Walter Butler Cheadle.

On the principles and exact conditions to be observed in the artificial feeding of infants: The properties of artificial foods and the diseases which arise from faults of diet in early life; a series of lectures delivered in the post graduate course at St. Mary's Hospital, and at the hospital for si online

. (page 9 of 14)
Online LibraryWalter Butler CheadleOn the principles and exact conditions to be observed in the artificial feeding of infants: The properties of artificial foods and the diseases which arise from faults of diet in early life; a series of lectures delivered in the post graduate course at St. Mary's Hospital, and at the hospital for si → online text (page 9 of 14)
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Recovery under proper feeding 1

RICKETS

ONE of the most interesting and remarkable of the
disorders which result from the faulty feeding of
young children is the condition of rickets. Its occur-
rence is limited almost entirely to the first two years
of life, in children fed entirely by hand, or after
weaning.

It is not my intention in the present lecture
to describe all the morbid changes found in the
bones and tissues. These are given in detail in
all the text-books, and to these I must refer you.
What I desire to do is to give a broad clinical picture
of rickets and its aetiology in relation to food, and to
this I shall chiefly confine myself.

The affection of the bones, so striking and so
obvious, has given this characteristic of the rachitic



1 68 DIET DISEASES OF EARLY CHILDHOOD

state undue prominence and importance, and rickets
has been in danger of being regarded as simply a
morbid state of the bony structures, leading to cer-
tain deformities and defects of the osseous skeleton.
It has been thus defined in leading text-books on
medicine until quite recently, and it is still classed
under diseases of the bones. It is something far more
than this.



RICKETS NOT MERELY AN AFFECTION OF THE
BONES

You are no doubt familiar with the type of the
rickety child : the square projecting forehead, the
open fontanelle, the beaded ribs, the enlarged ends
of the long bones, and their soft yielding structure
producing deformities such as the pigeon breast, the
depressed ribs, the protuberant belly, the curved
arms and clavicles, the bowed legs or knock-knees, the
contracted pelvis ; the delay in the appearance of the
teeth and their early decay ; the relaxed ligaments
producing the yielding ankles and the knock-knee,
and the curved spine. But these palpable defects of
the bony framework do not comprise the whole
morbid condition. The name of rickets ' is perhaps

1 Trousseau speaks of 'riquets,' an old Norman word applied to



RICKETS 169

unfortunate, as tending to identify the pathological
condition with bone changes alone.



OTHER TISSUES AFFECTED AS WELL AS THE
OSslbuS SYSTEM

For there are distinct deviations from the normal
healthy constitutional state in other organs and
functions which are less prominent, yet more impor-
tant, than the bone faults. The lymphatic glands
generally become enlarged, sometimes also the liver
and spleen ; the lungs partially collapsed by the
pressure of the depressed chest wall, with compensa-
tory emphysema and perhaps a friction patch upon
the heart and a pressure murmur there.

AFFECTION OF THE MUSCLES

Moreover, the rickety child suffers from general
constitutional debility in various forms. It is soft-
fleshed and flabby, the muscular feebleness being
often so great that it cannot sit upright ; is unable to
walk perhaps until it is two years old or more. This

deformed persons. Glisson first adopted the term * rickets ' from the
common name given to the disease in the West Country, where it was
first observed. He subsequently adopted the term ' rachitis ' from
pax's, the spine, which he thoteht was the first part affected.



170 DIET DISEASES OF EARLY CHILDHOOD

feebleness is indeed so extreme in some instances
that the child is supposed to have paralysis. I have
several times been consulted with regard to para-
plegia in a child, when the affection turned out to be
nothing but the muscular debility of rickets, and the
patient was restored to full walking by appropriate
diet and cod-liver oil. This feebleness of muscle as
well as softness of bone interferes seriously with the
action of the intercostals in respiration, and becomes
a serious factor when bronchitis supervenes.

ANEMIA — SWEATING— TENDENCY TO CATARRH OF
MUCOUS MEMBRANES

There are other constitutional signs too — anaemia,
profuse night-sweats, and a remarkable tendency to
catarrh of all mucous membranes ; of the bronchi,
and of the intestine, so that bronchitis is set up on
slight cause, and diarrhoea is a constant symptom.
Moreover, the lungs are injured by collapse and
compensating emphysema, the mechanical result of
the giving way of the soft chest walls in respiration.

THE NERVOUS SYSTEM INVOLVED

The nervous system suffers, too, from the general
malnutrition. A peculiar excitability and instability
of the reflex motor system arises, which is evidenced



RICKETS 171

by the special liability to convulsive disorder, viz.
laryngismus stridulus, or spasm of the glottis, tetany,
or carpopedal contractions, i.e. tonic spasm of the
hands and feet ; and general convulsions.

SLIGHT DEGREES OF RICKETS LIABLE TO BE
OVERLOOKED

These various signs and symptoms are not all
present together, and the absence of the most pro-
minent — as, for instance, curving of the long bones
— sometimes leads to the existence of the disease
being entirely overlooked. This is especially the
case with the children of the better class, amongst
whom slight cases are by no means uncommon. Now
and again the signs are extremely unobtrusive, limited
perhaps to an abnormally open fontanelle, some back-
wardness in teething, a little enlargement of the ends of
the long bones, slight contraction of the chest antero-
laterally, and maybe a just perceptible curving of the
legs, or a laxness of knee or ankle ligament causing
genu valgum, or weak ankles. But with this a distinct
anaemia, a general softness of flesh, sweating about
the head at night, a notable tendency to catarrh, both
bronchial and intestinal, trouble in teething, and not
unfrequently attacks of laryngismus.



172 DIET DISEASES OF EARLY CHILDHOOD

SYMPTOMS SUGGESTIVE OF SLIGHT RICKETS
If a child has marked predisposition to mucous
catarrh, or protracted, or late, or painful dentition, or
attacks of laryngismus, however slight, always ex-
amine carefully the bony structure for evidence of
rickets there.

Now this general fault of constitution affecting
bone, muscle, nerve, and mucous membrane, which
is known by the term rickets, is largely a food
disorder.

FACTORS CONCERNED IN THE PRODUCTION OF
RICKETS

There are, I believe, generally several factors
concerned in the production of rickets. Defects of
diet, food disorders, causing prolonged vomiting and
diarrhoea, foul air, want of light and general mal-
hygiene, congenital syphilis, inherited tendency — all
may play a part. But these factors are not all in
action in every instance. Is any one of them efficient
alone ? Is any one of them constantly present?

INHERITED TENDENCY

To begin with the last. Although some statistics
have been given to show that rachitic parents tend to



RIPKETS 173

have rachitic offspring, I have seen nothing to
confirm this. Rickets dies out with childhood, and
is not likely to be transmitted. I believe the sole
influence of heredity is the transmission of a weakly
constitution in some instances ; that inheritance is
not a constant factor seems proved by the fact that
the children of perfectly healthy parents become
rickety.

CONGENITAL SYPHILIS

In the next place we may, I think, be quite
certain that rickets is not a simple expression of
congenital syphilis, as M. Parrot contended. In
many cases the history is absolutely beyond suspicion,
and the children bear about them none of the well-
established signs of congenital syphilis. The eruption,
the snuffles, the pegged teeth, the keratitis, the linear
scars, are alike wanting. And conversely, many
cases of congenital syphilis are not rickety. It is
clear that syphilis is not a constant factor. The
cases in which it does play a part have very special
features, of which I shall speak presently. Congenital
syphilis modifies rickets, it does not create it.



174 DIET DISEASES OF EARLY CHILDHOOD

MALHYGIENE AS A FACTOR

Again, conditions of general malhygiene are not
constant factors in the production of rickets. Many
cases arise where the patients are under excellent
sanitary conditions as far as air, and light, and
cleanliness, and warmth are concerned. A child may
enjoy all these to perfection, and yet become rickety
in marked degree. We see this constantly in children
of perfectly healthy well-to-do parents, amongst
whom rickets is by no means uncommon. It is
impossible to say in such cases that faults of hygiene
of this kind are concerned, and these examples, where
so many of the causes commonly credited as essen-
tial to the production of the disease are absent, throw
great light upon its aetiology. They simplify the
problem, and help to distinguish the essential from
the non-essential.



INFLUENTIAL BUT NOT ESSENTIAL

The truth is, that these general conditions of
malhygiene connected with air, and light, and clean-
liness, and warmth, are not essential factors always
present, but favour the production of rickets by
degrading nutrition ; they are generally at work, too,



RICKETS 175

in the most extreme cases, but they are not essential.
I have never seen a child develope rickets in the most
unhealthy surroundings if properly fed and free from
food disorder.

THE ONLY CONSTANT FACTOR IS THE FOOD
FACTOR

The only constant factor, always present, is the food
factor. Sometimes it is the only factor. The chief
cause, this fault of diet, is the commonest, the most
potent, and dominant of all. This much is, I think,
well established : the vast majority of cases of rickets
arise directly in connection with food.

THE QUALITY RATHER THAN THE QUANTITY
OF THE FOOD AT FAULT

The first fact which comes out with regard to the
relation of food to the production of rickets is, that
it is a question of quality rather than quantity — of
special fault of nutrition, not a general fault of nutri-
tion. A child may be in the last stage of atrophy,
and yet not rachitic. It may be fat and gross, and
yet extremely rachitic.



176 DIET DISEASES OF EARLY CHILDHOOD

CHILDREN AT THE BREAST RARELY AFFECTED

The second point to be noted is that it occurs
almost entirely amongst children brought up by
hand, or after weaning. It does not appear in children
at the breast, except in special instances where the
milk is insufficient or defective, as from special
debility of the mother or from prolonged lactation.
I think it may be affirmed broadly that children
feeding well on a full supply of good breast milk up
to the age of 8 or 10 months do not become rickety
during the time of suckling. Even with congenital
syphilis at work, the suckling does not become
rickety. Dr. Barlow and Dr. Lees l found that in
eleven children with cranio-tabes who were brought
up entirely at the breast, not one showed the smallest
sign of rickets. Elsasser, who first described cranio-
tabes, noted a similar absence of general rachitic signs.
If these children do become rickety, it is later — after
weaning.

ON THE OTHER HAND, CHILDREN FED CHIEFLY
ON FARINACEOUS FOOD CERTAINLY BECOME
RICKETY

I think it may also be affirmed broadly, on the
other hand, that children fed almost entirely on

' Path. Trans, vol. xxxii. p. 330.



RICKETS 177

farinaceous food, even if taking it well, without
apparent drawback, as certainly become rickety. We
see these experiments made daily before our eyes
with uniform result.

THE SPECIAL ASSOCIATION OF RICKETS WITH AN
ARTIFICIAL DIET IS STRONGLY SUPPORTED BY
RESULTS OF OBSERVATION AND EXPERIMENT
ON THE LOWER ANIMALS— GUERIN'S EXPERI-
MENTS

The artificial production of rickets by Gu6rin,
who substituted meat for the mother's milk, although
impugned by the later experiments of Tripier, has
been remarkably confirmed by the experience at the
Zoological Gardens in London. The lion whelps
weaned early and put upon a diet of raw flesh only,
invariably became rickety in such extreme degree
that it has been found impossible to rear them.

MR. BLAND SUTTON'S OBSERVATIONS AT THE
ZOOLOGICAL GARDENS

Mr. Bland Sutton, the hon. pathologist, informs
me that the young monkeys, deprived of their
mother's milk and fed entirely upon vegetable food;
became rickety. The most remarkable case observed

N



178 DIET DISEASES OF EARLY CHILDHOOD

was that of two young bears who were fed exclu-
sively upon rice, biscuits, and raw meat, which latter
they licked but hardly ate, and who died of extreme
rickets. That the condition is a true rachitis there
can, I think, be no doubt. There is the same mus-
cular feebleness, the same bending of bones, the same
general debility ; and the identity of the bone changes
has been established by the observations of Mr. Sutton,
who has so ably investigated the morbid anatomy of
the disease.

THEORIES AS TO THE EXACT NATURE OF THE
DIET FAULT — THE INFLUENCE OF WANT OF
LIME SALTS

Various theories have been put forward as to
the exact nature of the diet fault productive of
rickets. The first which naturally suggested itself
was that the bones being obviously soft and deficient
in mineral matter, a want of lime salts in food was
at the bottom of it. Chossat and Milne-Edwards
produced curvature of the bones in pigeons and
dogs by privation of the earthy salts ; these results
are, however, impugned by the later experiments
of Friedleben, 1 who found that, although atrophy

1 Vide Fagge, Path. Trans, vol. xxxii. p. 318.



RICKETS 179

follows, the characteristic features of rachitic bone are
wanting. Wegner, however, claims to have produced
rickets by administration of phosphorus and priva-
tion of lime salts at the same time. And the amount
of lime salts in rickety bone is below normal.

MERE DEFICIENCY OF LIME NOT THE SOLE
FACTOR

Yet that mere want of lime, in the form of hydrate-
or carbonate, is not, per se, the essential cause of
rickets, is proved by convincing evidence. First, the
fact that rickets is common in limestone districts
where the drinking-water is heavily charged with
lime, and the children must necessarily take abun-
dance of it. In my native town, situated in one of
these districts, goitre and rickets were both extremely
common. Moreover, many children of the better
class who become rickety have had lime water
regularly added to their food. Secondly, the fact
that the foods upon which children are especially
liable to become rachitic, the farinaceous foods, are
rich in lime and phosphoric acid. Dr. Luff has tested
this point for me, and the results of his analyses are
given in Table II. So that the presence of lime salts
in abundance in the food will not prevent the develop-



180 DIET DISEASES OF EARLY CHILDHOOD

merit of rickets, nor is deficiency of lime salts in food
usually associated with it, but rather, on the contrary,
an ample supply.

These earthy salts are present in sufficient
quantity in most articles of an infant's diet. If the
earthy salts were grossly deficient in food, the soft
condition of bone would no doubt be favoured by the
lack of this material ; but, as a matter of fact, they
are actually abundant.

THE LACTIC ACID THEORY OF RICKETS

Another theory, suggested by the special associa-
tion of rickets with farinaceous food, is that lactic
acid is the evil agent. Starch, imperfectly digested,
ferments, and lactic acid is formed in excess ; this is
supposed to unite with the lime about to be deposited
in the bones, and carry it off in soluble form ; or,
according to a later theory of Heitzman, by irritating
the ossifying tissue and provoking growth when
the necessary lime was wanting for the structure.
Heitzman found lactic acid in the tissue of rickety
animals, and claims to have produced rickets by the
administration of lactic acid.



RICKETS 181

FACTS WHICH NEGATIVE THIS HYPOTHESIS

But against this hypothesis there are these
weighty facts : first, that rickets arises in children who
have no apparent disorder of digestion to favour
lactic acid formation, who digest the starch or
dextrine or maltose, assimilate it, and wax fat on it ;
and, secondly, the fact that if the food on which the
child has grown rickety be continued, without other
change than the addition of certain elements which
are deficient, the child gets well. Moreover, if lactic
acid did exist in the blood, it would be neutralised
by the alkali there, so that clearly the starchy element
is not directly harmful.

TWO ELEMENTS DEFICIENT IN THE FOOD OF
RICKETY CHILDREN, VIZ. ANIMAL FAT AND
PROTEID — POSSIBLY, ALSO, PHOSPHATE OF
LIME

Now if we take cases of the. simplest kind, viz.
those of the children of healthy parents, born healthy,
and brought up under perfect hygienic conditions
as far as air, light, cleanliness, and warmth are con-
cerned, who become rickety, we find these constant
features — they have been brought up by hand, and



1 82 DIET DISEASES OF EARLY CHILDHOOD

the artificial food on which they have been fed is
uniformly deficient in certain elements, viz. animal
fat and proteid. How sadly wanting are these vital
ingredients in the foods in common use I have shown
in my earlier lectures ; and the evidence is set forth
in Tables I. and II. Possibly deficiency of earthy
phosphates may be a factor of some influence also in
certain cases, although, as I have shown, it cannot be
an essential because it is not a constant one.

ANIMAL FAT THE MOST ESSENTIAL ; —
EVIDENCE OF THIS

Animal fat is the most essential element. The
abundance of it in the type food milk, which is a
rich emulsion of fat, as I showed you before, indi-
cates its high importance in the nutrition of the
young organism. The occurrence of rickets in a
child brought up on skim milk, all other hygienic
conditions being unimpeachable, which came under
my personal observation, seems to indicate that pri-
vation of fat alone is sufficient. The acknowledged
curative power of cream and cod-liver oil affords
further evidence in the same direction. Fat is pre-
sent in every cell, and animal fat, introduced as fat
from without, is probably essential to vigorous cell-
life and structural power.



RICKETS 183

IMPORTANCE OF THE PROTEID ELEMENT —
CLINICAL EVIDENCE OF ITS VALUE

The deficiency of animal proteid in these ricket-
producing foods is probably of an importance second
only to the absence of fat. It is true that the pre-
sence of proteid in abundance will not prevent rickets.
The experiments of Guerin and the experience of the
Zoological Gardens prove this. Yet it may be an im-
portant aid in addition to the fat, and, as a matter of
clinical experience, rickety children improve much
more rapidly if they are given raw meat or its juice
in addition to cream or cod-liver oil, than on the
latter alone. The nitrogenous element, as I have
urged before, is essential to the nutrition of proto-
plasm — the indispensable active agent in all vital
processes — and probably benign or injurious in action
according as the other materials are present or absent.

VALUE OF PHOSPHATE OF LIME

Phosphate of lime appears to be present in every
tissue, and there are grounds for believing that no
cell-growth can go on without it ; in rapidly growing
cells it is present in large amount. The lowest



1 84 DIET DISEASES OF EARLY CHILDHOOD

forms of life, even, will not grow without earthy-
phosphates. 1 The dependence of rickets on the
deficiency of these three elements of food would
explain something more than the mere bone changes ;
it would equally explain the imperfect nutrition
of brain and muscle and nerve structure, which
no theory of mere excess of lactic acid or lime salts
would account for. It explains, moreover, why rickets
is so prevalent in large towns and dense populations,
where milk is scarce and dear, deprived of cream and
watered, and the poor driven to feed their children
on the cheaper farinaceous foods.

DEFECT IN DIET ALONE SUFFICIENT TO PRODUCE
RICKETS — EVIDENCE OF THIS IN THE CASE OF
ANIMALS

That defect in diet alone is sufficient to produce
rickets, and that these three elements, fat, proteid,
and earthy salts, are some or all of them chiefly con-
cerned, is strikingly shown by the recent experience
at the Zoological Gardens, to which I have already
alluded. As I told you, many young animals become
rickety there, and it had been found impossible to rear
the young lions from this cause ; they invariably died,

and died from extreme rickets.

1 Parkes' Hygiene, 4th ed. p. 176.



RICKETS 185

EXPERIENCE AT THE ZOOLOGICAL GARDENS —
DIET ON WHICH YOUNG ANIMALS GROW
RACHITIC

The lion whelps were fed solely upon the flesh of
old horses, almost entirely destitute of fat. The bones
were found to be proof against the teeth even of adult
lions, and those of the cubs were powerless against
them. About once a week they had goat's flesh, which
is about the fatness of venison. So that in this case,
again, animal fat and earthy phosphates would be de-
ficient. The food of the young bears who became
rachitic on biscuits and rice, and that of the young
monkeys fed chiefly on bananas and fruits, would be
deficient in the same elements. The feeding of the
last litter of lion cubs was commenced in the usual
way. The dam had very little milk, which ceased
entirely at the end of two weeks, and they were
then put on horseflesh alone as before ; they became
extremely rickety, and one died.

THE REMARKABLE EFFECT OF A CHANGE OF
DIET ALONE

Then, at Mr. Bland Sutton's suggestion, the diet
was changed. The meat was continued, but in



1 86 DIET DISEASES OF EARLY CHILDHOOD

addition to it, milk, cod-liver oil, and pounded bones
were given. No other alteration whatever was made in
any way. They were kept in the same dens with the
same amount of air, and the same light and warmth
as before. The change which followed was remark-
able. In three months all signs of rickets had dis-
appeared, and they grew up perfectly strong and
healthy and well developed. It was a unique event
in the history of the Society.

You will observe that no change was made in the
conditions of existence except in feeding only, and
the change in the food consisted practically in the
simple addition of fat and bone salts.

This is a most striking and crucial experiment in
the production and prevention of rickets, and seems
to be absolutely conclusive as to the chief points in
its aetiology.

DIET EFFICIENT ALONE TO PRODUCE RICKETS —
OTHER FACTORS USUALLY ENGAGED ALSO —
SYPHILIS — VOMITING — DIARRHOEA

Ordinary rickets can be set up by a rachitic diet,
and cured by an antirachitic diet, as certainly as scurvy
can be caused by a scorbutic diet and cured by an
antiscorbutic diet.



RICKETS 187

Do not forget, however, that there are generally-
other factors engaged in the production of rickets in
addition to the food factor. Bad air and want of light
lower vitality, syphilis seriously impairs nutrition, and
in many instances these agents probably aggravate
and emphasise the disease. But far more potent still
are chronic vomiting and diarrhoea in the production
of rickets ; but these latter act practically as food
factors, since they no doubt produce their effect by
draining off nourishment. And it is to be noted that
the loss would fall chiefly on the proteid and fat, which
require time for digestion before they can be absorbed,
whereas the carbohydrate element, sugar of milk, is
already in a state of solution, and fit to pass at once
into the circulation.

EFFECTS OF THESE FACTORS IN MODIFYING
RICKETS

The disease is undoubtedly modified by the action
of other factors. It is probably only developed in its
most extreme degree when the food defect is aggra-
vated by generally bad hygienic conditions, or by
syphilis, and exhibits a variety of forms according to
the particular cause or combination of causes which
give rise to it.

When rickets is produced by chronic vomiting



188 DIET DISEASES OF EARLY CHILDHOOD

and diarrhoea, when it is merely a part of general
starvation, and when it is the result of congenital
syphilis, the child is usually small, puny, wasted. We
have a small rickets. In the case of syphilitic rickets
there are further distinctive features : thinning of the
flat bones of the skull, the cranio-tabes of Elsasser,
and projections on the frontal and occipital bones —
the so-called cranial bosses. These, I am convinced,
are most common and most marked in syphilitic cases )
although they are also met with in cases of simple
rickets in which there is no reasonable presumption
of syphilitic taint. Dr. Barlow and Dr. Lees ' found
a certain history of syphilis in 47 per cent, and Dr.
Baxter found 75 per cent, clearly syphilitic. I think
that it may eventually turn out to be the case also
that the enlargement of the liver and spleen, which is
found in certain instances, described by Sir W. Jenner


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Online LibraryWalter Butler CheadleOn the principles and exact conditions to be observed in the artificial feeding of infants: The properties of artificial foods and the diseases which arise from faults of diet in early life; a series of lectures delivered in the post graduate course at St. Mary's Hospital, and at the hospital for si → online text (page 9 of 14)