reaction to electricity. The lack of muscular tone is also in great measure
responsible for the prominent abdomen and the constipation.
Rhachitic children are usually fat but their flesh is not firm and they are
anaemic; they frequently exhibit lymphatic enlargements, hypertrophied
tonsils and adenoids and fall an easy prey to any acute disease, being par-
ticularly prone to all affections of the mucous membranes of the respiratory
or digestive tracts. The condition of the blood is not typical; anaemia is
usually present in varying degrees and the leucocytes may or may not be
increased in number.
The liver and spleen are often palpable either as a result of enlargement
or of the downward pressure of the thoracic deformities.
The diagnosis is seldom difficult. Rickets is to be differentiated from
syphilis by the facts that in the former disease the bone affections are at the
epiphyses rather than in the extremities or shafts, that necrosis never occiirs
and that the enlargements are of the bones themselves, while in syphilis they
appear rather like soft swellings over the bone. In scurvy there are the
typical gum lesions and the haemorrhages, and the various paralytic condi-
tions may be separated from rickets with extreme muscular weakness by
testing the electrical reactions, the patellar reflexes and studying the cerebral
The spine of rickets is flexible, the curves are less acute than those of Pott's
disease and disappear when the patient is laid flat. The other symptoms
of rickets are present, and these with the absence of the characteristic mani-
festations of tuberculous hip and congenital dislocation render the differ-
entiation of the former affection from the two latter conditions a simple
The prognosis is favorable, rickets alone never resulting fatally. There is
always danger that the child may fall a victim to complicating disease. The
course is chronic, the symptoms often continuing for months. Their prog-
ress usually ceases at the age of about one and a half years probably because
the diet by this time has become more general and the child is allowed more
in the open air. Under proper treatment gradual improvement takes place.
The health of the patient is not permanently impaired unless there is marked
deformity of the chest, although the bowing and shortening of the legs may
prevent him reaching normal stature.
Treatment. Rickets being to a great extent a preventable disease and due
to improper feeding and unhygienic surroundings, the prophylaxis consists
in the avoidance of these factors in the causation of the affection. When
previous children have suffered from rickets those who follow are markedly
predisposed to the affection and upon this account should be the more carefully
Treatment proper consists primarily in diet regulation. Breast-fed babies
when rickety should be artificially fed with properly modified cow's milk unless
a wet nurse whose milk is of normal composition is available. Older children
who are able to take food other than milk should be given a diet consisting
chiefly of proteids and fats, carbohydrates being excluded as far as possible;
284 CONSTITUTIONAL DISEASES.
milk, cream, beef juice, eggs, red meat and fresh fruit, either raw or stewed,
should make up the greater part of the regimen. Farinaceous foods and par-
ticularly the proprietary infant foods should be interdicted.
Hygienic treatment is at least as important as diet regulation and often
more difficult to arrange. Fresh air, sunshine and out-door life are absolutely
essential, consequently city children should if possible be removed to the
country, or if this is impracticable the patient should spend as much time as
possible in the parks or upon the roof where oftentimes a sort of play-ground
can bet:onstructed. Free ventilation of Hving and sleeping rooms is essential
and the mother may be assured that if properly clothed and protected from
draughts the child will be in no danger if the window of the sleeping room
is kept open. Flannel night drawers with feet, and warm coverings are to
be advised and as a hardening measure a quick sponge off with water at from
65° to 70° F. (18.5° to 21.5° C.) after the daily bath is excellent.
With regard to drugs it may be stated that codliver oil — which is a food
as well as a drug — is our chief reliance. It may be given in doses of a drachm
(4.0) or less, to ^ an ounce (15.0), 3 times a day unless it disturbs the stomach
when it should be administered by inunction either pure or mixed with
lanolin in the proportion of i to 3 or 4. In very hot weather it is often wise
to temporarily discontinue treatment by means of this agent. Phosphorus
has been much used in rhachitic conditions and may be given combined with
olive or codliver oil in doses of -j^-q to y^'o of a grain (0.0003 to 0.0006) 3
times a day after meals; larger doses may cause digestive disturbances. The
following formula is a useful one: phosphorus ^ grain (0.008), oil of sweet
almond ^ ounce (15.0), acacia 2 drachms (8.0), syrup 2 drachms (8.0), distilled
water to 4 ounces (120.0). Dose, i teaspoonful 3 times a day after meals.
Lecithin may be substituted for phosphorus, its dosage being i to 2 grains
(0.065 to 0.13) 3 times a day in codliver oil. Calcium has been prescribed in
the hope that it would supply the lack of mineral matter in the bones but this
hope is probably vain for it is believed that any Hme taken into the organism
in excess of that provided by the food is excreted through the ahmentary
tract. Calcium, however, has a certain tonic effect in some instances and may
be exhibited as the following formulae suggest. Calcium phosphate 75 grains
(5.0), calcium carbonate 2^ drachms (lo.o), milk sugar 3! drachms (15.0),
to be divided into 30 powders of which 2 to 4 may be taken daily. Codliver
oil, lime water and syrup of calcium lactophosphate equal parts; one teaspoon-
ful 3 times a day.
Iron in the form of the syrup of the iodide may be prescribed in anaemic
patients. Arsenic is also useful.
Upon the theory that the disease is the result of a disorder of the thymus
gland the administration of the fresh calf thymus in dose of 15 grains (i.o)
for each month of the age of the patient has been suggested, or, if desired,
thymus tablets may be substituted for the gland substance. Atropine in
doses of -jio of a grain (0.000012) for a child of i year will lessen the tendency
In preventing the deformities it is necessary to avoid lifting the child as
much as possible and to discourage any inclination on the part of the patient
to support himself in the standing position; he should not be allowed even
to sit up unless supported. The deformed chest may be brought nearer into
normal shape by ordering systematic respiratory exercises and gymnastics,
children even as young as 3 years may be taught simple calisthenics, and the
use of the pneumatic chamber has been suggested. The tendency to spinal
curvatures may be lessened by keeping the patient upon a hard bed without
a pillow under the head, but, if necessary, a thin pad under the lumbar region,
so that this part of the back shall be raised slightly higher than the shoulders
and buttocks. Daily placing of the child in the prone position and over-
correction of the deformity by lifting the buttocks, the lumbar region being
held stationary meanwhile, is useful. In advanced instances orthopaedic ap-
paratus may become necessary. The curvatures of the legs may be corrected
manually and when slight they may even be outgrown; the child should never
be allowed to sit with the legs crossed beneath him or habitually in ally position
because of the tendency of the limbs toward deformity. Braces may become
necessary but any treatment of this sort after the age of 2^ years is usually
futile on account of the firmness of the bones; osteotomy is necessary after
this period but should usually be delayed until the child is at least 4 years
old and the bones have become whoUy hardened. Knock knees, bowlegs
and curvatures of the radius and ulna may be corrected by this operation.
The flattened pelvis in women may necessitate Csesarean section or symphy-
seotomy during childbirth.
In the management of rickets it is necessary to remember that constitu-
tional treatment should be undertaken as early as possible and that it is usually
of little use to continue it after the beginning of the i8th or 20th month, for by
this time the active stage of the disease is past and merely the results of the
286 THE INTOXICATIONS.
THE INTOXICATIONS, INCLUDING THE EFFECTS OF EXPOSURE
TO HIGH TEMPERATURES.
Synonyms. Plumbism; Saturnism.
w^tiology. This is a common condition and one of which the sources are
numerous. The most important are: the use of soft water, carbonated waters
and alcohoHc drinks, especially beer, which have passed through lead pipes or
have been stored in receptacles lined with lead; the occupations of painters
(colica pictonum), plumbers, typesetters, gold miners, white lead workers,
potters, glaziers (Devonshire colic), because the laborers do not employ ordinary
cleanliness and neglect to wash the hands before eating; the use of lead hair
dyes and face powders, biting leaded white thread, eating certain canned fruits
(lead solder), sheet lead (tin foil) about tobacco or sweets, filling holes in mill-
stones with lead, playing with tin (lead) soldiers by children, the use of lead
carbonate on burns, of diachylon plaster as an abortifacient or of lead and
opium pills in dysentery, lead bullets in the flesh, the use of white or red lead
in the vulcanization of rubber, false-tooth plates of lead, and the use of
baking powder adulterated with lead chromate to give buns an attractive
yellow color, have all been followed by chronic plumbism.
Lead is, perhaps, the best example of a poison which is comparatively
harmless when taken in a single large dose, but of which most minute doses,
if taken for a sufficient period, result fatally.
The lead enters the organism through the skin, respiratory tract or the
alimentary system; in most instances of poisoning the toxic substance has
been chiefly taken in through the mouth. Elimination takes place through
the skin, kidneys, intestinal tract, saliva and milk.
Pathology. Normally a small amount of lead is present in the body and
it is not very unusual for minute traces of the metal to be excreted by the
urine. In plumbism lead is demonstrable in the organs and tissues. The
muscles are the seat of fatty and fibrous degeneration; the nerves are in a
state of degenerative neuritis, sometimes fatty changes are also present. The
ganglion cells of the anterior cornua of the cord may be in a condition of
atrophy similar to that found in anterior poliomyelitis. In acute intoxica-
tion the lesions of intense enterocolitis may be found.
LEAD POISONING. 287
Symptoms. Acute poisoning is most frequently due to taking lead acetate,
a very large amount of which is necessary to produce a fatal eilect, particu-
larly since a great part of that ingested is generally vomited. Gastro-intestinal
symptoms such as salivation, thirst, dysphagia, abdominal pain, emesis and
diarrhoea result and the vomitus consists of a whitish fluid containing curd-
like matter; in consequence of the astringency of the lead the purging is less
intense than that caused by other irritant poisons, constipation being some-
times observed. The stools may be blackish owing to the presence of lead
sulphide and these and the vomitus may contain blood. These symptoms
are followed by weakness, coldness of the extremities and collapse. After
recovery the patient may suffer from chronic plumbism.
A subacute form of intoxication is sometimes observed in which, after a
short exposure to the effects of the metal, the patient suffers from anaemia,
acute neuritis and even epileptiform convulsions and delirium similar to that
caused by alcohol.
Chronic poisoning, it is said, may sometimes be detected by painting the
skin with ammonium sulphide or sodium thiosulphate; three or four coats
should be applied to a patch of skin several inches square and in the presence
of plumbism this area will turn dark in about 24 hours due to the formation
of lead sulphide. The presence of lead is also demonstrable in the urine.
In the form of the sulphide lead is sometimes deposited upon the edge of the
gums producing the characteristic "lead line," this is black in color and due
to the presence of hydrogen sulphide produced by the action of bacteria;
if the teeth are sound and kept clean this manifestation is usually absent.
The Une is also observed in some instances at the junction of the anal mucous
membrane with the skin.
The most prominent of the peripheral nerve effects of plumbism is lead
colic, a phenomenon which is due to violent contraction of the intestinal
muscles, probably resulting from stimulation of the nerve endings. As it is
greatly relieved by the nitrites and other vaso-dilators it may be inferred that
a primary vaso-constriction is one of its causes. With the colic the intestinal
spasm forces the blood from the splanchnic area and the general blood pres-
sure is raised, the pulse being slowed and rendered hard and tense. The
pain, which is extreme and grinding in character, is chiefly located in the
umbilical region, and the abdomen is retracted and hard; paroxysms of the
most acute agony are often succeeded by intervals of comparative ease. The
colic is usually preceded by constipation and may be accompanied by vomiting.
The paroxysms may last for several days or a week, and then disappear to
recur at intervals.
Other nervous symptoms apparently of peripheral origin are anaesthesia
of various parts, lasting perhaps one or two weeks, and lead arthralgia,
which consists of sharp lancinating or boring pain in the joints, bones, or the
288 THE INTOXICATIONS.
muscles about the joints; this latter usually appears and disappears quite
suddenly. Neuralgias are sometimes observed; these may be of central
origin or due to peripheral neuritis. Lead amblyopia is a rare phenomenon;
the sight may be lost entirely or merely somewhat impaired. This manifes-
tation may be due to optic neuritis, which if allowed to continue leads to atrophy
of the nerve, to uraemia with effusion into the optic sheath or to albuminuric
In what is termed encephalopathia saturnalis the disorders observed are
for th| most part of cerebral origin, although the lower portions of the central
nervous system are also involved at times. The cortex is chiefly affected
and an irritation is produced which is followed by paralyses, both sensory and
motor, although the latter, are the more pronounced. There are usually
muscular contractures and later choreic movements. Sometimes convulsions
occur as a result of uremia due to the nephritis which invariably follows
chronic plumbism, sometimes they are due to the lead itself. The motor
stimulation is ultimately followed by paralysis. In addition there is deHriimi,
succeeded by depression and coma which latter may be urgemic. On the
motor system the efl'ects produced by the lead are neiiritis, paralysis and
atrophy. The usual site of the lesion is probably in the peripheral nerves
and muscle cells, though in certain instances the central nervous system
seems to be involved. A common characteristic of lead poisoning is the
''drop-wrist" or "painter's palsy," which is probably attributable in part
to paralysis of the extensor muscles and partly to the active contracture of
the opposing flexors. A characteristic of lead palsy is that the supinator
longus is not involved and the electrical response of the affected muscles is
less than in other t^-pes of peripheral neuritis.
The patient afflicted with chronic plumbism is always anaemic; this con-
dition of the blood is at first due to the constriction of the peripheral vessels
and later to diminution of the haemoglobin and red corpuscles in the blood.
There is granular basophilic degeneration in many of the red cells and the
presence of this condition is of some diagnostic value. Nucleated red ceUs
are often found even if the anaemia is not of severe grade. Jaundice may
result from the breaking up of red corpuscles and the liberation of large
amounts of haemoglobin. The leucoc}-tes are often increased in number.
The results of lead intoxication upon the circulatory system consist in the
production of arteriosclerosis which is early evidenced by a high tension of
the pulse and an accentuation of the 2d aortic sound. These manifestations
may be demonstrable before either colic or palsy is observed. Cardiac h}^er-
trophy is common and the wall of the organ may be in a state of fatty or
In the kidneys lead causes marked irritation in the process of its elimi-
nation, consequently nephritis is frequent in instances of acute poisoning
LEAD POISONING. 289
and is uniformly found in chronic plumbism both as a result of this irritation
and of the arteriosclerosis induced by the presence of lead in the organism.
A remarkable circumstance in connection with lead poisoning is the fre-