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 RJ 369.D54 
 Rickets: a study of economic conditions 
 
 3 1924 012 169 441 
 
INFLUENZA 
 
 ESSAYS 'BY SEVERAL AUTHORS 
 
 Edited by F. G. Crookshank, M.D. Lond., 
 F.R.C P., Physician Prince of Wales General 
 Hospital, the French Hospital, etc. 
 Royal 8vo. 
 
 In this volume the editor has brought together a 
 number of papers, especially written by himself and some 
 nine or ten associates, that deal with various aspects — 
 historical, epidemiological, bacteriological and clinical 
 —of influenza. Amongst the writers are Dr. Hamer 
 (London), Dr. DONALDSON (London), Dr ABRAHAMS 
 (London), Mr. WHALE (London), Mr. S. BOYD (London), 
 and Dr. SMITH Ely Jellifpe (New York), and Dr. 
 DWIGHT Lewis (Virginia). The volume will be of 
 assistance and interest to all those who desire a broad 
 and comprehensive view of the manifold and difficult 
 problems raised by the attempt to elucidate the study of 
 influenza and the allied epidemics and diseases. 
 
 WM. HEINEMANN (Medical Books) Ltd. 
 20, Bedford Street, London, W.C. 2 
 
RICKETS 
 
 A Study of Economic Conditions and their Effects 
 
 on the Health of the Nation, in two parts 
 
 combined in one volume, freely 
 
 illustrated 
 
 BY 
 
 LAWSON DICK 
 
 M.D. Ed., F.R.C.S. Eng. 
 
 DEPUTY COMMISSIONER OF MEDICAL SERVICES, LONDON REGION, 
 
 MINISTRY OF PENSIONS ; AUTHOR OF '' DEFECTIVE HOUSING 
 
 AND THE GROWTH OF CHILDREN," ETC., ETC. 
 
 NEW YORK 
 E. B. TREAT & Go. 
 
 45 EAST 17 STREET 
 1922 
 
N.W.L.D. 
 
 Printed in Great Britain. 
 
PREFACE. 
 
 When I was asked by the publishers, some eighteen months 
 ago, to write a monograph on the subject of rickets, I undertook 
 the task the more readily in that the subject had been one 
 which had occupied my attention for many years. 
 
 One fact early impressed upon me was the comparatively 
 limited world distribution of the disease, or in other words, 
 that over large portions of the surface of the globe, notably 
 in Africa, India, and the Far East generally, rickets was absent, 
 or at all events was so slight and so occasional in its appear- 
 ance that it was a factor of no importance in considering 
 the health of these countries. 
 
 It was difficult to see why this should be, for experience 
 taught that the life of the native of these uncivilised or 
 semi-civilised regions was beset with hardships and dangers 
 to which the young infant, in more sheltered conditions at 
 home, was not exposed. The cult of the untutored savage 
 does not now appeal to the imagination as it did during the 
 eighteenth century, but nevertheless, there is no doubt that 
 the child of such a race to-day escapes many of the diseases 
 and morbid conditions to which children in civilised industrial 
 communities in Europe are exceedingly prone. A notable 
 example of such a disease is rickets. 
 
 At an early date I was further impressed with the inadequacy 
 of the usual theories as to the Jetiology of rickets. In Africa, 
 India, and China, ignorance as regards the simplest dietetic 
 principles is much more profound than in Europe, and gross 
 errors in infant feeding are much more common. Under- 
 feeding and the early administration of starchy foods are very 
 frequent among rice-eating peoples. In many parts deaths 
 .from starvation and marasmus are common, and at recurring 
 intervals, in India and China, there are devastating famines 
 which involve the loss of many thousands of infants. If the 
 prevailing theories as to the causation of the disease were true, 
 
vi Preface 
 
 rickets should abound, whereas the extraordinary fact is, that 
 under these circumstances rickets is conspicuously absent. 
 
 Prolonged lactation, as will be shown later, is exceedingly 
 common among native races all over these countries, to an 
 extent unknown in Europe, and with the breast feeding, at a 
 very early date, starchy pap foods are given to the child, factors 
 which are constantly blamed for the production of the disease 
 in Europe. 
 
 Intestinal infections in the southern hemisphere and all over 
 the Far East, of an acute nature, such as are seldom seen in 
 England, are very prevalent, and chronic infections are frequent 
 and stubborn and produce a high mortality. 
 
 Yet with all these adverse factors at work, rickets remains 
 notably absent over the southern hemisphere and over Asia 
 generally, or if present is slight and infrequent. 
 
 With children of European parentage, both in Africa and 
 India, breast feeding is, as a rule, very inadequate. In South 
 Africa, women of Dutch, and French, and English parentage, 
 have now for many generations been resident in the country, 
 and a strong and virile population has resulted. But even in this 
 healthy climate, continued breast feeding is the exception, and 
 failure of the supply of milk in healthy mothers at an early 
 period is exceedingly common. 
 
 In India and China, where European stocks do not as a rule 
 settle down to a permanent residence, suckling the child is still 
 more difficult. As a result of this defect of feeding, and the 
 associated absence of a proper dairy supply, many dangers to 
 young infant life arise, but rickets is not one of them. 
 
 In Europe, rickets affects the majority of children to some 
 degree, especially in the colder temperate zone. But there are 
 notable differences, in various areas, as to the severity and the 
 frequency of occurrence of the disease. 
 
 In the seventeenth century in England, rickets was an 
 exceedingly formidable and severe affection, and its rapid 
 diffusion caused widespread consternation throughout the land. 
 Quite commonly it terminated fatally. At the present day the 
 disease is more widely diffused in England throughout all 
 classes, but the type has become considerably modified, and in 
 itself is but seldom fatal. 
 
 To find cases of the severer type to-day one must proceed 
 to the Continent of Europe. In no capital has the disease been 
 
Preface vii 
 
 more rife or of a severer type for many years than in Vienna. 
 During a residence of some months, spent at the Orthopjedic 
 Clinic in Vienna, some seven years before the beginning of the 
 late war, not only was I impressed with the extreme prevalence 
 of the disease, but the severe nature of the malady was borne 
 in upon me. Cases of a type of severity, such as is described in 
 the classic work of Glisson and in the writings of Mayow and 
 other seventeenth century writers as occurring in England at 
 that time, were quite common in Vienna long prior to the war. 
 
 From the point of view of the origin of disease the study 
 of rickets is exceedingly important. It is an error of growth, 
 and begins, as a rule, soon after birth. It is essentially a 
 disease of the first two years of life, but no greater mistake 
 could be made than to consider it only as a disease of infancy. 
 The effects of rickets, contrary to what is generally supposed, 
 are exceedingly prolonged. The disease tends towards recovery 
 at an early period, but the results are well-marked throughout 
 school life, and are very commonly evident in perverted and 
 diseased growth in the adult. In a man of forty, by a study 
 of the signs present in the skull, skeleton, and teeth, and by 
 considering deviations which have occurred in the general 
 growth, one can often make a shrewd guess as to the state of 
 health and the environmental conditions during the first years 
 of infancy. 
 
 Probably no single factor at the present time has a more 
 potent influence than rickets on the standard of national 
 health. It attacks the new-born infant at the time when it 
 is released from a vegetative existence, in which its nutriment 
 is elaborated and supplied through the maternal circulation, and 
 its environment is the sheltered seclusion of the womb. The 
 child at birth has rapidly to adapt itself to an enormously 
 extended environment and has to carve out for itself, as it 
 were, the course and line of growth which it will take. 
 
 To the agency of the rachitic state must be ascribed, in a 
 large measure, the production of the defective class, the 
 existence of which was so vividly brought before the nation in 
 the late war. Statistics of the rate of incidence of births and 
 deaths in the general population convey but little information 
 as to the state of the public health. What is required is a 
 detailed survey of the general health of the people, and of the 
 degree of mental and physical vigour to which they attain in 
 
viii Preface 
 
 ail classes of the community. The partial observations which 
 were made during the late war prove that enquiries on these 
 lines are entirely at variance with the favourable results 
 suggested of late years by mortality tables and birth rates. 
 
 A detailed study, extending over some twelve years, of the 
 conditions prevailing in the north-east sector of London, the 
 limits of which are defined later, has enabled me not only to 
 furnish statistics of the incidence of the disease, but also to 
 examine critically the factors which are concerned in its 
 production. Through the courtesy of the London County 
 Council, I have had extensive opportunities of making a 
 special study of the school children in this area. This I have 
 been able to amplify later by a study of infant growth at the 
 welfare centres in the industrial areas of Hackney, which also 
 come within this sector. 
 
 The social conditions of this part of London have, as will 
 be shown, been very carefully and accurately worked out by 
 Mr. Charles Booth, in his minute enquiries into economic 
 conditions in London. 
 
 In considering the geographical distribution of rickets, in 
 addition to relying on personal observation, I have culled 
 information from many sources. Nothing is more tedious and 
 conveys less to the mind than a bare enumeration of the areas 
 in which a disease is found, and therefore, as far as possible, 
 where the information lends itself to such treatment, it is 
 arranged in the form of tables which can be readily 
 apprehended. 
 
 To the Surgeon-General of the United States Public Health 
 Service, Washington, and to Dr. W. H. Davis, Chief Statistician 
 for Vital Statistics, Washington, I am indebted for much 
 valuable help. From the members of the profession throughout 
 America I have also received that friendly courtesy and 
 readiness to help which my experience while travelling in the 
 United States would have led me to anticipate. 
 
 From the colonies I have received much valuable inform- 
 ation, and I am under a debt of obligation to Mr. A. M. 
 Laughton, Government Statist for Victoria, for many facts 
 regarding rickets in that State. Dr. T. Fletcher Telford, 
 Medical Officer of Health for Christchurch, New Zealand, 
 has taken the trouble to circularise and tabulate the answers 
 from eighty-seven medical men in the Canterbury- Westland 
 
Preface ix 
 
 district, and the results are all the more interesting in that 
 they show an almost complete absence of the disease. I have 
 to acknowledge much friendly help from Mr. C. E. WaUis, 
 L.D.S., in my work on the teeth. 
 
 Lastly, I would like to record my indebtedness to the board 
 members, and more especially to the specialists, attached to 
 the London Region Headquarters of the Ministry of Pensions, 
 who have brought to my notice many cases illustrating the 
 subject in which it was known I was interested. 
 
CONTENTS 
 
 PAGE 
 
 Preface ... ... ... ... ... v 
 
 PART I. 
 
 THE GEOGRAPHICAL DISTRIBUTION, SIGNS 
 AND SYMPTOMS OF RICKETS 
 
 I. Introduction ... ... ... ... i 
 
 1 1 . The Geographical Distribution of Rickets. Gen eral 
 Distribution and Distribution in Great Britian 
 and Ireland ..; ... ... ... i6 
 
 III. The Geographical Distribution of Rickets. Distri- 
 
 bution in Europe and Asia ... ... 30 
 
 IV. The Geographical Distribution of Rickets. Distri- 
 
 bution in the Colonies ... ... ... 41 
 
 V. The Geographical Distribution of Rickets. Distri- 
 bution in America ... ... ... 56 
 
 VI. Food in relation to the Geographical Distribution 
 
 of Rickets ... ... ... ... 71 
 
 VII. The Early Signs and Symptoms of Rickets ... 87 
 
 VIII. The Early Signs and Symptoms of Rickets 
 
 {continued) ... ... ... ... 100 
 
 IX. Changes in the Bones of the Vault of the Cranium 
 and in the Bones of the Upper and Lower 
 Extremities visible to the Naked Eye ... 117 
 
 X. Microscopic Anatomy of the Bony Changes in 
 
 Rickets ... ... ... ... 126 
 
 XI. Common Deformations produced in the Long 
 Bones and Certain Deformities appearing at 
 Adolescence and their Relation to Rickets. 
 Late Rickets ... ... ... ... 138 
 
 XII. Deformities of the Thorax in Rickets ... ... 154 
 
xii Contents 
 
 CHAP. PAGE 
 
 XIII. Deformities of the Spine and of the Pelvis asso- 
 ciated with Rickets ... ... ... 163 
 
 XIV. Changes in the Bones of the Face in Rickets ... 176 
 
 XV. The Teeth in Rickets ... ... ... 190 
 
 XVI. Skin Affections in Rickets. Lamellar Cataract and 
 some other Conditions of the Eye associated 
 with the Rachitic State ... ... ... 208 
 
 XVII. The Nervous System in Rickets ... ... 227 
 
 XVIII. Affections of the Blood and of the Lymphatic 
 
 System in Rickets ... ... ... 244 
 
Contents xiii 
 
 PART II. 
 
 THE NATURAL HISTORY OF RICKETS. 
 
 THE ETIOLOGY OF THE DISEASE AND 
 ITS TREATMENT 
 
 CHAP. PAGE 
 
 XIX. The Literature of Rickets. Glisson and His Times 261 
 
 XX. Ancient Medicine and Rickets ... ... 288 
 
 XXI. Some Parliamentary and Other Records and the 
 Literature of Rickets following the Pub- 
 lication of Glisson's Work to the close of the 
 Eighteenth Century ... ... ... 301 
 
 XXII. Economic Factors in Relation to Rickets from 
 Early Times to the Roman Occupation of 
 England ■■■ ••• ... ... 316 
 
 XXIII. Economic Factors in Relation to Rickets from 
 
 the Roman Occupation to the Close of the 
 Eighteenth Century ... ... ... 331 
 
 XXIV. Conditions Present in Slum Areas which Tend 
 
 to Produce Rickets. The Conditions in 
 North-East London, with a Statistical 
 Enquiry into the Incidence of Rickets in 
 this Area ... ... ... ... 352 
 
 XXV. The Relationship of Rickets to the National 
 Health as Revealed in the Army Recruiting 
 Records 
 
 XXVI. The etiology of Rickets ... 
 XXVII. The .^Etiology of Rickets (cowtoweii) , 
 XXVIII. The etiology of Rickets (cowtowed) 
 XXIX. The Treatment of Rickets ... 
 XXX. The Treatment of Rickets (continued) 
 
 .371 
 397 
 415 
 436 
 
 455 
 470 
 
PART I 
 
 THE GEOGRAPHICAL DISTRIBUTION, SIGNS AND 
 SYMPTOMS OF RICKETS 
 
CHAPTER I 
 INTRODUCTION 
 
 In the study of disease there are two ways in which the 
 subject may be approached, firstly, as it affects the indi- 
 vidual, and secondly, as it affects the community of which 
 the individual forms a part. In ordinary practice, there is 
 a danger of considering morbid states simply as they affect 
 patients and of forgetting the larger issue. 
 
 There is a national pathology as well as a clinical entity 
 which can be summarised as a definite morbid state affect- 
 ing the individual. This national tendency to disease is 
 acted upon by numerous and diverse factors. Race, climate, 
 economic conditions and environment, diet and customs, all 
 produce wide variations. 
 
 In the enthusiasm which followed the discoveries of 
 Pasteur, Lister and Koch, the study of the microbic environ- 
 ment of man led to a wide and wholesome broadening of 
 the outlook on the factors which produce disease, and on 
 the steps necessary for the purposes of prevention and cure. 
 
 Instead of the control of disease being simply a matter 
 of treating symptoms by the individual practitioner as cases 
 came under his observation, the medical officer of health 
 took up the practice of preventive medicine with the greatest 
 benefit to the community at large. Typhus and typhoid 
 fever have been well nigh abolished over large areas, and 
 that from great towns and cities, where the task might well 
 have seemed impossible to the observers at the beginning of 
 last century. Diphtheria has become a diminished scourge, 
 and tuberculosis, up to the beginning of the great war, 
 seemed to be lessening apace, while conditions such as 
 malaria are now within the means of control. 
 
2 Rickets 
 
 The outlook of state medicine has, however, up to the 
 present time been comparatively restricted. The results of 
 state efforts on behalf of the public health have been esti- 
 mated in terms of percentages of deaths, reckonings of the 
 periods of the expectation of life, and the rate of incidence 
 of zymotic disease, but morbid conditions as they affect the 
 essential virility of the race have been largely unobserved 
 till the advent of the great war. The rate of reproduction 
 is no criterion for estimating national health, for under the 
 worst conditions populations frequently increase with extra- 
 ordinary rapidity, as indeed occurred during the period of 
 unprecedented distress leading up to the industrial revolu- 
 tion in the beginning of last century. Notwithstanding the 
 enormous benefits which have accrued from the practice of 
 public health, it is doubtful if to-day the total incidence of 
 disease has been greatly diminished within the last few 
 centuries, and it may be questioned if the national health, 
 as measured by the powers of resistance of the general 
 population to disease and the capacity for work and healthy 
 living, has much improved. 
 
 The defective state of the national health was brought in 
 a very lively manner before the eyes of the nation in the 
 late war. Reason will be shown later for believing that the 
 results of the work of the Ministry of National Service, as 
 detailed in their report for the year dating from November 
 1st, 1917, that is in the fourth year of the war, cannot be 
 accepted as a true estimate of the state of the pubUc health. 
 But what the figures do reveal is the existence of an 
 enormous amount of disease and of faulty and impaired 
 development of the nation, which hitherto had been quite 
 unsuspected. 
 
 In considering the factors which interfere with the 
 efficiency of the nation, those which produce their effects on 
 the infant and on the growing child must be given the first 
 place. 
 
 A poison such as alcohol may in one sense be called a 
 racial poison, but it probably exerts its influence on the 
 adult only. By leading to poverty and incompetence in 
 
Introductory 3 
 
 the head of the family, it produces hardships which bear 
 heavily on the young of the nation, and is, in this way, 
 dysgenic, but it is open to serious question if the abuse of 
 alcohol has any direct influence on the progeny. The 
 probability is that alcoholism is part of a vicious circle, and 
 that an inefficient population born and bred in slum sur- 
 roundings is more likely to give way to excess than one 
 more healthily placed. There is a universal and natural 
 impulse in human nature to seek relief from adverse sur- 
 roundings, whether it be in alcohol, as in the northern 
 temperate zone, or in opium or cannabis indica, as in the 
 East. 
 
 Lead is an example of an industrial poison which pro- 
 duces more far-reaching effects and tends to lead to abortion 
 and still-birth. Fortunately, it is a poison which is more 
 capable of control than most of the so-called racial poisons. 
 
 Certain conditions, however, bear directly on the infant 
 and the young child, and tend not only to lead to a high 
 mortality in the young, but also to produce a large number 
 of defects in those who survive, and lead to a lowering of 
 the standard of health in the general population. .Such 
 conditions are syphilis, tuberculosis, rickets, and the 
 incidence of zymotic diseases, notably scarlatina, measles, 
 and whooping cough. 
 
 Of all these, rickets is the commonest disease of children 
 in our large towns, and at the present day it is probably the 
 most serious factor interfering with the efficiency of the 
 nation. Syphilis and tubercle have both a high mortality, 
 but the rachitic state is seldom directly fatal, and yet, by its 
 profound action on the young organism at the period of 
 greatest growth, it has probably a more direct influence on 
 the national standard of health than any other single factor. 
 The housing of the nation at the present day is deplorable, 
 and the breathing of vitiated air, the absence of ventilation, 
 combined with the lack of the opportunity of exercise and 
 the neglect of proper cleanhness, are aU factors which bear 
 heavily on the new-born infant. The want of sunshine is a 
 deprivation of the first moment. 
 
4 Rickets 
 
 Rickets is the sum of the penalties which the young pay 
 for the unnatural conditions under which they live. It is a 
 disease of the first two years of life, beginning as a rule 
 immediately after birth, and, as already noted, in enquiring 
 into the origin of diseased conditions, no subject is of 
 greater importance than the study of rickets. In response 
 to abnormal environment the vital processes of growth are 
 retarded, and wide changes result throughout the system 
 producing alteration of structure, not only in the bony 
 skeleton, but in most of the organs of the body, and notably 
 in the nervous system. 
 
 It may be stated with conviction, that in the infant of 
 two, the child of school age is already clearly adumbrated, 
 and that the retardation of growth, and the deviations in 
 development which are found in the adult of forty, are 
 commonly the result of the evil influences which bear so 
 heavily on the young infant in this the great formative 
 period of its existence. It is not maintained that rickets is 
 the only condition arising as a result of unhealthy environ- 
 ment. Tuberculosis and the incidence of zymotic diseases, 
 as already noted, are also agents which have a profound 
 influence on the national standard of health, but of all the 
 factors bearing on the young infant, rickets is probably the 
 most potent. 
 
 The climate of England naturally renders its inhabitants 
 prone to the disease. There is much rain and for a long 
 period of the year but little sunshine. The population tends 
 to congregate in large manufacturing centres, and the towns 
 are covered with a pall of smoke from factories and houses 
 which still further limits the amount of available sunshine. 
 The use of artificial light has enabled the day to encroach 
 far into the night, and the habits of the people have become 
 so changed that a new phase of the day's employment is 
 only beginning when, under natural conditions, man would 
 be retiring to rest. In Shakespeare's day, at the public 
 theatres the performances usually began at two o'clock in 
 the winter, and three o'clock in the summer, and lasted from 
 two to three hours. Now, eight, eight-thirty, or even nine 
 
Introductory 5 
 
 o'clock is considered early enough to begin a long play. 
 Falstaff himself, when he wished to express a life of royster- 
 ing dissipation, could think of nothing more forcible than 
 " we have heard the chimes at midnight," which would be 
 but a mild sensation for the youth of to-day. Among the 
 poor the children keep very late hours, so that the nights are 
 shortened, and the child awakes late and misses an im- 
 portant part of the day which, for a long period of the year, 
 is already too short. Rickets is a malady which stunts the 
 growth of the body and retards the development of the 
 brain. It is dysgenic in so far as it interferes with the 
 development of the female pelvis and adds to the danger of 
 child-bearing. 
 
 The effects of the disease, widespread throughout the 
 system and commencing at an early period in the history of 
 the individual, lead not only to arrested development but 
 to deviations along pathological lines which have far- 
 reaching effects on growth, the powers of resistance to 
 disease and the virility of the race. It predisposes to 
 bronchitis and other catarrhal conditions in the young 
 infant, and increases the mortality arising from acute infec- 
 tions, such as measles and whooping cough. 
 
 The relationship between rickets and tuberculosis is of 
 prime importance considering the enormous frequency of 
 both diseases. It is generally supposed that there is an 
 antagonism between the two diseases, an idea which has 
 arisen from the fact that rickets is a disease of the first two 
 years of life, when tuberculosis is not supposed to be 
 common. More careful observation, however, has shown 
 that tuberculosis appears at an earlier age than was formerly 
 supposed. Thus, in a series of 500 consecutive cases of 
 tuberculosis in children, examined at the Great Ormond 
 Street Children's Hospital by Dr. Still, it was found that 
 tubercle attained its maximum frequency in the second year of 
 life.* One hundred and thirty cases, or twenty-five per cent., 
 occurred during the second year. Pulmonary tuberculosis, 
 
 * " Common Disorders and Diseases of Childhood," by Geo. Fredk, 
 Still, London, 19 15. 
 
6 Rickets 
 
 it is true, is rare in early life. The chief sites for the 
 tubercle bacillus to find a nidus in children are the lymphatic 
 glands, the bones, and the joints. Invasion of the mesen- 
 teric glands and of the bronchial glands is frequent, and 
 when pulmonary disease does occur in children, it is usually 
 secondary to an extension from the bronchial glands. It is 
 suggestive to note that the sites affected in rickets are very 
 similar, notably the ends of the long bones and the lymphatic 
 glands. 
 
 Pulmonary tuberculosis is very rare in early life, and 
 it is probable that the lymphatic type of child produced 
 by the rachitic state is more strongly resistant to tuberculous 
 invasion of the lungs than the healthy individual would be 
 if exposed to similar surroundings. The lymphatic glands 
 act as a vital filter, which not only arrests the bacillus but 
 actively attacks the germ when arrested. It is probable 
 that the general hyperplasia which takes place throughout 
 the whole lymphatic system in rickets is of the nature of an 
 adaptive change, and may be a factor of importance in 
 aiding the resistance to pulmonary tuberculosis. If this 
 line of defence, the lymphatic system, breaks down in 
 children, the disease is apt to become generalised and acute 
 mihary tuberculosis results. 
 
 Rickets causes much ill-health and tends to produce the 
 ineffective type of adult, deficient alike in physical stamina 
 and in nervous energy and stability. Much of the failure 
 of the man-power of the nation in the late war had its 
 origin in this disease. 
 
 One of the surprising features of recruiting was the 
 number of men who, without suffering from any organic 
 disease, had yet to be placed in a low category because they 
 entirely failed to come up to the very modest requirements 
 of the army standard. Apart from those who were rejected 
 as unfit for foreign service, many of the men sent to France 
 broke down under the strain of war service and were 
 sent home as cases of debility, disordered action of the 
 heart, etc. Another type was the man who did his work 
 fairly well in civil life and whose nervous system was able to 
 
Introductory 7 
 
 cope with the ordinary exigencies of a business Ufe at home, 
 but who broke down under the strain of war conditions. 
 These were frequently sent home as cases of shell shock 
 and neurasthenia. In many, the defects which were latent 
 in the nervous system would never have developed in 
 ordinary civil life. It can readily be understood that 
 prolonged shell fire and the exposure to active service 
 conditions in the trenches would test severely even the 
 most robust, but in these subjects with defective nervous 
 stabihty the mere placing the man in the army, without 
 service abroad, was sufficient in many cases to lead to a 
 breakdown. 
 
 A very large number of men who served during the war 
 suffered from deafness and discharging ears. These men 
 constitute a heavy drain on the country by coming on the 
 pension list, and also from the fact that their economic 
 value in the labour market is very small. In ear infections, 
 as a rule, the disease has existed from early childhood. 
 Not infrequently it dates back to an attack of scarlet fever 
 or measles, but in the great majority the condition which 
 predisposed to infection from various sources arose shortly 
 after birth and was directly due to an unwholesome environ- 
 ment and the development of the rachitic state. 
 
 In large numbers of these men the catarrhal suppurative 
 otitis media does not stand alone but is associated with 
 defects typical of rickets, such as the high arched palate 
 accompanied by irregular and decayed teeth, deflected 
 septum of the nose, hypertrophic rhinitis, adenoids or a 
 history of adenoids, with the typical heavy expression of the 
 confirmed mouth breather. 
 
 These three classes of men, namely, those who tend to 
 swell the ranks of men suffering from debility and disordered 
 action of the heart, those who suffer from nervous break- 
 downs frequently classed as neurasthenia, and those who 
 suffer from old-standing conditions of otorrhoea associated 
 with the history or presence of adenoids, enlarged tonsils, etc., 
 are to a large extent those whose growth and development 
 have been delayed and thwarted from earliest childhood. 
 
8 Rickets 
 
 They have passed through a rachitic stage, and, while the 
 disease is no longer active, the results have persisted so that 
 these individuals constitute a heavy economic loss to the 
 State ; they are weakly and ailing, ineii&cient in most walks 
 of life, unable to rise out of the vicious environment which 
 surrounds them, and are likely to perpetuate these same 
 conditions in their children, owing to the fact that they 
 are exposed to a like environment. 
 
 Disease and health are only relative terms, and in a very 
 real sense it may be maintained that there is no distinction 
 to be drawn between pathological and physiological pro- 
 cesses. All so-called morbid states of the body are but the 
 normal response of the tissues of the living body to meet 
 altered conditions, and as such are strictly speaking 
 physiological. To state that infantile mortality is only a 
 statistical expression of bad conditions by which infant life 
 is surrounded, is a trite saying often quoted, which is only 
 half a truth. For conditions inimical to proper growth and 
 development do not necessarily lead to fatal lesults, but may 
 produce changes of an adaptive nature which fit the young 
 organism to survive under abnormal conditions which could 
 not support robust and healthy life. 
 
 There is an essential difference between morbid states in 
 early childhood and old age. In the very young infant, 
 apart perhaps from congenital syphilis, diseased conditions 
 are developmental. Disturbance of growth occurs which 
 may assume the form of a simple retardation, or may lead to 
 more or less wide deviations from the normal standard. In 
 the aged, diseases are no longer developmental, but are due 
 to failure on the part of the eliminative organs. Rickets is 
 a type of the disease found in infancy, gout is the type 
 found in advancing years. 
 
 Diseased conditions may, in infancy and early child- 
 hood, be adaptive processes actually tending towards the 
 preservation of the race in an environment wholly inimical 
 to the production of a sound and healthy manhood and 
 womanhood. Rickets is such an adaptive disease and is 
 produced by an unhealthy environmtent acting on the young 
 
Introductory 9 
 
 infant at the most impressionable period of growth, that is, 
 immediately after birth. 
 
 Up to that time, the infant has been screened from 
 adverse conditions in the security of the womb by the 
 intervention of the placenta, and how perfect that protection 
 is will be shown later. But at birth, the child is immediately 
 thrown on its own resources, as it were, and has to provide 
 for a rapid growth of the body seemingly out of aU pro- 
 portion to the food intake. At no period in its Hfe is the 
 organism more dependent on a healthy environment, and 
 among the poor and the working class of ovir large industrial 
 centres, at no period are the surroundings of the child 
 worse than during the first two years of life. 
 
 The fault is not in the feeding. The great majority of 
 the mothers breast-feed their infants, and the great majority 
 of these children develop rickets. The mothers of the in- 
 dustrial class feed well. The coal miners as a community, 
 to take a definite example, even before the war did not 
 restrict themselves as regards wholesome food. But the 
 conditions of life otherwise, as regards housing and all the 
 ordinary amenities of life were, and are, harmful in an 
 extreme degree to the new-born infant. The mother is not 
 exposed in the same degree to these harmful influences. 
 True, she suffers from them, as the whole community does, 
 but she leads a free and independent existence necessitating 
 a certain amount of change in her surroundings. But the 
 young infant, especially during the severe winter months, is 
 likely to remain practically in one room day after day for 
 weeks and months, and the unwholesome influences which 
 operate on it during the day are stiU further concentrated on 
 it at night. 
 
 Though this unhealthy environment, ending in the 
 production of rickets may, in this country, be reproduced 
 in good class homes and under the most varied conditions, 
 it is essentially associated with the growth of great industries 
 and large cities, and especially with the development of 
 slum areas. Contrary to what is usually held, it will be 
 shown that the disease is one of comparatively modern 
 
lo Rickets 
 
 times in England, having existed as a common disease 
 among the people for probably not more than four hundred 
 years. The reasons for coming to this conclusion wiU be 
 explained fully in discussing the natural history of the 
 disease. 
 
 During this period, a sparse population in England, 
 forming a purely agricultural community, widely distributed 
 over the country, has grown into an enormous industrial 
 population mostly concentrated in large cities. The greater 
 part of this growth has occurred since the end of the 
 eighteenth century, and so rapid has been the increase that 
 there has been no time to lay out a healthy plan of expansion. 
 Nature has been faced with the enormous problem of how 
 best to adapt this rapidly increasing population to these 
 extraordinary changes in environment, and in the whole 
 manner and mode of living of the people. From being a 
 people dwelling in small communities, regulating their lives 
 by the sun and spending the greater part of their day in the 
 fields, they have developed into a people living in slum 
 dwellings in densely crowded areas, spending their days in 
 factories and workshops and prolonging their activities far 
 into the night. 
 
 Rosy pictures of this agricultural period are often painted, 
 portraying a life of measured toil and ease, when the people 
 lived on dairy produce and food was plentiful. The reverse 
 was the case. Life was a hard and strenuous struggle for 
 the common people ; the commonalty lived from hand to 
 mouth, and the diet was monotonous, scanty and coarse. 
 
 Milk was universally interdicted for the use of children. 
 Of the numerous books written for the use of midwives and 
 nurses, all agree that cow's milk is poison to the child. Nor 
 was this without good foundation in fact. Cleanliness in 
 the handling of milk was not understood, and dysentery and 
 diarrhoea were so generally fatal when it was given, that its 
 use was universally and entirely avoided in the nursery. 
 The difficulties and dangers of infant feeding in these early 
 times were much greater than now. These matters will be 
 gone into later in discussing economic factors in England 
 
Introductory 1 1 
 
 bearing on the disease. Yet with all these strenuous con- 
 ditions and hardships, rickets, as will be seen later, was a 
 disease unknown in England between three and four 
 centuries ago, and it was only as the people were weaned 
 from the land and were compelled to live in houses and 
 great cities under highly artificial conditions, that the disease 
 arose and spread over the land. 
 
 To adapt the population to these rapid economic 
 changes, the means adopted by nature have been many, and 
 the production of the rachitic state is one of the chief of 
 these methods. 
 
 Malthus believed that one of the chief weapons em- 
 ployed by nature, was a high mortality as the increasing 
 population kept pressing towards the limit of the means of 
 subsistence. In 1798, was published his famous Essay on 
 Population, in which it was maintained that while the popu- 
 lation increased approximately in a geometrical ratio, the 
 means of subsistence did so in an arithmetical ratio only. 
 Thus the population was ever pressing towards the limit of 
 the means of subsistence, and when it came perilously near, 
 vice and misery stepped in as correctives. This was a 
 soothing doctrine t'o the governing classes at the close of the 
 eighteenth century, in that it tended to show that the terrible 
 conditions which had arisen were the result of inexorable 
 natural law. Malthus was a clergyman, sincere and estim- 
 able in his character, who was profoundly struck with the 
 deplorable spectacle of many people starving and all work- 
 men miserable in a population amounting to ten milUons. 
 But Malthus did not reckon with the power of adaptability 
 of nature, and in place of the population diminishing, it was 
 found that the greater the misery the more the population 
 increased in numbers. 
 
 Broadly speaking, then, it is maintained that rickets is a 
 disease of crowded slum areas, but, as will be shown, 
 wherever conditions comparable to these are reproduced — 
 and this is readily accomplished in such a climate as that of 
 England, even in the homes of the wealthy and in the 
 midst of country surroundings — ^the disease tends to arise. 
 
12 Rickets 
 
 The fact that it can be produced in such surroundings does 
 not alter the fact, however, that rickets has grown up as the 
 result of the industrial concentration of the population. 
 
 Now, in speaking of these conditions as associated with 
 the development of the rachitic state, it will be well to 
 define at once what is the nature of the industrial conditions 
 referred to. It is not the effect of employment in the 
 workshop or factory or warehouse on the parent, for 
 rickets is not an inherited condition. Nor, in considering 
 the cause of rickets, are we at all concerned with the effect 
 of child labour or of the employment of women, whether 
 married or unmarried. The employment of child labour 
 will be referred to later, but it must be remembered that 
 rickets is a disease which originates soon after birth, in the 
 first few months of infancy, and that, though the results of 
 work in the factory on the young organism were pernicious 
 in the extreme, the influence on the rachitic state was a 
 secondary one, on a disease already estabHshed and due to 
 other causes. Wise legislation has fortunately removed most 
 of the gross evils connected with the employment of women 
 and children, and while nothing can justify the employment 
 of the mother when this necessitates her giving up suckUng 
 her child, the probabiUty is that her employment in healthy 
 surroundings under ordinary labour conditions is no bar to 
 a normal pregnancy and the rearing of a healthy child. Up 
 to the seventeenth century, and later, every mother bore her 
 active share in the support of the household, as part of her 
 ordinary work, in looking after the children and the home. 
 
 Rickets originates during the first two years of life, and 
 generally appears almost immediately after birth, though it 
 may arise at any time, even as late as the period of adolescence 
 in rare cases. The essential conditions associated with 
 the development of industries which produce rickets are de- 
 fective housing and overcrowding in slum areas, with all 
 the attendant evils in the way of defective hygiene. 
 
 The food factor plays no part in the origin of the disease 
 No deficiency or defect of feeding will produce rickets 
 when the child is exposed to bright sunshine and lives much 
 
Introductory 1 3 
 
 in the open. Over a large area of the globe's surface where 
 such conditions prevail, rickets is for all practical purposes 
 unknown. Errors in diet in the East and in the tropics 
 generally, are more common and more gross than in Europe, 
 and the mortality from intestinal infections is often high, 
 but rickets does not result. On the other hand, the best 
 of feeding will not protect the child when it is exposed to 
 the conditions which produce the disease. 
 
 In discussing rickets, the geographical distribution of 
 the disease is first dealt with. The study of the world 
 distribution alone is sufficient to refute the food factor as a 
 cause of rickets. 
 
 Subsequently, the signs, symptoms and pathology of the 
 disease will be dealt with, and an effort will be made to trace, 
 in the adult, the stigmata which have developed as a result 
 of the aberration of growth which occurred in infancy. 
 The connection is a very direct one. 
 
 During the last quarter of a century, exceptional oppor- 
 tunities have arisen for studying the reaction of large 
 sections of the population to very varying conditions. In 
 the South African War, nearly a quarter of a million of men 
 were employed overseas under active service conditions. 
 There were many essential differences between the conditions 
 which prevailed in the late war and the Boer War. The 
 army in South Africa was entirely a volunteer army and 
 did not, therefore, draw on the physically unfit as the late 
 European War did. The conditions of service were, on the 
 whole, much easier and the climate in which the campaign 
 was conducted was one of the finest in the world. There 
 was nothing approximating the intense discomforts and 
 physical stress of trench warfare and the strain of continuous 
 and intense shell-fire, unless exception be made in the case 
 of the siege of Ladysmith. The great failure in the Boer 
 War was in the protection against typhoid fever, a disease 
 which was reduced to a minimum in the late war. Malaria 
 of a severe type was common in the South African War, and 
 was not infrequently combined with a typhoid infection 
 producing a high mortality. 
 
14 Rickets 
 
 But, apart from these infections, the strain on the general 
 physique and the nervous system was much less than in the 
 European War. Wounds in the South African War were 
 mostly caused by rifle fire and did not become infected as 
 wounds did in the late war, and recovery was generally 
 unimpeded. 
 
 The second and happier opportunity of studying a large 
 section of the population was afforded by the introduction 
 of the systematic inspection of school children, which 
 revealed many defects, notably impaired physique, myopia, 
 enlargement of the tonsils and adenoids and all the morbid 
 conditions associated with mouth breathing and defective 
 teeth. 
 
 A third and more important opportunity was given by 
 the development of infant welfare centres, when for the 
 first time an opportunity was given for the systematic 
 examination of young infants, and the origin and develop- 
 ment of such conditions as rickets could be critically 
 examined. 
 
 Lastly, and most important perhaps of all, in the late war 
 an opportunity was given for a rough census of the health of 
 the whole community. From the nature of things the results 
 obtained could at best only be approximate, but the numbers 
 dealt with were so enormous that a large element of error 
 was eUminated and figures of the greatest value were 
 obtained. Not only was the nation passed under a critical 
 survey, but their reaction to the severe strain of modern 
 active service conditions could be watched over a prolonged 
 period. All these various sources of information have been 
 freely drawn upon in working out the many problems of the 
 disease. 
 
 No fact was more clearly demonstrated in the late war 
 than that there existed a large number of developmental 
 errors which, while not incapacitating the individual when 
 employed in some subsidiary walk in civil life, yet unfitted 
 him for even the more moderate degrees of active service. 
 
 For a proper understanding of rickets, a critical his- 
 torical study of the disease is very essential, and a somewhat 
 
Introductory iS 
 
 wide excursion has, therefore, been made into the hterature 
 and history of the disease, which dates from the year 1650. 
 A still more enduring and more important record is found 
 in the study of the bones and teeth from the earUest times. 
 It is usual to state that civilisation and rickets run 
 together. Such a statement requires careful examination, 
 for the disease is entirely absent from all the early civilisa- 
 tions, and in ancient writings there is no description of the 
 disease which can be accepted as showing that these writers 
 were famiUar with it. This is all the more striking in so far 
 as rickets is a distinctive disease, very easily described, the 
 signs and symptoms of which are not easily missed. The 
 study of the causation has been placed at the end of this 
 excursion into the natural history of rickets, for to appre- 
 hend the aetiology it is necessary to have before one the 
 geographical and historical evidence as well as the clinical 
 and pathological aspects of the disease. 
 
CHAPTER II 
 
 THE GEOGRAPHICAL DISTRIBUTION OF RICKETS 
 
 General Distribution and Distribution in Great Britain 
 
 and Ireland 
 
 In the study of the development of a people, or of a nation, 
 and of the diseases from which it suffers, few factors are of 
 greater importance than the physical conditions which 
 surround it. Certain basic features of the environment mark 
 out, as it were, the route along which the nations shall travel, 
 and very often determine the degree of their advance, and set 
 a definite limit to its extent. The effect of climate and food 
 and the amount and nature of the toil required for the pro- 
 duction of the necessities of life are prime factors of the 
 greatest importance in moulding the career of nations. 
 
 It is a common statement that rickets is a condition 
 coeval with civihsation. This is certainly not true of the 
 early civilisations of Babylonia, Egypt, India and China. 
 Not only is there no evidence of the presence of rickets 
 among these early peoples, but there is now much positive 
 evidence to the contrary, and up to the present day riclcets 
 does not exist over these vast areas, or at least is so mild 
 and so infrequent that it is practically of no importance. 
 It is not that it is diminished in frequency, or in severity, but 
 for all practical purposes it is absent. 
 
 The earlier civilisations were cradled in kindly nurseries. 
 They had several great features in common. They were all 
 distributed along the same degree of latitude and they were 
 bred at the deltas and mouths of great rivers. The climate 
 was tropical or sub-tropical, and the food of these early 
 nations grew on the banks of these great rivers, which each 
 year carried down fresh alluvial deposits, and spared the 
 
 l6 
 
The Geographical Distribution of Rickets 1 7 
 
 labourer the unremitting toil necessary in colder temperate 
 climates. If the Tropic of Cancer be followed round a 
 globe of the world, it will be found that in the narrow 
 belt between this line and 32° north latitude, lie the delta 
 of the Nile, and the mouths of the Euphrates and Tigris, 
 and the outlets of the Ganges, and of the Yang-tse-Kiang. 
 At the estuaries of these great rivers were fostered all the 
 early civilisations. All these are factors of the greatest 
 importance in considering the development of these peoples, 
 whether mental, moral or physical. 
 
 The source of food supply differed from that of pre- 
 historic man in, say, the Neolithic period, and of the men of 
 later date, in that it was produced from the soil and not by 
 the stern toil of the chase. Food was relatively abundant 
 and was easily produced. Civilisation made rapid strides, 
 but, like all rapid growths, tended to a speedy culmination 
 followed by a rapid decay. Probably the tendency has been 
 to estimate their degree of civilisation too highly. Their 
 greatest achievements were the products of slave labour. 
 
 There are two factors to be considered, firstly, the relatively 
 ample production of food and its easy distribution. The 
 word relatively is used advisedly, for the diet, as it is indeed 
 to-day, was exceedingly restricted in variety. The date and 
 various giains in Egypt, and elsewhere rice and other grains 
 were the staple articles of food. In the earlier stages of the 
 Babylonian and Egyptian civilisations there was probably 
 a sufficiency of food for all, but in their later development 
 there is little doubt that enormous hardships and privations 
 were the lot of the great mass of the people. The second 
 factor to be considered is the tropical and sub-tropical 
 climates which these early peoples enjoyed. It is to this 
 factor that these early civilisations owe their immunity from 
 rickets, which is essentially a disease of modern civilisation 
 and of overcrowding in great industrial centres and of cold 
 climates and grey skies. All these are conditions depressing 
 to the adult, but their full force is brought to bear on the 
 young infant born in such surroundings, and it is little 
 wonder that, with an environment so unnatural, the whole 
 
1 8 Rickets 
 
 growth of the child is often perverted and tends to progress 
 along channels deviating widely from the normal. In Egypt, 
 India or China, where infants are brought up in the open 
 air and where they are bathed in daily sunshine from their 
 birth onwards, no errors in food will produce the disease. 
 In these countries and in the tropics generally, infant 
 mortality is high. Intestinal toxaemias are exceedingly 
 prevalent, and when they do not cause early death are apt 
 to be very chronic and difficult to treat. 
 
 Prolonged suckling for two and three years, the nursing 
 of the child while the mother is again pregnant, mixed feed- 
 ing and the addition of starchy foods to the diet from a 
 very early date, are exceedingly common errors in diet in 
 these countries, but they do not result in rickets. 
 
 In tropical lands the people live mainly upon cooked 
 cultivated vegetable foods. But little meat is used, not 
 from choice but from lack of opportunity. The protein 
 element in such a diet is small in amount, and this has a 
 markedly deteriorating effect on their whole development. 
 
 The Japanese, it is true, who are largely dependent upon 
 rice food, are a virile race, but they mature quickly and they 
 have not the staying power of Europeans. They age 
 rapidly and sixty years is considered a great and venerable 
 age, whereas in England a man at this age is often in the 
 enjoyment of full vigour. 
 
 Rickets, to-day, has a very striking geographical dis- 
 tribution. It is mainly a disease of the northern hemisphere, 
 and placing the limits fairly widely, may be said to occur in 
 Europe and North America between the latitudes 40° and 
 60° north. 
 
 In the southern hemisphere there are but few land 
 masses in the corresponding zone between 40° and 60° 
 south latitude. The 40° south latitude runs between 
 Australia and Tasmania, so that Tasmania is within this 
 zone. It runs through the southern portion of North 
 Island, New Zealand, about the latitude of the town of 
 WelHngton, so that the whole of South Island is included, 
 and it traverses the lower part of South America, so that the 
 
The Geographical Distribution of Rickets 19 
 
 whole of Patagonia is also comprised within the zone. It 
 is a remarkable and noteworthy fact that outside this 
 northern zone, in the rest of the northern hemisphere and 
 in the whole of the southern hemisphere, including this 
 corresponding zone, the disease is almost negligible and 
 ceases to be an important factor affecting the health of the 
 people. One exception will be noted in certain parts of 
 Australia, but even here the condition is only incipient and 
 is much less frequent and of a much milder type than in 
 Europe and North America. Its importance in Austraha at 
 the present time is potential rather than actual. 
 
 In Europe the lower limit 40° north latitude is somewhat 
 too far south. It would be more accurate to make the line 
 42° north, passing through the middle portion of Italy about 
 the level of Rome and cutting off the upper fourth of Spain 
 down to about the northern limit of Portugal. Roughly 
 speaking, in Europe this zone, showing prevalence of the 
 disease, reaches from the middle of Italy to the north of 
 Scotland. 
 
 This belt is characterised by several distinctive features. 
 Firstly, it embraces the most densely populated portion 
 of the surface of the globe. Only two other portions 
 of the globe's surface compare with it in this respect — 
 India and China. Secondly, it is incomparably the 
 wealthiest area on the surface of the globe and contains the 
 great industries of the world. It has the advantages as well 
 as the disadvantages of its industrial pre-eminence. The 
 nations comprised within these areas are not solely 
 dependent on the produce of the soil for their individual 
 support. Since it is the great industrial region, the means 
 of transport both by sea and land are highly organised, and 
 the means of distribution are excellent. The distribution 
 of wealth, though unequal, is yet vastly superior to what it 
 is under more primitive conditions in the Far East. The 
 failure of cereals in a portion of the United States of 
 America, or in Canada or even in Russia, may cause financial 
 loss and economic distress, but it would not be likely to 
 produce any great deficiency in the actual necessities of life 
 
20 Rickets 
 
 in the area involved. The deficiency could be readily 
 supplied from the outside. In India, on the other hand, 
 failure of the rice crop over a wide area means disaster. 
 Famine and deaths from starvation on a colossal scale — 
 even under present conditions — are common. 
 
 At no time in the history of the world had there been a 
 more equable distribution of food than there was in Europe 
 up to the time of the great war. Meat and fish were, and 
 are now, within reach of the common people, who up to 
 two or three centuries ago rarely ate beef or mutton and 
 were largely dependent on pork for the animal portion of 
 their diet. Dau-y farming has extended enormously. 
 Fruits, coffee, tea and sugar are imported from other parts 
 of the world, and from being luxuries are considered among 
 the necessities of even the very poor. The use of the 
 potato throughout the United Kingdom is universal, even 
 with the poorest, and is piobably the essential factor in 
 largely banishing the disease scurvy from England. Mal- 
 nutrition of varying degrees is common, but extreme 
 distress from want of food is uncommon, and a death from 
 starvation causes an agitation in the papers throughout the 
 country. The disadvantages appertaining to the industrial 
 areas will be dealt with in speaking of the conditions of hfe 
 in the crowded populations of our great cities. 
 
 These disadvantages are notably accentuated by the third 
 great feature which characterises this zone — that is, climate. 
 This belt is entirely included in the temperate zone, the 
 latitude from 40° N. to 45° N. belonging to the warmer 
 temperate zone, while by far the greater portion, from 45° N. 
 to 58° N. belongs to the colder temperate zone. The mean 
 isothermal lines running through it vary from 30° Fahr. in 
 the north to 80° Fahr. in the southern limit. In place of a 
 rainy season rain falls at all times ; there is much cloud 
 shutting off sunhght, the winters are long and cold and 
 wet, and the industries themselves affect the atmosphere of 
 the large towns so as further to shut off the sun's ra}^. 
 
 The fourth characteristic of this zone is, that in the main 
 it comprises the region of deciduous trees, and it is the great 
 
The Geographical Distribution of Rickets 21 
 
 grain growing belt for wheat, oats and rye. All these are 
 factors of prime importance in considering the incidence 
 and the aetiology of the disease. 
 
 Rickets is most prevalent in Great Britain, France, 
 Belgium, Germany, European Russia, Austria, Hungary, and 
 the United States of America. Countries in higher and lower 
 latitudes are much less subject to the disease. In Green- 
 land and the Faroe Islands and Iceland it rarely occurs. 
 Hirsch notes that Finsen, in five years' practice in Iceland, 
 only saw forty-two cases, and these of a mild type, while in 
 the Scandinavian kingdoms (Norway and Denmark) it has a 
 subordinate place in the statistics of sickness relating to the 
 earliest years of life.* Southern Italy and the southern pro- 
 vinces of Spain and Greece enjoy a notable immunity. In 
 Turkey rickets is usually thought to be rare, but some recent 
 observations of Marfan would seem to show that this opinion, 
 at all events for Constantinople, requires revision. In 1907, 
 while visiting the hospital Hamidie reserved for children, 
 Prof. Marfan was surprised to find a large number of severe 
 cases of rickets in the wards, so severe indeed, that many of 
 them required surgical interference for the correction of the 
 deformities produced. Further enquiry outside the hospital 
 elicited the information that rickets, often of a severe type, 
 was commonly seen in Constantinople, nor was there any 
 immunity of race — Turks, Greeks, Armenians, and Jews 
 suffering alike, f When the conditions of life in this city 
 of many nations is considered, it is little wonder that rickets 
 is a factor affecting the health of young infants. Con- 
 stantinople is beautifully situated on a promontory, with the 
 Sea of Marmora and the Bosphorus on the south and east 
 and the Golden Horn on the north. The climate is healthy 
 but relaxing. It is damp and liable to great and sudden 
 changes of temperature. Sanitation is still very defective. 
 In 1900 the population was estimated at 1,125,000. The 
 
 * " Handbook of Historical and Geographical Pathology," by Dr. 
 August Hirsch, Professor of Medicine in the University of Berlin. Pub. 
 London. The New Sydenham Society, 1886. Vol. Ill, p. 733. 
 
 t " Traits de Medicine et de Th6rapeutique." Brouardel et Gilbert. 
 " XXXIX Maladies des Os, par Marfan." Paris, 1912. 
 
22 Rickets 
 
 streets are extremely narrow, dark, dirty and ill-paved, and 
 so crowded and tortuous that hardly any two of them run 
 for any length parallel to each other, the whole seeming one 
 vast and incomprehensible labyrinth of filthy lanes. The 
 houses are low and iU-built. It is but another instance of 
 how a situation, in many ways ideal, can be spoiled by an 
 utter lack of intelligence in town planning and carelessness 
 in the apphcation of the principles of every-day hygiene. 
 
 Distribution in Great Britain and Ireland. 
 
 In 1888, a committee appointed by the British Medical 
 Association made a special investigation into the geo- 
 graphical distribution of rickets, acute and subacute rheu- 
 matism, chorea, cancer, and urinary calculus.* The report 
 of the committee is of great value. The disease is common 
 in towns and thickly populated districts, and is especially 
 common where industrial pursuits are carried on. It is less 
 common in rural districts. In England and Wales there 
 are five great areas where the disease is very prevalent, and 
 these areas correspond with five great industrial centres. 
 These are : (1) the great northern coalfields of Durham 
 lying between the rivers Tyne and Tees ; (2) the coalfields 
 of Lancashire and Yorkshire, including the great industrial 
 towns of Lancashire ; (3) the coalfields of the " black 
 country," in the vicinity of Birmingham and Wolver- 
 hampton; (4) the coalfields of South Wales with Bristol 
 and Clifton on the other side of the Severn and Bristol 
 Channel; (5) the metropolitan area with its surrounding 
 suburbs. (See Fig. 1, p. 23.) 
 
 The first includes the great towns of the river Tyne and 
 the river Tees, and the seaport towns on the coast of Durham 
 between these rivers which belong to the northern coalfield. 
 The area in which the disease is prevalent does not extend 
 far into the coalfield, Durham itself being comparatively 
 
 * " Geographical Distribution of Rickets, Acute and Subacute Rheu 
 matism, Chorea, Cancer and Urinary Calculus in the British Islands " 
 Reports of the Collective Investigation Committee of the British Medical 
 Association, prepared by Isambard Owen, M.D., F.R.C.P., Secretary to 
 the Committee. British Medical Journal, January, 1889. ' 
 
I . ., /in® 
 
 >«/' 
 
 GeoBoE Philip 4. So- Lti 
 
 Fig. I. — Showing degree of prevalence of rickets tfirougliout Great 
 Britain and Ireland. It is interesting to note that the cross-marking 
 representing the areas where rickets is very prevalent also closely 
 corresponds with the areas of greatest prevalence of tuberculosis, 
 with the great coal-mining and industrial districts, and with the areas 
 of greatest density of population. 
 
 ^j| Rickets very prevalent. 
 
 Wz\ Rickets prevalent. 
 
 Rickets not prevalent. 
 
 23 
 
24 Rickets 
 
 free from rickets. Over a great area, including the greater 
 part of Northumberland, the northern parts of Cumberland 
 and Westmoreland, and the North and nearly aU the East 
 Riding of Yorkshire, the disease is not common. 
 
 The second area of great prevalence, and by far the 
 largest, is found in a broad zone which extends from 
 Lancaster on the west coast to Hull, Beverley, and Goole, on 
 the east coast. This zone extends downwards on the west 
 coast as far as the great industrial towns on the Merse5% and 
 from thence the area dips downwards into the centre of 
 England. It comprises the great coalfields of Lancashire 
 and Yorkshire, and extends downwards into Cheshire, 
 Staffordshire, Derbyshire and Nottinghamshire. It includes 
 Liverpool, Birkenhead, Manchester, Preston, Leeds, Bradford, 
 Halifax, Huddersfield, Sheffield, Derby and Nottingham. 
 An island in the centre marks the Peak of Derbyshire, which 
 is comparatively free from rickets. On its southern 
 boundary this zone luns into the third great area where the 
 disease is prevalent, and includes the great industrial towns 
 in the vicinity of Birmingham and Wolverhampton. The 
 fourth area of prevalence is found on either side of the Bristol 
 Channel. In South Wales this comprises the great Welsh 
 coalfields with Cardiff, Newport and Swansea as seaports, 
 and also the populous industrial valleys of Glamorgan and 
 Monmouth. On the other side of the Channel are Bristol 
 and Chfton, in both of which rickets is very common, as it 
 also is in Bath. From this, extending south towards the 
 south coast and west into Cornwall, rickets is much more 
 common than is usual in rural districts. 
 
 The report of the Collective Investigation Committee, 
 already referred to, points out that in only eleven towns of 
 30,000 inhabitants and upwards is the disease scarce. These 
 are CarUsle, York, DarMngton, Scarborough, St. Helen's, 
 Southport, Coventry, Buxton, Llanelly, Cheltenham, and 
 Southampton. Among towns of moderate size the disease 
 is still very prevalent, and it is not till small market towns 
 with four to five thousand souls are reached that the disease 
 again becomes rarer. The fifth great area where the disease 
 
The Geographical Distribution of Rickets 25 
 
 is prevalent comprises London and its outlying subiurbs, 
 In the slum areas in the East End of London, as will be 
 found later, rickets is exceedingly common, 80 per cent, 
 of children being rickety in the north-eastern sector of the 
 metropolitan area. 
 
 In the London area, the wealthy residential suburbs of 
 Mayfair and Belgravia are comparatively free from rickets. 
 In South Kensington, Hyde Park, Bayswater and Notting 
 Hill it is more common, but is still not frequent. In 
 the northern heights of London — Hampstead, Highbury, 
 Brondesbury, and Stroud Green, it is not common. Else- 
 where the disease is exceedingly prevalent within the 
 metropolitan area and also in the outlying suburbs. Along 
 the course of the river rickets is very common, even in the 
 wealthier suburbs of the upper reaches. It is obviously a, 
 matter of the first importance to study the conditions which 
 tend to produce these differences. If the child mortality 
 up to the age of five years be taken in four representative 
 metropohtan boroughs, the following striking results are 
 obtained : — 
 
 Lowest and Highest Death Rates from all 
 Causes,* 1911-14. 
 
 
 
 For 2nd year 
 
 
 
 During ist 
 
 of life per 
 
 From 2-5 years 
 
 
 year of life 
 
 1000 survivors 
 
 per 1000 
 
 
 per 1000 births. 
 
 at age of one 
 
 survivors at age 
 
 
 
 year. 
 
 of two years. 
 
 Hampstead 
 
 74 
 
 21-2 
 
 20-1 
 
 Westminster 
 
 92 
 
 22-9 
 
 2I-I 
 
 Shoreditch ... 
 
 148 
 
 67-1 
 
 44-8 
 
 Bethnal Green 
 
 126 
 
 58-6 
 
 38-6 
 
 In Shoreditch, during the first year, the infant mortahty is 
 exactly twice as great as it is in Hampstead ; in the second 
 year it is more than three times as great, and from the 
 second to the fifth year it continues to be more than twice 
 as great as in more favoured parts. It is obvious that what 
 
 * " Report on Child Mortality at ages 0-5 in England and Wales." 
 Forty-fifth Annual Report of the Local Government Board, 1915-16. 
 
26 Rickets 
 
 can be attained in Hampstead ought to be attained in 
 Slioreditch, or, if this is impossible, Shoreditch should be 
 condemned as an area unsuitable for the rearing of infant 
 life. The child has its own individual rights, but to place 
 it on no higher ground than that the child is the most 
 valtted asset of the State, it should not be allowed to suffer 
 from the accident of its plEice of birth. The main conten- 
 titMi as to the aetiology of rickets has always ranged round 
 two heads ; firstly diet, and secondly general unhygienic 
 conditions, induing defective housing and all the evil 
 consequences of confinement, overcrowding, vitiated air 
 and loss of sunlight which such conditions entail. All are 
 agreed that both are important. The question of adequate 
 feeding for the infant is one comparatively easy of solution, 
 and should be solved within a reasonably short time, but 
 the question of housing is a much more difficult problem. 
 
 In Scotland, as in England, rickets is again most 
 common in the industrial areas. It is especially prevalent 
 in the great industrial zone l3nng between the Firth of Forth 
 and the Firth of Clyde, bounded by Edinburgh and Leith 
 on the east coast and by Glasgow on the west. It is 
 exceedingly common in the whole Clyde vaUey, especially 
 in Glasgow and its suburbs, and in the north of Ayrshire. 
 In the coal-bearing districts adjoining the Firth of Forth 
 it is also common, and the area of prevalence then extends 
 up the east coast as far as Aberdeen. Beyond that it is 
 common in the larger towns lying on the shores of the 
 Moray Firth. It is not common in the south of Scotland 
 and in Perthshire, and it is rare in the Highlands. 
 
 Ireland is more favourably placed as regards rickets than 
 either England or Scotland. It is exceedingly common in 
 the populous areas around Dublin and Belfast. Donegal 
 excepted, there is more rickets in Ulster than in the rest of 
 Ireland, probably about to the same extent as it is found in 
 the south of England. Throughout the rest of Ireland 
 rickets is not common. Generally, it may be said that 
 nowhere in the British Isles is rickets unknown, but it is 
 mainly a disease of towns and industrial districts. It is 
 
The Geographical Distribution of Rickets 27 
 
 rare in the rural districts of Scotland, the north of 
 England, North Wales, and Ireland. In the rural districts 
 of Ulster and of the south of England it is more common 
 than in the rural districts elsewhere throughout the country, 
 and it is especially prevalent in Cornwall, Kent and North 
 Essex. 
 
 A striking fact is made out on examination of the map 
 of the distribution of rickets throughout Great Britain 
 and Ireland, namely, that the areas of greatest frequency 
 correspond very closely to the distribution of the coalfields 
 throughout the United Kingdom. The distribution corre- 
 sponds to the results of clinical experience of the disease 
 that it is most prevalent amongst the denser masses of the 
 industrial population. In the report of the Local Govern- 
 ment Board for 1915-16, on child mortality at ages 0-5 
 years in England and Wales, maps are given of the areas 
 of greatest mortality throughout the country, and the 
 important comment is made — " a map of the coal measures 
 of the country would almost serve as a map of the chief 
 areas in which child mortahty is excessive." In other 
 words, the areas of the greatest prevalence of rickets and of 
 greatest child mortahty correspond within very narrow 
 limits to the areas of greatest density of population and to 
 the geographical distribution of the great industrial centres 
 which have arisen around the coal measures of the country. 
 These are factors of the greatest importance in discussing 
 the aetiology of rickets. Ghsson believed that the disease 
 first started in the south-western regions of England, and 
 however that may be, it is certain that rickets is more 
 common at the present time in the rural districts of the 
 south and west of England than it is in the north. Its 
 prevalence in Bath is worthy of note, for, as a rule, the 
 houses are well built and the streets are airy, though the 
 town as a whole lies in a hollow. Mayow, who practised in 
 this city during the seventeenth century, agrees with Glisson 
 as to its prevalence in the south-western counties. Writing 
 in 1855, Schoepff Merei states that the disease is not common 
 in Bristol but that the poor in Bath show a high proportion 
 
28 Rickets 
 
 of rickets and an appalling mortality. The common occur- 
 rence of rickets in the south-western counties of England 
 is a striking fact which has been noted by several writers 
 on the subject of rickets since the year 1650, and it remains 
 as true of this portion of England to-day as it did three 
 centuries ago. These coimties are almost entirely rural, the 
 land being partly under agriculture, and partly under pasture, 
 so that they include much of the richest dairy farming 
 country in Great Britain. The reasons for this apparent 
 anomaly will be more fully enquired into in discussing the 
 history of the disease and the classic writings of Glisson. 
 
 Two points of interest arise where the disease, as de- 
 scribed by Glisson, differs from what pertains at the present 
 time. In the exceedingly accurate anatomical description 
 of the examination of the rachitic cases, the severity of the 
 cases he examined is very striking. Very rarely are such 
 cases seen now in this country, and probably to-day the 
 observer would have to go to the Continent, to such a town 
 as Vienna, to see cases of the extreme degree which he 
 describes. It seems as if the disease in this country, while 
 it has become more common and more widely distributed, 
 has assumed a milder form. It suggests the possibility that, 
 as a result of the enormous growth and the concentration 
 of industries which are taking place in England, a popula- 
 tion is being produced adapted to existence under the slum 
 conditions prevailing in our industrial areas. The second 
 point is that GUsson describes rickets as a disease of the 
 idle rich, associated with over-feeding and luxurious living. 
 His observations on this point are confirmed by other 
 observers. 
 
 To-day, while the disease occurs amongst wealthy 
 famihes fairly commonly, it is essentially a disease of the 
 poorer part of the population, who are not only badly 
 housed and live under unhygienic conditions, but who also 
 live on a deficient and a badly balanced diet. As regards 
 the diet, it may be stated broadly that among the poor 
 there is a deficiency of proteid and of fat and an excess of 
 carbohydrates. The insufficiency in the supply of proteid 
 
The Geographical Distribution of Rickets 29 
 
 is much the gravest defect in the diet of the poor, but let it 
 suffice for the present to say that these dietetic factors have 
 no influence in the production of rickets, though naturally 
 the quality and quantity of food have a marked influence in 
 the progress of the disease, once it is established. 
 
 During the years 1911-14 the chief causes of mortality 
 at the ages 0-5 in England and Wales, given in percentages, 
 were as follows : congenital debility, 23 per cent. ; bron- 
 chitis and pneumonia, 19-5 per cent. ; diarrhceal diseases, 
 15-8 per cent. ; measles, 7-3 per cent. ; tuberculosis, 5-3 per 
 cent. ; whooping cough, 5 per cent. The great majority of 
 deaths classed under congenital debility occurred during the 
 first year, and a considerable portion of these conditions is 
 due to congenital syphilis. In the other diseases, rickets 
 plays an important part, and it can be readily understood 
 that in zymotic infections, such as measles and whooping 
 cough, the already debilitated rickety child with its em- 
 barrassed respiration and circulation has a smaller chance of 
 recovery than the healthy child. Diarrhoea is not, in itself, 
 a common symptom of rickets, but the abdominal distension 
 and tendency to catarrh in rickets undoubtedly render the 
 child more liable to infection and make the chances of 
 recovery more remote. It is a general experience in all 
 children's hospitals, that no matter from what condition the 
 child is suffering, if the evidences of rickets are looked for 
 the percentage of rickety cases is found to be very high. 
 
CHAPTER III 
 
 THE GEOGRAPHICAL DISTRIBUTION OF RICKETS 
 
 Distribution in Europe and Asia 
 
 Distribution in Europe. 
 
 Prof. Baumel, in a paper read before the International 
 Medical Congress at Moscow, in 1897, gave the results of 
 an enquiry he had made from the best known physicians 
 for the diseases of children in the great centres throughout 
 Europe.* 
 
 In Paris, for example, Comby finds that rickets is very 
 common amongst the poor, and he states that it is 
 widespread in the following French departments — Nievre, 
 Calvados, and Seine and Marne. Leroux, taking dispensary 
 figures in Paris for the years 1884 to 1894, found that 1,362 
 children out of 7,000 to 8,000 patients suffered from rickets. 
 Marfan finds that in the children in hospital in Paris, 
 between the ages of six months and three years, nearly 
 50 per cent, are rachitic. From the fourth to the eighth 
 year the stigmata of the disease tend to disappear and are 
 only found in one patient out of four. He is of opinion 
 that of late years, while the slight forms have been as 
 common as in the past, the severe forms have seemed a 
 little less numerous, f This last observation is in accord 
 
 • " Comptes-rendus du XII Congrds Internationale de Medicine." 
 Moscow, 7th-i4th Aug., 1897. Vol. III. Section VI. Published Moscow, 
 1899. " Distribution gSographique du rachitisme." Prof. L. Baumel 
 (Montpellier). 
 
 t " Maladies des Os, par Marfan.'' " Nouveau Traitd de Medicine et de 
 Th6rapeutique," Brouardel et Gilbert, Paris, 1912. 
 
 30 
 
The Geographical Distribution of Rickets 31 
 
 with experience in London, the disease being as frequent 
 now as it ever was in the past, probably more frequent, but 
 at the same time tending to be of a milder form. Dr. 
 Seche5n:on and Dr. Bezy state the condition is very common 
 in Toulouse ; in Tours it is also common. (Chaumier.) 
 
 Simon, of Nancy, states it is very common in Lorraine, 
 and in Montpellier it is prevalent ; if one examines sick 
 children in hospital for the signs of the disease, it is found 
 in from 50-80 per cent. (Baumel.) 
 
 Hirsch notes the predominance of the disease in wet, 
 cold and marshy places, and states that countries with a 
 cold and wet climate, such as Holland, many parts of 
 England, the North German plain, the mountainous regions 
 of central and southern Germany, and the plains and 
 mountainous districts of northern Italy, if they are not the 
 exclusive seats of rickets, are at all events its headquarters. 
 It is common in the wet plains of Lombardy, of Alsace, of 
 Holland, of Belgium, and of North Germany, as well as in 
 the vaUeys, deeply cleft and traversed by many watercourses, 
 of the Giant Mountains, the Thuringian Forest, the moun- 
 tainous parts of south-western Germany, and the Alpine foot 
 hills of Austria and northern Italy.* 
 
 In Frankfort, Professor Rehn gives the incidence of rickets 
 as from 50 to 60 per cent.f Prof. Epstein says the disease 
 is common in Prague and throughout Bohemia generally, 
 80 per cent, of the children under two being affected. In 
 Vienna, Kassowitz, who has made a close and detailed 
 study of the disease, states that it is of very frequent 
 occurrence and gives the proportion as 80 per cent. In 
 Buda-Pesth, according to Prof. Bokay, it is also rife. 
 Nauwelaers, of Brussels, says rickets is present in about 
 50 per cent, of the population of that town, and finds that 
 it is not uncommon in the better classes. 
 
 Merei, after many years' experience of rickets, both on 
 the Continent and in England, states in 1855 that in Paris, 
 Vienna and Pesth, cases of rickets abound. It prevails to a 
 
 * Hirsch, loc. cit., p. 737. 
 ■f Prof. Baumel, loc. cit. 
 
32 Rickets 
 
 great extent in Dresden and Munich, and is indeed common 
 in all the large continental towns. As a result of his 
 experience, he finds that it is much more common in Austria 
 and Hungary than it is in England, and that it is more 
 common in wealthy famihes on the Continent than in 
 England. This agrees with later experience, and the cases 
 in Vienna seem of a more severe type than is met with in 
 England. In discussing the effects of the late war on the 
 populations of Europe, it is important to remember the 
 extreme prevalence of rickets which has existed all over the 
 Continent for many years. Thus, one report mentions that 
 in a Leipzig home for dehcate children after the war, 40 per 
 cent, of the children were found to be rachitic. There 
 seems to be no doubt that the children examined were 
 suffering from severe malnutrition, but the conclusion that 
 is drawn that rickets has greatly increased as a consequence 
 of the war is not justified by the percentage of rickety cases 
 found. Careful examination would probably have revealed 
 a higher percentage before the war. 
 
 In Spain, Prof. Borobio says the disease is common in 
 Saragossa. It is also fairly common throughout the north 
 of Spain, down to the Portuguese frontier, disappearing 
 towards the south. In Lisbon, it is not common. 
 
 In Italy, Salmon notes that it is commonly seen in 
 Florence, and Prof. Concetti finds it prevalent among the 
 poor in Rome. In the low-lying parts of the provinces of 
 Milan and Pavia it is common ; as already noted, it is 
 diffused throughout the plain of Lombardy generally and in 
 the northern heights of Italy. 
 
 The endemic nature of rickets in many parts has 
 suggested an infective origin for the disease. Frey * 
 points out its resemblance to tuberculosis, in that it is 
 common in low-lying and damp localities, while it is rare 
 at the sea coast and also at an altitude. It is most frequent, 
 and presents the characteristics of an endemic disease, in 
 humid marshy countries such as Holland and Belgium, in 
 Alsace, and at the mouths of the Rhine, and in the low-lying 
 
 <■ Frey, " &iologie du rachitisme." Bale, 1896. 
 
The Geographical Distribution of Rickets 33 
 
 parts of Silesia. In speaking of Somersetshire and the 
 western counties of England, it is noted that there is 
 still a marked tendency to its occurrence in the low-lying 
 hollows between the hills. This is found also to be the 
 case in the mountainous parts of northern Italy. At a 
 height the disease tends to disappear. 
 
 Maffei,* who devoted many years to the study of 
 cretinism and its distribution, states that rickets in its habitat 
 resembles cretinism ; where cretinism prevails, rickets is 
 found, and where neither goitre nor cretinism is present, 
 rickets is but rarely seen. At 3,000 feet and over, according 
 to Maffei, no rickets is met with ; between 2,000 and 3,000 
 feet it is but seldom seen, but between 2,000 feet and 1,300 
 feet it becomes again more prevalent and is very frequently 
 seen in the low-lpng towns and villages among the poor, 
 especially among those who Uve in damp, confined, and 
 gloomy dwellings. 
 
 Excessive moisture and the poisonous air engendered in 
 the damp and sunless dwellings are, according to Maffei,' the 
 essential causes of rickets. 
 
 In Davos, Volland and Sprengler did not find a single 
 case, although the greater part of the infants were not 
 nourished at the breast and only received very coarse 
 nourishment from the first days of their birth. This agrees 
 with common experience where it is found, that although 
 all the conditions as regards feeding which are commonly 
 supposed to cause rickets are present, but the climatic en- 
 vironment is not conducive to the disease, it remains for all 
 practical purposes absent. On the other hand, when the 
 child is confined in close, small, gloomy, and badly ventilated 
 rooms in a climate such as ours, the disease will inevitably 
 develop, although the mother's milk be ample and her health 
 beyond reproach, and although the mother may herself have 
 free means of exercise outside the close confines of the 
 house. 
 
 In marked contrast to this widespread concentration 
 
 * " Der Kretinismus in den Norischen Alpen," von Dr. MafiEei. Erlangen, 
 1844, p. 179. 
 
34 Rickets 
 
 throughout Europe is the almost comjdete absence of this 
 condition from warmer and especially tropical countries. 
 Palm, who was for nine years resident in Japan, was struck 
 with the absence of rickets in that country, and the enquiry 
 made by the British Medical Association as to the distri- 
 bution in England suggested to him an enquiry made on 
 similar hnes through medical missionaries resident in China 
 and Japan and India as to (1) the presence or absence of 
 rickets ; (2) the Ijiabits and diet of the people ; (3) the 
 climate and sanitary conditions.* The results obtained are 
 of great interest. They are almost entirely negative. The 
 margin of error in the enquiry is reduced to a minimum. 
 The evidence of the observer is usually the result of 
 prolonged experience, and he is, as a rule, well acquainted 
 with the life and habits of the natives. The number of 
 patients suffering from general diseases is mostly very large. 
 Rickets in its more marked forms is not a disease likely to 
 be missed, and the uniform reports from the various sources 
 that the condition is entirely or practically unknown show 
 that the testimony is reliable. These results may be 
 epitomised as shown on the following tables : — 
 
 Locality. 
 
 Observer. 
 
 Presence of 
 Rickets. 
 
 Sanitation and 
 Climate. 
 
 Food. 
 
 China. 
 Manchuria. 
 
 D. Christie. 
 
 In six years 
 had not seen 
 a single case. 
 
 Lat. 41-5° N. 
 
 Millet, rice, 
 pork and vege- 
 tables. Infants 
 nursed till 3 or 
 4 years of age. 
 
 Mongolia. 
 
 G. P. Smith. 
 
 Had not~seen 
 a single case. 
 
 Air dry. Cold 
 in winter, 
 warm in sum- 
 mer. Scrofula 
 and phthisis 
 common. 
 
 
 * " The Geographical Distribution and Aetiology of Rickets," by 
 Theobald A. Palm, M.A., M.D. The Practitioner. Vol. XLV. Oct., 1890. 
 
The Geographical. Distribution of Rickets 35 
 
 Locality. 
 
 Observer. 
 
 Presence of 
 Rickets. 
 
 Sanitation and 
 Climate. 
 
 Food, 
 
 Tientsin. ' 
 
 Dr. Roberts 
 
 Rickets almost 
 
 Atmosphere 
 
 Practically 
 
 
 Dr. King. 
 
 unknown in 
 
 dry and 
 
 vegetarians. 
 
 
 
 this province. 
 
 stimulating 
 with bright 
 sunshine. 
 
 Millet flour 
 and occasion- 
 ally rice are 
 chief articles 
 of diet with 
 greens and 
 beans in 
 season. 
 
 Peking. 
 
 E. T. Prit- 
 
 Out of many 
 
 Conditions in- 
 
 Poor, largely 
 
 
 chard. 
 
 thousands of 
 
 sanitary. 
 
 vegetarians. 
 
 
 
 patients had 
 
 Scrofula and 
 
 Rice, millet. 
 
 
 
 seen no mar- 
 
 phthisis com- 
 
 flour, beans 
 
 
 
 ked case in 
 
 mon. 
 
 and vege- 
 
 
 
 three years. 
 
 
 tables. Chil- 
 dren suckled 
 till late. 
 
 Pehing. 
 
 Dr. Dud- 
 
 Almost un- 
 
 Scrofula and 
 
 Children weaned 
 
 
 geon. 
 
 known. 
 
 tubercle com- 
 mon. 
 
 very late — 
 three years, 
 sometimes 
 four or five. 
 Rice, wheaten 
 flour, bean 
 curd and vege- 
 tables, chiefly 
 salted. 
 
 Chichow, 
 
 Dr. Mac- 
 
 Rickets rare. 
 
 
 
 interior 
 
 fcirlane. 
 
 
 
 
 of North 
 
 
 
 
 
 China. 
 
 
 
 
 
 Shantung 
 
 W. W. 
 
 Out of 4,837 
 
 Bright sun- 
 
 Chiefly grain — 
 
 Province. 
 
 Shrubsall. 
 
 patients, only 
 
 shine. 
 
 Indian corn. 
 
 
 
 one case of 
 
 Agricultural 
 
 wheat, millet ; 
 
 
 
 rickets and 
 
 district. 
 
 beef, mutton. 
 
 
 
 that slight. 
 
 Anaemia and 
 phthisis rare. 
 
 fowls at inter- 
 vals. 
 
 Provinces 
 
 
 
 
 
 of 
 
 
 
 
 
 Hupeh, 
 
 Shantung, 
 
 W. L. 
 Pruen. 
 
 In many years 
 has never 
 
 
 
 Szechuen. 
 
 
 treated a case. 
 
 
 
36 
 
 Rickets 
 
 Locality. 
 
 Observer. 
 
 Presence of 
 Rickets. 
 
 Sanitation and 
 Climate. 
 
 Food. 
 
 Hangchow. 
 
 D. Duncan. 
 
 In eight years 
 has only seen 
 a'few mild 
 cases. 
 
 City of half a 
 million in- 
 habitants. 
 Houses of one 
 storey. Sani- 
 tation very 
 bad. 
 
 
 Canton. 
 
 J. G. Kerr. 
 
 Out of tens of 
 
 Dense popula- 
 
 Rice, vegetables. 
 
 
 
 thousands of 
 
 tion. Warm 
 
 salt fish and a 
 
 
 
 cases can re- 
 
 bright sun- 
 
 little animal 
 
 
 
 crII no well- 
 
 .shine. 
 
 food. 
 
 
 
 marked cases 
 
 Anaemia, 
 
 
 
 
 of rickets. 
 
 scrofula, 
 syphilis com- 
 mon. 
 
 
 Thibet. 
 
 Dr. Karl 
 
 In two and a 
 
 High altitude. 
 
 
 
 Marx. 
 
 half years 
 found no 
 rickets. 
 
 11,300 ft. 
 
 
 India. 
 
 
 
 
 
 Kashmir. 
 
 A. Neve. 
 
 Out of many 
 
 Populous town, 
 
 Children suck- 
 
 
 
 thousands of 
 
 100,000 in- 
 
 led for two or 
 
 
 
 patients. 
 
 habitants. 
 
 three years. 
 
 
 
 about one 
 
 Streets nar- 
 
 
 
 
 case of rickets 
 
 row. Sanita- 
 
 
 
 
 annually. 
 
 tion bad. 
 
 
 Punjab. 
 
 Dr. Hutchi- 
 
 After 20 years' 
 
 Houses small 
 
 Maize ground 
 
 
 son. 
 
 practice 
 
 and badly 
 
 whole, baked 
 
 
 
 found rickets 
 
 ventilated but 
 
 into cakes and 
 
 
 
 very rare. 
 
 occupants 
 spend small 
 portion of 
 time indoors. 
 
 eaten with 
 some vege- 
 table. Wheat, 
 barley and mil- 
 let, occasion- 
 ally. Ghee or 
 clarified butter 
 and oil. Fruits. 
 Rice too dear 
 for common 
 use. 
 
 Rajputana. 
 
 Wm. 
 
 Out of 10,000 
 
 Air dry. Bril- 
 
 Grain-eating 
 
 
 Huntley. 
 
 patients had 
 
 liant sunshine. 
 
 people. Meat 
 
 
 
 only one case 
 
 Sanitation 
 
 rarely eaten. 
 
 
 
 of rickets. 
 
 bad. 
 
 See dietary 
 given below. 
 
The Geographical Distribution of Rickets 37 
 
 Locality. 
 
 Observer. 
 
 Presence of 
 Rickets. 
 
 Sanitation and 
 Climate. 
 
 Food. 
 
 Madras. 
 
 Dr. Elder. 
 
 During 13 yrs. 
 and seeing 
 20,000 cases 
 annually, 
 never had a 
 case of rickets 
 to show his 
 students. 
 
 
 
 Neyoor 
 
 E. S. Fry. 
 
 Out of 17,173 
 
 Sanitation bad. 
 
 Food is insuffi- 
 
 (South 
 
 
 patients had 
 
 
 cient. Chil- 
 
 Travan- 
 
 
 one case of 
 
 
 dren suckled 
 
 core). 
 
 
 rickets. 
 
 
 till two years 
 old. 
 
 Ceylon. 
 
 J. D. 
 
 AU state rick- 
 
 
 Other diseases 
 
 
 Macdonald 
 
 ets is very 
 
 
 due to bad 
 
 
 and four 
 
 rare, if it 
 
 
 feeding are 
 
 
 others. 
 
 exists at all. 
 
 
 common, e.g., 
 mesenteric 
 disease, etc. 
 
 Morocco. 
 
 
 
 
 
 Tangier. 
 
 Dr. 
 
 No cases 
 
 Clear atmo- 
 
 
 
 Churcher. 
 
 among Moors. 
 Two or three 
 among Jews. 
 
 sphere. Bad 
 sanitation. 
 Syphilis very 
 prevalent. 
 
 
 Japan. 
 
 T. A. Palm. 
 
 In nine years' 
 
 All varieties of 
 
 Rice and fish. 
 
 
 
 dispensary 
 
 climate. 
 
 Of late years 
 
 
 
 and hospital 
 
 Much mois- 
 
 have begun to 
 
 
 
 practice, un- 
 
 ture, but gun- 
 
 eat beef and 
 
 
 
 able to recall 
 
 .shine is bril- 
 
 milk. Fresh 
 
 
 
 a well-marked 
 
 liant both 
 
 vegetables 
 
 
 
 case. 
 
 summer and 
 winter. 
 
 abundant. 
 People are 
 fairly well fed. 
 
 Dr. Huntley, speaking of the food of the natives in 
 Rajputana, makes some interesting observations on their 
 dietary. He subdivides it into four classes ; I and II being 
 the dietaries of the better fed natives, while III and IV are 
 those of the poorer classes, the last being the ordinary 
 village diet. 
 
38 
 
 Rickets 
 
 
 I 
 
 II 
 
 Ill 
 
 IV 
 
 Wheat 
 
 li lbs. 
 
 if lbs. 
 
 o 
 
 o 
 
 Pulse 
 
 ilb. 
 
 ilb. 
 
 Jib. 
 
 o 
 
 Coarse brown sugar 
 
 2 OZ. 
 
 2 OZ. 
 
 2 OZ. 
 
 o 
 
 Butter 
 
 2 OZ. 
 
 ilb. 
 
 O 
 
 o 
 
 Buttermilk 
 
 
 
 ad lib. 
 
 little. 
 
 Barley 
 
 
 
 I J lbs. 
 
 2 lbs. 
 
 Rice, on account of its comparative expense, is seldom 
 eaten by the natives, and milk is nevei drunk by the vast 
 majority of the people. Dr. Huntley believes, with reason, 
 that the nutrient values of these dietaries completely contra- 
 dict Dr. Cheadle's view that a deficiency of animal fat causes 
 rickets. Mothers in Rajputana are frequently only thirteen 
 years of age. They do not take milk while suckhng, and the 
 menses reappear about three or four months after the birth 
 of the child. The child is suckled till the age of two. After 
 six months the young infant is given wheaten porridge. 
 They nurse one child till another comes and then frequently 
 both continue to take the breast. 
 
 Later, in discussing the aetiology of rickets, the bearing 
 of these facts will be more minutely gone into, but in the 
 meantime it may be noted that in the vast population of 
 the East and of tropical countries generally, all the factors 
 which are commonly supposed to be the exciting causes 
 of rickets are present in an extreme degree. England is 
 one of the wealthiest countries in the world and rickets 
 abounds ; India is one of the poorest but is practically im- 
 mune. In India, millions live on the verge of starvation 
 and all our efforts are still unable to prevent the death of 
 enormous numbers in recurring times of famine. Under- 
 feeding in this sense of the word is unknown in England. 
 Throughout the East, mothers suckle their infants and wean 
 them late. Frequently they continue nursing during preg- 
 nancy and mixed feeding while the child is at the breast is 
 the rule. The diet lacks variety for the great mass of the 
 
The Geographical Distribution of Rickets 39 
 
 population, and taking the East generally, if rice fails no- 
 thing can prevent dire distress. Compared with the East, 
 the diet in England is of the most varied kind. 
 
 Infantile mortality in the tropics is high. Weaning is a 
 difficult and dangerous period. The great danger of this 
 period is diarrhoea and dysentery from infections with 
 amoebae or bacilli. Deaths from diarrhoea and dysentery 
 and intestinal toxaemias are exceedingly common, and 
 when they do not end in death, these conditions are apt 
 to be chronic and to influence the health of the child 
 over a long period. But these infections do not end in 
 rickets, as one would expect if it were true, as is usually 
 maintained, that rickets is of the nature of an intestinal 
 toxaemia. 
 
 The outstanding feature in the lives of all these vast 
 communities is that their life is much in the open air and 
 there is brilliant sunshine. The huts may be unhygienic, 
 but there is no comparison, as regards health conditions, 
 between the hut of the native village in India, bathed in con- 
 stant sunshine, and the basement room of a slum dwelling 
 in London, Manchester, or Glasgow, where for from six to 
 eight months the sun is but seldom seen and the weather is 
 dark, cold, and bleak. Speaking of the distribution of the 
 disease in Europe, it was noted that rickets resembles goitre 
 in its distribution, and in certain districts in the Alps the 
 two conditions were frequently found together. In the 
 Himalayas, it is interesting to note that endemic tetany is 
 found in goitrous districts. This disease is characterised by 
 bilateral, intermittent, and usually painful spasms of the 
 hands and feet, and at times other parts of the body, and 
 increased excitabihty of the nervous system. Tetany is a 
 disease which is peculiarly associated with rickets, and 
 CasteUani notes that when tetany is found in the Himalayas, 
 it is frequently necessary to treat the associated condition of 
 rickets.* McCarrison has pointed out that congenital goitre 
 is extremely common in certain Himalayan villages, nearly 
 
 * " Manual of Tropical Medicine," CasteUani & Chalmers, London, 
 1919, p. 1922, 
 
4° Rickets 
 
 every man and woman being affected. The mothers are 
 often myxcedematous and 60 per cent, of infants at the 
 breast show evidence of goitre. The common association 
 of rickets with these diseases has frequently given rise to 
 the speculation that rickets itself may be of an infective 
 nature. The relationship between rickets and endemic 
 goitre will be treated at greater length in discussing the 
 aetiology of rickets. 
 
CHAPTER IV 
 
 THE GEOGRAPHICAL DISTRIBUTION OF RICKETS 
 Distribution in the Colonies 
 
 Rickets in South Africa. 
 
 From personal observations made up country by the 
 author during the years of the South African war and 
 afterwards, and from a wide experience of the country, 
 rickets even in its mildest form is exceedingly uncommon 
 in the immense elevated plateau, of which the Karroo forms 
 so great a part. This applies to native children and to the 
 offspring of Dutch and English parentage alike. With 
 mothers belonging to the European stocks lactation is 
 often a matter of difi&culty, and is frequently cut short at an 
 early date owing to failure of the breast milk. Even when 
 the mother continues to nurse her infant, the dietary usually 
 requires to be supplemented with other food in the early 
 months. Dairy produce is scarce, and the diet, especially 
 with the Dutch community, consists largely of bread, meat 
 and coffee. The conditions affecting the adult are largely 
 of a rheumatic nature, not acute rheumatism, but the 
 chronic forms usually classed under the term muscular 
 rheumatism and fibrositis. Chronic indigestion is frequent. 
 Dysentery and diarrhoea in young infants are common, and 
 marasmus and other wasting diseases are by no means 
 infrequent, especially among the children of European 
 parentage. Young infants have often to struggle through 
 periods of great difficulty in their alimentation during the 
 early months of their lives. But these cases do not end in 
 rickets. Up country tuberculosis is uncommon, though it 
 is increasing in some of the seaport towns, such as 
 Port Elizabeth. Prolonged droughts tell severely on the 
 
 41 
 
42 Rickets 
 
 health and spirits of the sparse population occupying 
 the vast territory of the Karroo, but the outstanding 
 characteristics of the climate are the rarefied air of the 
 high elevation and the brilliant sunshine, which lead to a 
 high degree of diaphaneity. This renders the great heat 
 comparatively easily borne. In South Africa, though the 
 sunshine is brilliant and the heat often intense, much time 
 can be spent in the open air, and sunstroke and heat stroke 
 are rare. Tennis and other active games can be played even 
 without headgear, whereas in India it would be dangerous to 
 cross a road withoiit effective protection to the head. This 
 is due to the fact that the rarefied air does not retain the 
 heat as does the heavier air of, say, the Deccan, in India — a 
 great plain but little raised above the sea-level. Under 
 such conditions as prevail in the Karroo, it is practically 
 impossible to produce rickets, no matter what deficiencies 
 and errors occur in the diet of the infant, and these are 
 many. 
 
 Writing in June, 1920, in response to an enquiry from 
 the author as to the prevalence of rickets. Dr. J. GaUoway, 
 part time Medical Oihcer of Health for Port Elizabeth, 
 Cape Colony, who has had many years' experience of 
 medical practice in the city, states ; "I have seen a very 
 few cases of rickets during my whole experience in Port 
 Elizabeth. Here and there have been cases of a very mild 
 type. I have never seen a case which you could diagnose 
 at a distance as rickets." 
 
 From East London, Cape Colony, Dr. Ernest Hill, 
 Medical Officer of Health, writes in July, 1920, in response 
 to a similar request : "I have made enquiries of the doctors 
 practising in this town, and the general opinion is that 
 rickets scarcely ever occurs in any section of the community, 
 but one doctor, who has been in practice for a great number 
 of years, replies that it occurs fairly frequently in the poorer 
 class of whites, occasionally in the well-to-do, rarely in 
 natives living in the country, and occasionally only among 
 those living under urban conditions." 
 
 The notable immunity of the South African native, 
 
The Geographical Distribution of Rickets 43 
 
 although he has been under the influence of European races 
 since the beginning of the seventeenth century, is very 
 remarkable, when it is considered that the American negro 
 suffers severely from the disease. In South Africa, however, 
 the white man came to the country of the native, while in 
 America the negro was removed from his home and natural 
 surroundings and was transplanted into an entirely un- 
 natural environment, where in course of time the population 
 concentrated into great industrial centres. The explanation 
 lies in the different circumstances under which they live in 
 these two countries. In South Africa the distinction 
 between black and white is still very strictly drawn, and the 
 coloured portion of the population still retain many features 
 of their native life. 
 
 The native, as a rule, lives in a settlement outside the 
 town usually known as the location. Even the domestic 
 servants return to the location at the end of the day's work. 
 According to the class of native, the houses vary from mere 
 huts to fairly well-built houses, but the life approximates to 
 the native state and is not at all comparable with the life 
 of the slum areas of large American cities, in which the 
 native tends to occupy the worst part. As regards food, the 
 South African native frequently does not fare so Well as 
 the American negro either as regards quantity or variety. 
 A large proportion of the food for the locations is carried 
 home from the leavings of the not over-abundant table of 
 the white man. Even the best of breast-feeding does not 
 protect the negro infant in America from the onset of severe 
 rickets. 
 
 From Durban, in Natal, Dr. Norman H. Walker, Assistant 
 Medical Officer of Health, writes in August, 1920, in answer 
 to an interrogation addressed to him on the subject : 
 " Enquiries which I have made from local practitioners 
 suggest that rickets is not a common disease in Durban or 
 Natal. Such cases as are met with are of a mild type, and 
 the disease is scarcely ever found in members of the better 
 (Class. One doctor expressed the opinion, that he had more 
 cases in Indians than in natives." 
 
44 Rickets 
 
 Rickets in Australia. 
 
 The study of rickets in Atistralia is one of great interest 
 and importance. Most clinicians find difSculty in believing 
 that the disease first rose in England at the beginning of 
 the seventeenth century, and have dismissed Glisson's 
 original statement to this effect without any real enquiry 
 into the subject. 
 
 In Austraha to-day can be witnessed the onset and 
 growth of this disease, which is not indigenous to the 
 country, but which is increasing for precisely the same 
 reasons as it arose and spread in England, namely, the 
 growth of dense populations and slum areas. Not that all 
 these cases occur in slums, for, as has been previously 
 shown, it is easy to reproduce the conditions of vitiated air, 
 deficient sunlight, and want of exercise in the homes of the 
 wealthy. But the great mass of the well-marked cases 
 comes from slum areas where overcrowding is the constant 
 and predominant feature. It is the more remarkable in 
 Australia because the climate is not at all favourable to the 
 growth of rickets. On examining the map, it will be found 
 that the more thickly populated areas lie in the south- 
 eastern corner of the continent, near the coast in the states 
 of Queensland, New South Wales, Victoria and part of 
 South Australia. Roughly, this thickly populated area lies 
 between 27-5° south latitude which passes through Brisbane 
 and 39° south latitude which touches the southernmost 
 point of the continent. In Europe, this zone is compara- 
 tively free from rickets. The distribution of the population 
 in Australia shows one pecuhar and unfortunate character- 
 istic which is of great economic importance, and that is that 
 of a population of less than 5,000,000 there are 2,000,000 
 living in the capitals of the various states. The exact pro- 
 portion for the four chief states is shown on the next page. 
 
 It will be noted that in New South Wales, with much 
 less than two milHons of a total population, considerably 
 more than three quarters of a million live in one huge city, 
 Sydney. 
 
The Geographical Distribution of Rickets 45 
 
 Such a state of affairs is naturally not a desirable one, 
 for so great a town population can hardly expect to. find 
 industrial occupation provided for it by a population which 
 is but little in excess of the number spread over the whole 
 state. Naturally, this leads to unemployment and poverty 
 with all its attendant evils, crowded, unhygienic, and squalid 
 domestic surroundings, associated with poor feeding. Sydney, 
 it must be remembered, is already an old town. It was a 
 considerable town in the days when, in the home country 
 and elsewhere, but little or no attention was paid to town 
 planning and houses were allowed to grow up haphazard. 
 The streets are irregular in width, many of them narrow 
 and close together, and Sydney has consequently more the 
 
 Last Census of Commonwealth, 1911 ; Estimated 
 Population, December, 1916. 
 
 state. 
 
 Population. 
 
 Chief City. 
 
 Population. 
 
 Proportion of 
 population of 
 Chief City to 
 whole State. 
 
 New South Wales 
 Victoria ... 
 Queensland 
 South Australia... 
 
 1.855.908 
 
 1.399.779 
 
 669,467 
 
 431.814 
 
 Sydney ... 
 Melbourne 
 Brisbane 
 Adelaide 
 
 764,000 
 
 , 695,000 
 
 168,393 
 
 223,718 
 
 41-15 per cent. 
 49-10 „ 
 25-15 ,. 
 51-59 .. 
 
 appearance of an old world town than any other city in 
 Australia. It stands in the centre of a great coal-bearing 
 basin, and is naturally the seat of numerous manufactures, 
 to the prosperity of which the abundance and cheapness of 
 coal have been conducive. Besides shipping and railways, 
 there are tobacco factories, flour mills, boot factories, sugar 
 refineries, tanneries, meat preserving and soap works. 
 Carriages, pottery, glass and furniture are made. The popu- 
 lation of Sydney has increased with marvellous rapidity. In 
 1861, it was (city and suburbs inclusive) 95,000 ; in 1881 
 it had increased to 237,300, and in December, 1916, it was 
 estimated at 764,000. Such a rapid increase is attended 
 with considerable risk to the health of the community. 
 
46 Rickets 
 
 But while Sydney is the oldest city in Australia, it has 
 many natural advantages. It is beautifully situated on the 
 shores of Port Jackson in latitude 33" 51' south. It has a 
 mean temperature of 63° Fahr., and the range of temperature 
 between mean summer and mean winter temperature is 17° 
 Fahr. The rainfall is about 50 inches. The skies are clear 
 and the prevailing state of the weather is characterised by a 
 genial warmth. Such conditions are not conducive to the 
 onset of rickets, but the important lesson is again pointed 
 out that the best surroundings can be perverted by want of 
 knowledge or carelessness. Even to-day, in England, the 
 population generally, while it feels vaguely that something 
 must be done to improve the comfort of the home sur- 
 roundings of the worker, is not yet impressed with the fact 
 that should by this time be abundantly obvious, that until 
 our slum areas have been swept away no great improvement 
 can be expected in the health of the industrial labotirer and 
 of the poor. A truly enormous task, but the magnitude of 
 the evil is Ukewise very great, and means not only chronic 
 iU-health and blighted opportunities to the individual, but 
 entails a very great economic loss to the State. 
 
 The standard of life is altogether higher in Australia than 
 it is in the home country. The food is good and wholesome 
 and is on a more generous and ample scale than at home. 
 Cases of actual want are very rare. There is not the same 
 ignorance as regards dieting as is found amongst the very 
 poor in England. The life of the child, and indeed of the 
 population generally, is spent much in the open. But the 
 evil effects of crowded and unwholesome environment are 
 concentrated on the young infant in the first few months of 
 its existence. When it is able to move about by itself, say at 
 the age of two years, the child participates in the advantages 
 of the more open-air life, and on this account prolonged 
 and severe cases of rickets are but seldom seen. The 
 disease in Australia is of a very mild type. There is no 
 essential change or improvement in the child's diet at, say, 
 the age of two, but immediately it is left to its own resources 
 and is not entirely dependent on the mother for the oppor- 
 
The Geographical Distribution of Rickets 47 
 
 tunities of fresh air and exercise, which the mother of the 
 poor seldom has leisure to give, the child begins to make 
 rapid headway towards recovery from the condition. In 
 Melbourne, poorer quarters and mean narrow streets also 
 exist, but not to the same extent as in Sydney. It is also a 
 great manufacturing centre, tanning, wool washing, bacon 
 curing, flour milling, brewing, iron founding, etc., being 
 considerable industries. 
 
 The prejudicial effect of city surroundings on infant life 
 in Australia, as at home, is evidenced by the mortality being 
 markedly heavier in urban than in country districts. In 
 Victoria, on the average of the past five years, the deaths 0^ 
 children under one year of age to every 1,000 births in the 
 large towns, were 77 in Melbourne, 83 in Ballarat, 74 in 
 Bendigo, and 70 in Geelong, as against 55 in the rest of the 
 state. In Greater Melbourne, the varying death rate for the 
 various metropolitan boroughs speaks eloquently of the 
 pernicious effects of overcrowding. The deaths under one 
 year per 100 births during 1918 varied from 11-90 in 
 Port Melbourne City to 4-98 in Kew Town.* The 
 centres having the lowest death rate were residential, whilst 
 those with the highest death rate were the most thickly 
 populated. 
 
 The death rate from rickets, as one would expect, is 
 exceedingly small. Mr. A. M. Laughton, Government 
 Statistician to Victoria, informs me that in Victoria during the 
 ten years from 1910 to 1919, 51 deaths occurred from this 
 disease, 32 males and 19 females, and of these, 42 died under 
 the age of two years. A. Jeffries Turner, writing in 1892, 
 draws attention to the infrequency of rickets in Australia as 
 compared with European cities. Improper feeding, he 
 believes, is not the exclusive cause of rickets, for improper 
 feeding is as common in Australia as in England. Turner 
 gives the following reasons for the disease being less common 
 in Australia : (1) children of two years and upwards are better 
 fed and recover more completely and more rapidly on that 
 
 • " Victorian Year-Book, 1918-19," by A. M. Laughton, F.S.S., Govern- 
 ment Statistician. 
 
48 Rickets 
 
 account ; (2) the warmer climate leads to diminished con- 
 sumption of hydro-carbons and proteins and so renders 
 the relative deficiency less injurious ; (3) abundance of 
 fresh air ; life in the open ; wooden houses ; abundance of 
 sunlight.* 
 
 In 1889, Dr. Springthorpe f states that owing to the 
 absence of abject poverty and of profound dietetic ignorance, 
 rickets is practically unknown amongst Australian children. 
 That was written over thirty years ago. In 1908, speaking of 
 the disease in Sydney, Dr. W. F. Litchfield comes to the 
 following conclusions : (1) rickets does occur in Sydney, 
 but it is not a common disease ; (2) the disease, wheie it 
 occurs, is generally of a mild type, enlargement of the ends 
 of the long bones being rare in the active stage ; (3) the 
 number of cases requiring surgical interference is very small ; 
 (4) deformity of the pelvis sufficient to obstruct labour is 
 rarely, if ever, seen.t 
 
 In a report by the Medical Officer of the Victorian 
 Education Department, 1911-12, the results are given of a 
 careful enquiry into the presence of rickets in school- 
 children in Melboiurne. The signs of the disease were 
 systematically looked for in a whole series of children. The 
 results are noteworthy. Out of 1,327 boys examined, 
 355 — that is 26 per cent. — showed rachitic signs, such as 
 deformities of the chest and spine, knock knee, or bow legs, 
 square shape of the head, beading of the ribs, pot belly, and 
 enlarged liver and spleen. That is to say, that a quarter of 
 the school-children examined were suffering from rickets or 
 had suffered from rickets of a mUd form. In the opinion of 
 the writer, this explains whj', with all the children sitting at 
 the same desks, only some show deformities due to postural 
 influences. He notes two types : (1) the precocious, 
 bright, nervous child, usually thin and weedy, prone to 
 constipation and indigestion and with a capricious appetite, 
 
 * Australian Medical Gazette, January, 1892, p. 104. 
 
 t " Hygienic Conditions in Victoria," by J. W. Springthorpe, M.D., 
 M.R.C.P. 
 
 X " The Incidence of Rickets in Sydney," by W. F. Litchfield, M.B., 
 Australian Medical Congress, October, 1908. 
 
The Geographical Distribution of Rickets 4.9 
 
 often excessive ; (2) the solid type, often fat and flabby 
 and over-weight, and yet nervously unstable. These are 
 the backward children. 
 
 The report attributes the condition to two factors, 
 namely, defective feeding and defective hygienic conditions, 
 such as overcrowding in ill-ventilated rooms and the 
 breathing of vitiated air. It is pointed out that marked 
 rickets is more common amongst children fed on artificial 
 foods than in those who are breast fed. This is well 
 known, but it is also to be noted that the breast feeding 
 is no protection against the onset of the disease. It 
 should also be remembered that the child is not rickety 
 because he has been fed on artificial food, but is very 
 frequently taken off the breast and placed on artificial 
 food because he is suffering from a rachitic form of mal- 
 nutrition and does not thrive. As previously stated, when 
 the child is exposed to the evil conditions which produce 
 rickets, breast feeding will not save it from the disease, 
 though it will in all probability modify its severity ; and on 
 the other hand, a native child Hving in the East under 
 native conditions may, and frequently does, have every 
 conceivable error made in its diet and suffers severely 
 accordingly, but it does not develop rickets. Even in 
 Australia, it is found that a considerable proportion of 
 breast-fed babies are rickety. , 
 
 In August, 1920, Dr. Harvey Sutton, speaking of New 
 South Wales, finds that 25 per cent, of ordinary school- 
 children showed slight but definite signs of rickets.* Dr. 
 Sutton believes that overcrowding (less than four rooms) 
 and artificial feeding in the first six months, are responsible 
 for most of the severe forms. He notes the curious fact 
 that there is a lower percentage of rickety cases, however, 
 when the artificial feeding begins at birth. In these cases 
 the probabiUty is that the child, under medical advice, is 
 placed on a properly regulated regimen and thrives in spite 
 of the artificial feeding. 
 
 * " Manifestations of Rickets in School-Children,'' by Harvey Sutton, 
 O.B.E., M.D., Principal Medical Officer, Department of Public Instruction, 
 New South Wales. 
 
 E 
 
so 
 
 Rickets 
 
 What plays havoc with the infant's health is when the 
 anxious mother, usually on the advice of kindly neighbours, 
 tries first one food and then another^ changing from cow's 
 milk to dried milk, and from one form of dried milk to 
 another, and from that to condensed milk. Nothing is more 
 important in infant feeding than system and regularity, and 
 the medical man is freqpiently at fault in that he leaves the 
 decision of such an important matter to the judgment of an 
 inexperienced and anxious mother. Dr. Sutton points out 
 that hypoplasia of the teeth is not nearly so common in 
 Australian children as in EngUsh children. He states he is 
 frequently able to assert that a child is an immigrant solely 
 because of the appearance of the teeth. Now these various 
 careful observations, made at different periods dviring the 
 last thirty years, tend to show that rickets was not originally a 
 serious factor in infant life in Australia, but that it is rapidly 
 becoming one of great importance, for even mild rickets has 
 far-reaching results. There is no reason to suppose that the 
 quality of the food, either for the mother or for the infant, 
 has deteriorated in AustraMa during that time ; indeed the 
 reverse is true. 
 
 Infantile Death Rates from Certain Causes, 
 1891-3 and 1918.* 
 
 Cause of Death. 
 
 Deaths under one year per 1,000 
 Births in — 
 
 
 1891-3. 
 
 1918. 
 
 Diarrhoeal diseases, all forms 
 
 Wasting diseases (marasmus, atrophy, 
 
 etc.) 
 
 Bronchitis, etc. 
 
 Convulsions 
 
 29-66 
 
 22-24 
 
 11-37 
 6-83 
 
 ii-go 
 
 13-58 
 6-39 
 1-08 
 
 Total 
 
 70-10 
 
 32-95 
 
 Vital statistics show that the health of the nation has 
 improved. The increase in the incidence of rickets has 
 
 * Loc. cii., p. 198. 
 
The Geographical Distribution of Rickets s i 
 
 advanced at the same time that there has been a very 
 remarkable reduction in child mortality. A comparative 
 study of the deaths from certain causes for about thirty years 
 ago and to-day gives the above results. That is to say, 
 the mortality from these diseases is now much less than 
 half what they were thirty years ago. This is due to 
 better sanitation, better food supply, and to a large extent 
 to a more intelligent nurture of the young infant by the 
 mother. The development of skilled nursing during the 
 period of confinement, and in later years, the free dissemina- 
 tion of education in matters of child welfare have had a 
 wonderful effect in reducing, infant mortahty both at home 
 and in the colonies. Unfortunately, with this steady im- 
 provement, there has been a large access of overcrowding 
 due to the increase in density of the populations in the 
 large towns, and this has had a distinctly harmful effect on 
 the development of the child. 
 
 In South and West Australia, rickets, as might be 
 expected, is quite uncommon. Dr. H. R. Pomery, in answer 
 to a query on the subject, writes in August, 1920, from 
 Firanklin Harbour, South Australia, that rickets does not 
 occur in this part of Australia, and he states that in South 
 and West Australia generally, it is recognised as a very rare 
 disease indeed. Writing in July, 1920, the Government 
 Medical Officer in charge of the Wallaroo Hospital, South 
 Australia, states that in twenty years' residence in Wallaroo 
 he has never seen a case of rickets nor has any case been 
 admitted during the sixteen years he has been in charge of 
 the hospital. The hospital is the only Government Hospital 
 between Port Pirie, which is 60 miles north, and Adelaide, 
 100 miles south ; to the west there is the unlimited expanse 
 of West Australia, while Clare, Burra, and Kapunda hospitals 
 lie 80 miles to the east. There are copper mines situated 
 within this area but there are no slums. In these great and 
 sparsely populated areas, with a genial climate, blue skies 
 and brilliant sunshine, the conditions for the production of 
 rickets do not exist. 
 
 Before passing from the disease as it affects Austraha, 
 
52 Rickets 
 
 it may be noted that systematic observations, such as those 
 recorded in the report of the Medical Oii&cer of the 
 Victorian Education Department, 1911-12, and in the report 
 of Dr. Haivey Sutton, in New South Wales, are of the 
 greatest value. The cases recorded are all mild cases, and 
 as such are very likely to escape the eye of the practitioner 
 and will certainly escape the observation of the parent. 
 Only a systematic examination of the child, actually looking 
 for evidence of the disease, would reveal the existence of 
 these cases. It would be of the greatest value if a world 
 census of young school children and infants could be made 
 as regards the incidence of rickets. Two things are essential 
 for a complete examination, firstly, that the child should be 
 stripped as far as the waist, and secondly, that the mother 
 should be present to give essential details in the history, 
 such as the date in cutting the first tooth and the age of the 
 child when it began to walk and speak, besides particulars 
 of feeding during infancy. 
 
 Rickets in New Zealand. 
 
 The climate of New Zealand is in all parts a very healthy 
 one. The air is clear and stimulating with ample sunshine. 
 The population is nowhere dense and is situated mainly on 
 or near the coast line, where the chief centres lie. New 
 Zealand to-day is piobably the most healthy country in the 
 world. It is conspicuous as showing the lowest death rate 
 of the Australian States, the rates for which are considerably 
 lower than those of other countries. From 1896 to 1906, 
 the death rate varied from 9 to 10-50 per 1,000, and in 1912 
 the remarkably low death rate, the lightest in the world, of 
 8-87 per 1,000 of mean population was reached. The 
 infant mortality is very low. 
 
 The proportion of deaths of infants under one year to 
 every 1,000 births is as follows : — 
 
 1910 ... 67-73 
 
 1911 ... 56-31 
 
 1912 ... 51-22 
 
 1913 ... 59-17 
 
 with an average for the ten years up to 1913 of 65-03. 
 
The Geographical Distribution of Rickets 53 
 
 The following table shows that, as regards the preserva- 
 tion of infant Ufe, far better conditions obtain in New 
 Zealand than in most other countries : — 
 
 
 
 Rate of infantile 
 
 Birth rate per 1,000 
 
 Country. 
 
 Year. 
 
 mortality under i year 
 
 of mean 
 
 
 
 per 1, 000 births. 
 
 population. 
 
 New Zealand 
 
 1911 
 
 56 
 
 26 
 
 Australian 
 
 
 
 
 Commonwealth 
 
 igii 
 
 68 
 
 27-2 
 
 England and Wales 
 
 1911 
 
 130 
 
 24-4 
 
 Scotland 
 
 1910 
 
 108 
 
 26-2 
 
 Ireland 
 
 igii 
 
 94 
 
 23-2 
 
 France 
 
 igio 
 
 III 
 
 19-6 
 
 Belgium 
 
 igio 
 
 134 
 
 23-7 
 
 Germany 
 
 1911 
 
 192 
 
 28-6 
 
 At home, those deaths under one year are often looked 
 upon as largely inevitable owing to the child, from its very 
 birth, not being adapted for the maintenance of an inde- 
 pendent existence, either as the result of congenital disease 
 or of some inherited weakness of constitution. The low 
 death rate of New Zealand compared with that of England, 
 Belgium and Germany, shows that environment is responsible 
 for a very large part of this mortaUty. In England, the condi- 
 tions as regard cUmate are extremely unfavourable when 
 compared with the weather conditions which prevail in New 
 Zealand. It is exceedingly difficult in England for the 
 children, even of the wealthy, to escape entirely from the 
 onset of rickets during the long and dreary winter months. 
 The weather conditions of New Zealand cannot be repro- 
 duced at home. All the more it is necessary to see that the 
 children of the home country are placed in the most 
 favourable position possible as regards housing and 
 environment, so that as much fresh air and sunlight as are 
 available may reach them during the long tedious winter 
 months. 
 
 The regulation of the feeding is comparatively a simple 
 matter, but when a family of six is accommodated in two 
 or three rooms in a crowded street or alley, the difficulties 
 in the way of the mother providing a healthy regimen for 
 
54 Rickets 
 
 the infant, as regards proper ventilation and exercise, seem 
 well-nigh insurmountable. Rickets is a factor of no iin- 
 portance at the present day in New Zealand. Writing on 
 3rd September, 1920, Dr. T. Fletcher Telford, Medical 
 Officer of Health, Christchurch, writes as follows : " With 
 reference to your enquiries regarding the prevalence of 
 rickets in the Canterbury- Westland health district, out of 87 
 replies received in this office from practitioners in this 
 district, in response to circulars issued from this office, no 
 less than 69 have not seen a case of rickets during their period 
 of practice in New Zealand. The remaining 18 have seen 
 this disease, but not frequently, their cases being noticed in 
 immigrants arriving in this country, those from England 
 coming from the industrial parts in particular. You will 
 see from this report that rickets is a disease of moderate 
 raritj' in this country. The more roomy housing conditions, 
 with larger open spaces and abundance of sunshine, helps 
 largely to militate against its incidence. Further, immigrants 
 domiciled in this country adopt a much higher standard of 
 living. The wages are very good, and labour being scarce, 
 there is a constant demand for this type of worker, so that 
 there is no occasion for any serious loss of time, leading to 
 poverty with its painful effects in the form of shortage of food 
 and ill-nutrition." From Wellington, the Chief Health 
 Officer writes in a similar strain under date 16th July, 1920 : 
 " In reply, I have to state that in New Zealand as a 
 whole, rickets is an extremely rare disease." As regards 
 WeUington City, the District Health Officer reports as 
 under : " Personally, I have only seen one case of rickets 
 during the last six years. I have, however, made en- 
 quiries from several Wellington practitioners and have been 
 informed that, although occasional cases do occur, the 
 disease is very rare in WeUington. One practitioner stated 
 that a case came under his notice about a year ago, and a 
 second practitioner stated that he had not seen a case for 
 over five years." 
 
 Writing on 14th July, 1920, the District Health 
 Officer, Dunedin. writes : " Your questions re rickets 
 
The Geographical Distribution of Rickets S5 
 
 in respect of Provinces of Otago and Southland, New 
 Zealand : (1) there are very few slum areas, and rickets 
 is extremely rare ; (2) among the well-to-do, it is also 
 extremely rare ; (3) when present it is of a mild type only. 
 
 " The general practitioner fifteen years ago saw an 
 occasional case of mild rickets in babies, head sweatmg, 
 slight bony thickening, etc. Marked deformities are almost 
 unknown, either affecting the long bones or pelvis. These 
 mild cases occur mostly in artificially fed babies, both rich 
 and poor. Of late years infant feeding has improved and 
 rickets is very rare. 
 
 " These remarks apply, I think, for New Zealand 
 generally. Air space is good and infantile mortality rate 
 just under 50. Our difficult labours (bony) occur only with 
 women from the Northern Hemisphere." 
 
CHAPTER V 
 
 THE GEOGRAPHICAL DISTRIBUTION OF RICKETS 
 
 Distribution in America 
 
 If a map showing the density of the population in the 
 United States be studied, the greatest density will be found 
 to exist in the Eastern States. In 1900, eight states of the 
 Union had a density exceeding 100 persons to the square 
 mile : Ohio 102-0, Maryland 120-5, Pennsylvania 140-1, 
 New York 152-6, Connecticut 187-5, New Jersey, 250-3, 
 Massachusetts 348-9, Rhode Island 407-0. The centre of 
 population* has tended to move rapidly westwards, and in 
 110 years has moved more than 500 miles, almost exactly 
 along the 39° parallel of latitude. That is to say, it has 
 passed from 76° longitude in 1790, about twenty-three miles 
 east of Baltimore, to 86° longitude, in the southern part of 
 Indiana, in 1900. Passing from the Atlantic coast west- 
 wards the population continues very dense up to about the 
 90° longitude ; between 90° and 100° longitude it becomes 
 less dense, and from 100° longitude to the Pacific coast the 
 population is sparse till Cahfornia is reached, when it again 
 becomes somewhat dense, though to a much less extent 
 than on the Atlantic side. 
 
 As regards climate the United States may be divided 
 into three distinct regions : — 
 
 1. the Atlantic slope and great central plain possess 
 a climate distinguished by great extremes — ^low winter 
 temperatures alternating with high summer heats. 
 There is abundant rain, ranging from 13 to 30 inches 
 annually, the north-east being the rain-bearing wind. 
 In this region rickets is exceedingly prevalent : 
 
 2. the Rocky Mountain zone has a climate which is 
 continental in its character. In the physical appear- 
 ance of the country, the rarefaction of the air, the 
 brilliant sunshine and the comparative absence of rain, 
 this region resembles the elevated plateau of South 
 
 * The centre of population is a point through which, if a line be drawn 
 east and west, there will be as many people to the north as to the south of 
 it ; if a line be drawn through it running north and south, there will be as 
 many people to the east as to the west of it. 
 
 56 
 
Distribution in America 57 
 
 Africa. The diumal variation of the thermometer is 
 extreme, and the annual rainfall varies from 3 to 20 
 inches. In this region rickets is an uncommon con- 
 dition, even in its milder form : 
 
 3. the Pacific slope enjoys a genial, mild cliniate 
 with abundant sunshine. The rains are periodical, 
 falling in winter and spring. In this region rickets is 
 present, although not nearly to the same extent as on 
 the Atlantic slope, and the type of the disease is very 
 much milder. 
 
 If the nineteenth century was remarkable with regard to 
 national and urban growth the world over, it was particu- 
 larly so in the United States of America. The first general 
 census in 1790 showed a population of 3,929,214 ; by 1900 
 it had grown to 76,304,799. The average rate of increase 
 has been over 30 per cent, for each decade. 
 
 The proportion of population living in cities seems to 
 have been practically constant throughout the eighteenth 
 century and up to 1820. The marked tendency towards 
 concentration in cities and the growth of great towns has 
 been a result of industrial expansion and the developments 
 of railroads since that date. In 1790, out of 100 persons 
 3 lived in cities and 97 in the open country or in small 
 villages ; in 1840 the ratio of urban to rural population was 
 9 to 91 ; in 1890 it was 29 to 71. 
 
 Rickets is not, so far as is known, a disease indigenous 
 to America. Bones in ancient graves in California, in the 
 north-west coast, and in Peru and other localities in South 
 America do not show any signs of disease, even though 
 examinations of extensive osteological collections have been 
 made. It has arisen and made rapid progress as great in- 
 dustrial centres have developed throughout the country. It 
 is essentially a disease of the great cities and it prevails 
 chiefly in the densely populated areas lying in the eastern ■ 
 portion of the United States. As one passes westwards the 
 disease tends to disappear ; in the more densely populated 
 parts of California it reappears, but only in a very mild form 
 and with a frequency not at all comparable to what obtains 
 on the Atlantic coast. 
 
 Among the negro population the results have been 
 
58 Rickets 
 
 very disastrous, so much so that in certain great cities 
 it is stated that no negro infant escapes, while the disease 
 is frequently of a severe type. " Rickets," says Findlay 
 in the Introductory Historical Survey,* "would seem to 
 be tmknown when savage races live under natural con- 
 ditions, but exceedingly rife when these peoples dwell in 
 civilised countries, e.g., in New York, where one hardly 
 sees a negro child without some evidence of the disease. 
 The same is a striking feature here {i.e., in Glasgow). I do 
 not recall ever seeing a non-rachitic half-caste negro child. 
 It is notorious that these native races in civilised countries 
 inhabit the worst quarters of our towns." In a private 
 communication addressed to me by Dr. Clifford G. Grulee, 
 of Chicago, under date AprU, 1920, he writes, " Of interest 
 to you, probably, would be one fact which I feel confident 
 to state, and that is, that in a large experience with negro 
 babies in Chicago, I have never seen one between the ages 
 of six and eighteen months, whether breast or artificially fed, 
 that did not have very definite signs of rickets." In a 
 subsequent letter, dated May, 1920, Dr. Grulee writes, " My 
 experience with the ItaUans and Greeks in Chicago conforms 
 very well with that of yours in London. A thing which 
 strikes me forcibly is that the ItaUans and Greeks have their 
 habitat in a much warmer climate, and it is amongst these 
 races that we certainly get the largest percentage of cases and 
 also the severest types. With us the negroes, Italians and 
 Greeks form a part of the population which is confined very 
 largely to the slums, but on the other hand, among the Slavic 
 races, such as the Poles and Bohemians, rickets certainly has 
 not the tendency to be so severe, and I question whether the 
 involvement of the children of these races is so universal." 
 
 In the East end of London, where there is a very large 
 Pohsh population, my experience has been that though the 
 type of rickets is undoubtedly much less severe, the fre- 
 quency of occurrence of the disease is much the same as 
 among other slum dwellers in that area, that is, about eighty 
 
 * " A Study of Social and Economic Factors in the Causation of Rickets." 
 Medical Research Committee, National Health Insurance. London, 1918. 
 
Distribution in America 59 
 
 per cent. The Polish section of the community in the East 
 end of London is almost entirely Jewish, and the excellent 
 nutrition of these children modifies the type but not the 
 rate of incidence of the disease. In America the disease 
 has long been rampant amongst negroes. Writing in 1894, 
 Acker* states that in the towns all over the United States 
 negroes are almost without exception rachitic. Negroes 
 belong to the lowest stratum of society, and all the evil 
 influences which produce and aggravate the disease are 
 present in a concentrated form. They occupy the worst 
 quarter of the town and suffer from impure air from over- 
 crowding and want of sanitation. They are prone to 
 intemperance. Clothing is insufficient and food is scanty 
 and of poor quality. The mothers nurse their babies 
 irregularly, as many of them are in service during the day. 
 In Buffalo, Snow, discussing the incidence of the disease 
 amongst Neapolitan children, found that seven-tenths of 
 these infants suffer from rickets. 
 
 Unfortunately, no general survey has been made of the 
 disease throughout the whole country and statistics are not 
 as a rule available. Rickets in America is not, among the 
 native born, of so severe a type as in Germany, Austria, and 
 Switzerland, t and on that account probably has not excited 
 the same interest as in Europe, where its great frequency 
 and grave consequences have long compelled the attention 
 of observers. In 1899, J. L. Morse made a systematic en- 
 quiry into the incidence of rickets in 400 consecutive infants 
 under two years, who were attending as medical out- 
 patients at the Infants' Hospital in Boston. | Eighty per 
 cent, he found showed more or less marked signs of the 
 disease. In sixty-one per cent, of the children the feeding 
 was either wholly or partially from the breast — eighteen per 
 cent, wholly and forty-three per cent, partly. The only 
 factor, according to Morse, acting on all alike was im- 
 
 * " Rickets in Negroes," by Geo. A. Acker, M.D., Washington, D.C., 
 Archiv. of Pediatrics, Vol. II, 1894. 
 
 t " The Diseases of Infancy and Childhood," by Henry Koplik, M.D., 
 London, 1919- 
 
 J " The Frequency of Rickets in Infancy in Boston and Vicinity," by 
 John Lovett Morse, Boston Medical and Surgical Journal, 1899. 
 
6o Rickets 
 
 proper hygienic conditions, and these he considered were 
 the most important causes in Boston and its vicinity. The 
 rachitic rosary he found to be one of the commonest and 
 earUest and most reliable signs. Next most common was 
 delayed dentition. 
 
 This proportion, eighty per cent, of rachitic cases 
 occurring among the out-patients of the Infants' Hospital, 
 Boston, seems very large, but it must be remembered 
 that Boston is already an old city, dating from 1630, 
 and though many of the conditions prevailing in ^the 
 old town, such as tortuous and narrow streets and in- 
 sanitary houses have largely been done away with since the 
 great lire in 1872, many of the characteristics of the old 
 colonial town stiU exist. East winds are keen and cold and 
 render a climate otherwise healthy somewhat trying to 
 young infants. The concentration of population in and 
 around Boston is very great, so that in 1900 the territory 
 within fifty miles of the city contained almost three millions 
 of inhabitants — a population second only to that in the 
 corresponding area round New York. Later it will be 
 noted that Dn Grulee, of Chicago, beUeves that among the 
 poorer classes of Chicago the proportion is much the same 
 as Dr. Morse found in Boston. Prof. Hess, who has 
 devoted much attention to scurvy and to rickets in children, 
 believes that in the temperate zone the great majority of 
 children suffer from rickets. In his work on scurvy he 
 states, " In any metabolism study of infantile scurvy great 
 care will have to be exercised that the disorder is not 
 complicated by rickets. The danger of this complication 
 may be reaHsed when we bear in mind that the majority of 
 infants have rickets to some degree."* J. Lewis Smith 
 quotes some observations made by Dr. John S. Parry, of 
 Philadelphia, in 1872, who found that twenty-eight per cent, 
 of the children who came under his care between the ages 
 of one month and five years in the Philadelphia Hospital 
 suffered from rickets, f 
 
 • " Scurvy, Past and Present," by Alford F. Hess, Philadelphia and 
 London, 1920. 
 
 ■f Article on Rickets in " Ashhurst's Encyclopaedia of Surgery," Vol. 
 VII, Loudon and New York, 1895. 
 
Distribution in America 
 
 6i 
 
 The following observations are the result of an enquiry 
 addressed by me to the Bureau of the Public Health Service 
 in Washington, to the Public Health Departments of the 
 various States and to private practitioners throughout the 
 country during the year 1920. 
 
 Dr. W. H. Davis, Chief Statistician for Vital Statistics, 
 Bureau of the Census, Washington, informs me that the 
 number of deaths in the registration area of the United 
 States in 1918 was 564. This of coiurse, for reasons 
 already stated, is no criterion of the frequency of the 
 disease, but the distribution of these deaths throughout the 
 various registration areas gives a fairly accurate clue as to 
 the states in which it is most prevalent. 
 
 In order of frequency, the first six states lie wholly in 
 the eastern portion of the Union, as follows : — 
 
 Area. 
 
 Number of deaths from 
 
 
 Rickets, 1918. 
 
 Pennsylvania 
 
 93 
 
 New York 
 
 72 
 
 Massachusetts 
 
 36 
 
 Illinois 
 
 34 
 
 Michigan 
 
 33 
 
 Virginia 
 
 31 
 
 The following six states, lying wholly to the west, show, 
 the lowest mortality : — 
 
 Area. 
 
 Number of deaths from 
 Rickets, 19 18. 
 
 Utah 
 
 Montana 
 
 Colorado 
 
 Oregon 
 
 Washington 
 Califomia 
 
 
 
 1 
 2 
 3 
 4 
 6 
 
 For the sake of clearness, and to avoid reiteration, the 
 following communications from various sources have been 
 arranged in tabular form. In the absence of systematic 
 surveys these remarks must, for the most part, be taken 
 simply as expressions of personal opinions and not as 
 official statements :— 
 
62 
 
 Rickets 
 
 Locality 
 
 Observer 
 
 Remarks 
 
 Chicago, 
 
 CUfEord G. 
 
 Among poorer classes per- 
 
 Illinois. 
 
 Grulee 
 
 centage of rickets would agree 
 with statement of Dr. Morse as 
 to frequency in Boston, i.e., 80 
 per cent. Even among better 
 class, if rachitic rosary is a 
 criterion, it is present in 
 probably at least half of the 
 children. Negroes, Italians and 
 Greeks inhabit slums and suffer 
 severely. Very doubtful if diet 
 alone can cause rickets. 
 
 Milwaukee, 
 
 Geo. C. Ruhland, 
 
 Well-to-do fairly free from 
 
 Wisconsin. 
 
 Commissioner 
 
 rickets. Essentially a disease 
 
 
 of Health 
 
 of poorer districts. Particu- 
 larly frequent among foreign 
 population. Greek. Polish, 
 Russian Jew and Italian. 
 
 Newark, 
 
 Julius Levy, 
 
 Rickets very common among 
 
 New Jersey. 
 
 Director Child 
 
 negroes and Italians, develop- 
 
 
 Hygiene 
 
 ing among breast-fed as well 
 
 
 Division 
 
 as among those artificially fed. 
 Has seen disease develop 
 among negroes when feeding 
 was adequate, hygienic surT 
 roundings good. Believes that 
 defective feeding rather than 
 unhygienic surroundings is 
 cause of condition. 
 
 Baltimore. 
 
 John S. Fulton, 
 
 Concerning rickets visible at a 
 
 Maryland. 
 
 Secretary 
 
 glance, it is much more common 
 
 
 Department of 
 
 among negroes than among 
 
 
 Health 
 
 the white population. 
 
 Minneapolis, 
 
 Chas. E. Smith. 
 
 I. BeUeves rickets is less pre- 
 
 Minnesota. 
 
 Jr., Executive 
 
 valent among poor in slum 
 
 
 Officer State 
 
 areas than among well-to-do. 
 
 
 Board of Health 
 
 because the poor breast-feed 
 their babies. 
 
 2. Most of the cases, even among 
 well-to-do, are due to artificial 
 feeding. 
 
 3. Negro population is very 
 prone to rickets. 
 
 4. Type of disease not so acute 
 as in the eastern portion of the 
 Union. 
 
 JeflEerson City, 
 
 Geo. H. Jones, 
 
 Disease is of a mild type, and is 
 
 Missouri. 
 
 Secretary 
 
 more frequent among the poor 
 
 
 Bureau of Vital 
 
 in slum areas and the negro 
 
 
 Statistics 
 
 population. 
 
Distribution in America 
 
 63 
 
 Locality 
 
 Observer 
 
 Remarks 
 
 Cleveland, Ohio. 
 
 Sacrameato, 
 California. 
 
 Los Angeles, 
 California. 
 
 R. J. Ochsner, 
 CMef Bureau of 
 Child Hygiene 
 
 Irving R. 
 Bancroft, 
 Executive 
 Officer 
 State Board 
 of Health 
 
 R. J. Scott, Jr., 
 Hospital for 
 Babies, L.A. 
 
 R. E. Ramsay 
 
 Among the poor there is a, 
 moderate degree of rickets, 
 among the well-to-do some- 
 what less. Greater proportion 
 present among the Italian 
 population, still larger among 
 the negroes. 
 
 Rickets is so negligible in Cali- 
 fornia that the State Board of 
 Health has never attempted to 
 amass statistics of any sort on 
 the disease. The variety of 
 food consumed is such that 
 cases are negligible. 
 
 Has seen rickets in Italian and 
 Mexican races quite frequently, 
 less frequently among Japanese. 
 Only very rarely are even 
 slight signs seen in well-to-do 
 class. 
 
 Disease present in all classes of 
 society, but is of a milder type 
 than is seen in the Eastern 
 States. Racial factor here 
 is not so pronounced. Dis- 
 tinction between rich and poor 
 as regards means of living 
 not important, as sunlight and 
 fresh air are so generally avail- 
 able for rich and poor alike. 
 
 Records of Los Angeles County 
 Hospital during 7J years ending 
 June I, 1920, show 28 cases 
 diagnosed as rickets, 6 of these 
 being uncomplicated, while 7 
 showed rickets complicated by 
 bronchitis, otitis media, etc. 
 Parentage : 13 American, 6 
 Mexican, 2 negro and i each 
 of various nationalities. 
 
 The diagnosis of rickets in this 
 series, small as it is, rests often 
 on slender foundation, pointing 
 to the apparent mildness of 
 rachitic manifestations. The 
 small number of cases recorded 
 in this period in a great general 
 hospital, whose admissions total 
 15,000 annually, is a graphic 
 intimation of the inf requency of 
 rickets in Southern California. 
 
64 
 
 Rickets 
 
 Locality 
 
 Los Angeles, 
 California. 
 
 Montreal, 
 Canada. 
 
 Saskatoon, 
 Saskatchewan . 
 
 Observer 
 
 C. Edgerton 
 Carter 
 
 Albert L. HiU 
 
 Ezra S. Fish 
 W. V. C. Francis 
 Geo. P. Laton 
 
 J. R. Shuman 
 
 E. Gajmon 
 
 A. Wilson, 
 Medical Health 
 Officer 
 
 Kemarks 
 
 Among well-to-do thinks rickets 
 fairly common, judging from 
 occurrence of such signs as flat 
 foot and loss of health tone, 
 but without classical signs of 
 disease. 
 
 In slum areas severe cases very ' 
 infrequent, hardly enough to 
 secure good teaching material. 
 Cases showing a tendency to 
 rickets more common but still 
 not frequent. Among the 
 well-to-do, very infrequent. 
 
 Rickets not prevalent and not 
 severe. 
 
 Very rarely seen among well-to- 
 do. No slums in Los Angeles. 
 
 Greatest frequency of occurrence 
 among negro population, next 
 among the poor and least among 
 the well-to-do. 
 
 Rickets practically universal 
 among negro population re- 
 gardless of social condition. Is 
 more prevalent among the poor 
 in alien areas than among those 
 living in more favourable sur- 
 roundings. 
 
 Believes condition exists more 
 widely among well-to-do than 
 is generally supposed. 
 
 No statistics, but believes that a 
 great many cases could be 
 found if a careful examination 
 was made. Proportion of 
 severe cases not great and are 
 to be found mostly in the lower 
 grade of population among all 
 nationalities. 
 
 Rickets extremely rare in this 
 city. There is no poverty ; no 
 slums. 
 
Distribution in America 65 
 
 There can be but little doubt that rickets is a disease 
 which has greatly increased in the United States of America 
 during the last two generations. Writing in 1893, Dr. J. H. 
 Fruitnight,* of New York, states that twenty-five years 
 previous to that date rachitis was a disease but rarely 
 encountered in America. Owing, however, to the large 
 influx of immigrants and the consequent development of 
 overcrowding, analogous to what prevails in the teeming 
 centres of the old world, impure and insufficient air, lack 
 of ventilation, and want of proper exercise, have produced 
 their effects on the nation, so that to-day it has become 
 one of the most important and most common of the diseases 
 of nutrition and growth among the humbler classes of the 
 people. 
 
 It is to be regretted that no systematic survey of the 
 United States has yet been made as to the relative frequency 
 of the disease in its widely scattered and diverse environment. 
 Several facts, however, seem clear. There is no doubt that 
 rickets is an exceedingly common disease in the eastern por- 
 tion of the United States, and is met with chiefly under the 
 same conditions as in Europe, that is, in the great industrial 
 centres and especially among people who are subjected to the 
 evil environment associated with crowded slum dwellings. 
 Chicago is a town of mushroom growth. In 1830 it was a 
 viUage in the wilderness on the outskirts of civilisation. In 
 little more than the space of a long life it has grown into an 
 enormous city, with a population of 2,185,283, according to 
 the census of 1910. In spite of the facts that the streets are 
 well laid out and that its industries have developed great 
 wealth, this unnatural growth has led to overcrowding and 
 to the development of rickets to a formidable extent among 
 the population. 
 
 The standard of living is higher in Chicago than it is 
 in the great centres in Europe, and the cUmatic conditions 
 are more favourable, and the disease though very common 
 
 • " The Treatment of Rachitis with the Lactophosphate of Lime," by 
 J. Henry Fruitnight, " Trans, of the American Federation Society," Vol. V, 
 
 1893- 
 
66 Rickets 
 
 is less severe than it is in Europe. Indeed, taking North 
 America generally, if the alien immigrant population and 
 the negroes be excluded, the disease everywhere is of a 
 comparatively mild variety. As one passes westwards it 
 diminishes in frequency and severity, tUl in California only 
 comparatively slight cases are seen. In Canada the disease 
 is rare. 
 
 A striking feature of rickets in America is the universality 
 of the disease among the negroes and . the severity of 
 the form with which they are attacked. All over the States 
 the negro child is subject to the disease, so that even in 
 Los Angeles, where the climate and general conditions 
 are unfavourable to its development, Dr. J. R. Shuman 
 reports that it is practically universal among the negro 
 population. So much is this the case, that it is frequently 
 suggested that there must be some racial predisposition to 
 the disease. There is no reason to suppose that this is true. 
 Every nation seems to be subject to rickets if it be exposed 
 to the conditions necessary for its production. In South 
 Africa the native, though civiUsed and although he has been 
 associated with the white man for several centuries, has not 
 developed the disease to any appreciable extent. As already 
 noted, though the feeding among the African native races is 
 probably less adequate in South Africa than in the United 
 States, the conditions as regards overcrowding and defective 
 housing hardly exist when contrasted with what pertain in 
 the great cities of America. 
 
 In Jamaica rickets seems a rare disease among the 
 coloured children. Here the conditions as regards feeding 
 would all seem favourable to the early development of rickets. 
 The children are nursed by the mothers for periods varying 
 from six months to twelve months. At a very early date 
 this is combined with starchy pap. As soon as they are 
 weaned the diet consists of rice, bread, potato, yam, banana, 
 casava, corn starch, etc. Most of these foods contain from 
 sixty to seventy per cent, of starch in the dry state. The diet 
 is poor in protein and fat and is rich in starch, the type of 
 diet which in England and Europe is constantly blamed for 
 
Distribution in America 67 
 
 the production of rickets. In Kingston, the capitalj the 
 census of 1911 showed a population of 57,379, mostly 
 negroes. In Jamaica generally only two per cent, of the 
 population is white. Here, as elsewhere, the negro is 
 improvident. It is difficult to get him to work more than 
 four days a week, for so much labour supports him in comfort. 
 Sixty per cent, of the births are illegitimate, and such a state 
 of affairs, as is well known, is not conducive to the careful 
 nurture of the child.* And yet rickets does not develop. 
 Jamaica hes well within the tropics, between 17° 43' N. and 
 18° 32' N. and 76° 10' W. and 78° 20' W. The climate is 
 one of the chief attractions of the island. Near the coast it 
 is warm and humid, but that of the uplands, which occupies 
 two-thirds of the island, is delightfully mild and equable. 
 
 In Kingston the climate is dry and healthy, the tempera- 
 ture ranging from 93° to 66° Fahr. The natives hve in close 
 huts in many cases, it is true, but the great secret of their 
 immunity is found in the fact that the whole day is spent 
 in the open air in warm sunshine and a benign atmosphere. 
 Natives all over Africa and Asia tend to live in crowded 
 and confined quarters in huts at night, but this has but little 
 effect on the offspring, for the day begins with the sun and 
 ends with its setting. The whole of the day is spent in the 
 open, under the most favourable conditions as regards fresh 
 air, free ventilation and sunshine, and where such circum- 
 stances prevail rickets cannot arise. The sleeping conditions 
 are akin to what is found in the life of the wild animal. The 
 mother with her young sleeps in close and confined quarters, 
 in her burrow, but rickets never develops. Immediately, 
 however, the young animal is removed from its natural 
 habitat and is placed in confinement, and is deprived of 
 sunshine in close and restricted quarters the disease tends 
 to appear. Rickets remains the scourge in zoological 
 gardens to-day, very much as it has been in the past ; con- 
 finement, in the case of wild animals, is only a relative term^ 
 
 * " Observations upon the Coloured Children of Jamaica, with especial 
 reference to Rickets and to Mongolian Spots," by A. E. Vipond, Archiv. 
 of Pediatrics, Vol. XXV, 1908, p. 503. 
 
68 Rickets 
 
 Deer confined in a park, no matter how commodious, are 
 seldom in the same condition as the animal in its native 
 state. The limbs, as a rule, are clumsy and the joints tend 
 to be thickened. The coat is long, coarse, and shaggy, and 
 the speed and power of sustained action in running are much 
 impaired. 
 
 If the young infant from Jamaica were removed to one 
 of the great cities of the United States, and Hved under the 
 same conditions that the negro population generally does, 
 no matter what quality of food was given, rickets would 
 certainly develop. 
 
 In speaking of rickets in Los Angeles, in Cahfornia, Dr. 
 Ramsay shrewdly remarks that the disease is present in a 
 mild form in all classes of society, but that the racial factor 
 and the distinction between rich and poor are not so im- 
 portant here as elsewhere. Slums are not common, and 
 sunlight and fresh air are available for all and for rich and 
 poor ahke, so that variations in feeding and the amenities of 
 Ufe have not the same effect as they would have were the 
 child brought up in damp and overcrowded surroundings, 
 deprived of sunhght and fresh air, and exposed to a foul 
 and vitiated atmosphere. 
 
 It is not, of course, implied that over any large area of 
 the world's surface there is a total and complete absence of 
 rickets. It is probable, when a complete survey is made 
 of the world distribution of rickets, and the disease is 
 systematically looked for, that it will be found in many 
 parts where its presence was not previously suspected. 
 Thus, in Austraha the disease is of a very mild form, and, 
 as has already been noted, but for the systematic inspection 
 of school-children, actually looking for traces of the disease, 
 the probability is that its presence would have been entirely 
 overlooked. In the adult there would be no traces in the 
 skeleton and but few in the teeth, for in the Australian-born 
 hypoplasia seems to be quite uncommon, and the medical 
 man in the course of general practice would not be likely 
 to come in contact with the condition or to be struck by 
 its presence. 
 
Distribution in America 69 
 
 It cannot, however, be argued that the disease even 
 , in a mild form is of no importance. It leads to much 
 secondary disease ; it affects the growth of the whole body 
 and especially of the delicate nervous system ; it leads to 
 the development of enlarged tonsils and adenoids, and these 
 are quite common conditions in Austraha. The recognition 
 of its presence is of prime importance to the public health 
 authorities, in so far as it points to the direction in which 
 the development of town conditions is becoming dysgenic 
 in a new country, and in older European countries, to the 
 steps which must be taken to free the young from the vicious 
 circle which surrounds them in infancy at the most active 
 period of growth, and at the time when they are most help- 
 less and most susceptible to morbid influences. 
 
 The probability is that when carefully looked for traces 
 of rickets will be discovered in every part of the world, 
 but that is not likely to alter the fact that over a great 
 portion of the globe's surface its presence is so infrequent, 
 and the type of disease so slight, that it is of relatively no 
 importance. Thus, it can be taken as a general statement 
 that in Egypt, Algeria, Morocco, West and East Africa, 
 Central Africa and South Africa, in other words, over the 
 whole continent, and throughout India, China, and Japan, 
 rickets is almost non-existent at the present time. The fact 
 that Prof. Marfan * saw among a troupe of natives from 
 Senegambia, who were being exhibited in Paris, a negro boy 
 of three or four years of age who exhibited marked signs of 
 rickets in the enlargement of the epiphyses, rachitic rosary, 
 and knock knee, does not alter the general statement. From 
 what is known of the development of rickets among negroes 
 in the United States of America, it would not be a matter of 
 surprise if, in the long reaches of the Senegal River, natives 
 were found who lived under such conditions that rickets 
 occasionally developed ; that would not alter the fact that 
 within the tropics it is an extremely rare disease. In this 
 case it may quite well be that the child suffered from acute 
 rickets developed during the course of the voyage and the 
 
 * Marfan, " Maladies des Os," Paris, 1912. 
 
7° Rickets 
 
 sojourn in Europe. Nor does it alter the fact, which has 
 an important bearing on the aetiology of the disease, that no 
 matter what the conditions are as regards food and the 
 feeding of the infant, rickets does not develop within these 
 regions. 
 
CHAPTER VI 
 
 Food in relation to tlie Geogrraphical Distribution of 
 
 Rickets 
 
 The rise of the earlier civilisations has already been touched 
 upon, and the explanation as to why these peoples advanced 
 while others remained stationary has been referred to the 
 fertility of the soil and to the genial climate allowing of the 
 supply of a cheap and abundant national food. This led to 
 an accumulation of wealth and to the development of a 
 leisured and intellectual class, which was able to devote 
 itself to extending the boundaries of knowledge. Unfor- 
 tunately this ease of production was not, and never has 
 been, entirely beneficial, for it led to a cheap labour market, 
 an unequal distribution of wealth and power, and to the 
 development of slave labour on a scale which the world has 
 never seen equalled. 
 
 But not only have abundance of food supply, genial 
 climate, and easy methods of distribution been important 
 agents in the development of old civilisations in past ages. 
 They .remain to-day potent influences governing the health 
 and physical and mental growth of nations. In the East 
 the inhabitants adapted themselves with ease to the mild 
 conditions imposed by beneficent physical features and a 
 warm climate, but in the colder temperate zones the fruit of 
 the soil, and still more, animal foods, were only acquired 
 with difficulty and after long and strenuous toil. But the 
 very stress brought to bear on these later civilisations, has 
 had a most beneficial effect on the peoples so influenced, 
 and has allowed of a rapid development, especially during 
 the nineteenth and twentieth centuries, such as never could 
 have taken place under the conditions affecting these older 
 nations. 
 
 In still colder climates, north of the temperate zone, the 
 struggle for the means of subsistence is so severe that it 
 practically fills the life of the individual, and the Laplander 
 
 71 
 
72 Rickets 
 
 and the Eskimo have but little time and less inclination for 
 the pursuit of purely intellectual progress. In tropical 
 regions, as has already been noted, the food is mainly 
 derived from the vegetable kingdom, with but little ad- 
 mixture of animal food, leading to a low protein and fat 
 value and a considerable excess of carbohydrate. In 
 temperate climates the diet is highly azotised, and is derived 
 from both the animal and vegetable world, while in still 
 colder climates the food is chiefly derived from animal 
 sources with an abundant supply of fat. At one period of 
 his existence man lived upon raw materials unaltered by the 
 chemical and physical changes produced by cooking, but 
 to-day food is everywhere used more or less cooked. 
 Following the eating of raw materials there was a period 
 when man cooked his food, but did not cultivate vegetables 
 nor rear animals for food. During this period the vegetable 
 world was the main source of supply, as this class of food 
 was more easily obtained than the product of the chase. 
 In modern times the bushman of South Africa and the 
 aborigines of Australia had not advanced beyond this stage. 
 No extracts of chemical substances such as sugar were 
 made, and such natural products as honey were therefore 
 greatly prized. This was followed by a stage in which man 
 cultivated vegetables and reared animals for food. 
 
 Wheat was probably first cultivated in Mesopotamia, and 
 bread making appears to have been known to the Chaldeans 
 and Egyptians some 3,000 years before Christ. Rice was 
 cultivated in China about the same period, and was introduced 
 into India by the Aryan invasion. From India it passed 
 into Europe with the army of Alexander the Great, in 
 334 B.C., and was carried from Europe to America in the 
 fifteenth or sixteenth centuries. Maize, on the other hand, 
 was first cultivated in America by the ancient inhabitants of 
 Peru and Mexico, and was brought by the Spaniards to 
 Eiirope, and its culture is now practicaUy universal. Millet 
 was cultivated from very ancient days in Africa and Asia, 
 and even in the Stone Age its culture had extended into 
 middle and southern Europe. 
 
Food in relation to the Distribution of Rickets 73 
 
 The development of tropical medicine within the 
 present century has shown the immense importance of 
 the study of the food factor in diseases affecting these 
 regions. Beri-beri has now been demonstrated to be, what 
 has been well termed, a deficiency disease affecting rice- 
 eating peoples. In the tropics by far the most important 
 article of diet is rice. It is calculated that it forms the staple 
 food of some 400,000,000 Indians, Chinese, Japanese, and 
 Malays.* It is a grain of comparatively poor nutrient value, 
 being very deficient in nitrogenous substances, fats and salts, 
 and exceedingly rich in starch. Taking the six chief grains — 
 wheat, barley, rye, oats, maize, and rice, Parkes found that 
 rice was the richest in starch and the poorest in azotised 
 substances, fats and salts. According to Castellani, rice 
 eating began in the over-population of Eastern Asia, leading 
 to food difficulties and the great movements of peoples. 
 Rulers invoked the aid of religion, and meat, which was 
 scarce, was forbidden. To this day these religious principles 
 are still in force, and the people avoid the use of animal 
 food though the need for the enforcement of these enact- 
 ments has largely passed away. Fats and oils among these 
 people are not easily obtained, and ghee, for instance, in 
 India, which is butter made from Indian buffalo milk, and 
 clarified to resemble oil, is a luxury which is much prized, 
 but which is not often within the reach of the common 
 people. McCayt investigated the dietary of primitive peoples 
 in Chota Nagpur, in Bengal, and gives the following estimate 
 of their diet in food values. For purposes of comparison 
 this has been placed alongside a " mean " dietary constructed 
 from various sources. | 
 
 Daily diet of people in 
 Chota Nagpur (McCay). 
 
 Daily diet for a man 
 in ordinary work. 
 
 Proteins ... 
 
 Fats 
 
 Carbohydrates 
 
 80 grammes 
 300 „ 
 
 122 grammes 
 100 „ 
 332 
 
 • " Manual of Tropical Medicine," Castellani & Chalmers, London, 1919. 
 t McCay, D., Indian Medical Gaietie, XLII, 1907, p. 370. " Scientific 
 Memoirs," Govt, of India, Nos. 34, 37. and 48. 
 
 1 " Food in Health and Disease," by J. Bumey Yeo, London, 1893. 
 
74 Rickets 
 
 McCay has shown that where the protein standard of a 
 tropical diet is very low, the physique, capacity for work, 
 health and resistance against disease are all lowered, as in the 
 rice-eating Bengali. What is true of Bengal is true of 
 England, and on protein depend muscular power, physical 
 endowment, powers of endurance and resistance to disease. 
 Too little protein affects the growth of the Bengali boy, so 
 that he grows up slender and defective in vigour and 
 vitahty. Loss of weight, anaemia, debihty and prostration 
 are exceedingly common and produce a high mortaUty, for 
 young subjects bear starvation badly. Not infrequently the 
 digestive functions are so degenerated from want of use that 
 when a sufficiency of nutriment is given the system cannot 
 utihse it. These badly nourished children suffer greatly 
 from a cachectic condition associated with wasting and 
 chronic diarrhoea, but rickets is not a common disease, as 
 one would certainly expect it to be if the dietetic factor, and 
 especially deficiency of fat, were the determining cause of 
 rickets. 
 
 McCarrison has made some interesting observations on 
 the people of the State of Hunza, situated in the extreme 
 northernmost part of India.* They live a life of much hard- 
 ship, owing partly to the scanty supply of food and partly to 
 the severity of the winter in that part of the Himalayas. Their 
 huts are of the most primitive kind. So limited is the food 
 supply that McCarrison notes these people are not able to 
 keep dogs. There is no dairy produce and the food consists 
 of grains such as wheat, barley and maize, and an abundant 
 supply of apricots. Yet with this limited dietary the people 
 are long-lived and are but little subject to disease, and the 
 children are well developed. 
 
 The inference McCarrison seeks to draw is that the diet 
 contains the vitamins necessary for healthy growth. Such 
 an explanation will not bear examination. Compare the 
 lot of the infant and child brought up under these rigorous 
 conditions with that of the child of the mill-worker 
 in Oldham, in Lancashire, or of the collier in any of our 
 * " studies in Deficiency Disease," by Robert McCarrison, London, 1921. 
 
Food in relation to the Distribution of Rickets 75 
 
 great coalfields. In variety and quantity of food the home 
 child fares better than the native, for these workers live well 
 and do not stint themselves as regards food. The general 
 impression that the native child is nourished on an ample 
 supply of wholesome breast milk does not, as has been 
 shown in the case of the Indian native elsewhere, agree 
 with the facts of the case. Prolonged lactation and the 
 early addition of starchy foods are common faults in 
 India and all over the East, and in the State of Hunza there 
 is but little dairy produce to make good any deficiency. Yet 
 rickets is rampant in Oldham and in the colliery districts, in 
 spite of the fact that malt and cod-liver oil are freely ad- 
 ministered to these aihng children, while in India the disease 
 is absent. 
 
 The essential difference is in the environment. The 
 native lives the life of a wild animal, in touch all day with 
 the vivifying forces of nature, fresh air and sunlight, and 
 engages in abundant exercise. The young infant is 
 allowed to crawl at will in the open. The hut is a place of 
 shelter but not of habitation. The child of the slum 
 dweller at home lives for from eighteen months to two 
 years in the vitiated atmosphere of a close and crowded 
 room ; it is surrounded by mean streets and houses, in the 
 midst of a great industrial centre, where all wholesome 
 environment that makes for health is excluded. 
 
 Generally throughout India rice is the staple article of 
 diet. Two varieties of rice are in use in the East : (1) Indian 
 or country rice or paddy, usually described as unpolished ; 
 (2) Burma or white rice, usually described as polished. 
 
 It has been estabhshed that it is to the removal of the 
 germ and pericarp, which contain the essential necessary 
 food factor, in the process of polishing of the grain, that the 
 deficiency disease beri-beri is due. It must be remembered 
 that a rice diet is exceedingly low in fat value, and that 
 among these peoples the use of animal fats is greatly 
 restricted. From the point of view of the geographical 
 distribution of rickets, it is important to observe that among 
 the enormous population of rice-eating peoples rickets is for 
 
j€> Rickets 
 
 all practical purposes unknown. Such people subsist on a 
 diet of low nutrient value, especially as regards protein and 
 fat and even that not constantly ensured, for they live ever 
 on the verge of starvation. Every known error in the 
 rearing of the young infant which is usually blamed for the 
 production of rickets in England is prevalent to an enormous 
 extent. The mortality in infancy is high and the incidence 
 of intestinal affections is very great, but rickets does not 
 result. Such facts are wholly against the theory which has 
 for long been accepted by most writers, that the dietetic 
 factor is the cause of rickets. 
 
 For many years deficiency of fat has been blamed for the 
 production of the disease on veiy slight evidence. Lately, it 
 has been claimed that absence of fat-soluble A, or an accessory 
 / food factor associated with the fats, is the essential cause 
 ' of rickets, while yet another school blames excess of food, 
 and especially of carbohydrates, and a badly balanced diet. 
 The consideration of the geographical distribution alone 
 clearly proves that the food factor is not the cause of the 
 disease. In so far as rickets is a disease of nutrition the 
 quahty and the quantity of the food undoubtedly have an 
 important bearing on its progress, just as it has in tuber- 
 culosis or any other morbid condition associated with 
 debihty and wasting. 
 
 It is well known that a very large number of chemical 
 bodies can be dissolved in the fluids of the body, producing 
 varying effects, but it is a matter of common experience that 
 certain substances are essential to the continuance of proper 
 nutrition, and that the continued abstraction of these from 
 the diet causes ill-health, and in the end death. These 
 substances are oxygen, water, proteins, fats and carbo- 
 hydrates, to which must be added certain mineral matters 
 and salts. In the continued absence of any one of these 
 constituents the body is unable to keep up normal tissue 
 change, and especially to maintain healthy growth, and the 
 prolonged absence of any one constituent from the food 
 inevitably causes death. But certain conditions are known 
 in which all these substances may have been supplied in 
 
Food in relation to the Distribution of Rickets 77 
 
 adequate quantity and yet nutrition becomes seriously im- 
 paired. In beri-beri there is an absence of a necessary food 
 factor which, while not actually required for the building 
 up of the cell in the same way as are the proteins, fats, and 
 carbohydrates, is yet essential for the maintenance of health 
 and even of the Hfe of the individual. This substance, 
 which is known as the anti-beri-beri or anti-neuritic factor, 
 is probably identical with water-soluble B, although it has 
 not yet been isolated in a pure condition. It is exceedingly 
 widespread in its distribution, and has been found in all the 
 natural foodstuffs examined at the Lister Institute, including 
 wheat germ, wheat bran, rice germ, yeast, peas (dried), 
 lentils, egg yolk, ox liver, beef muscle, and potatoes. It is 
 found in varying proportions. 
 
 Another conspicuous example of a deficiency disease 
 is found in Barlow's disease. In 1883, Sir Thomas Barlow 
 published the results of an analysis of thirty-one cases of 
 what he believed to be infantile scurvy. It will be seen later 
 that the disease, infantile scurvy, was first described by 
 Francis Glisson, in 1650, in his classical description of 
 rickets. Not only did he describe the disease, but he 
 defined the position of scurvy in relation to rickets, and 
 maintained that infantile scurvy was an entirely inde- 
 pendent condition, but that the two diseases were frequently 
 associated together. In 1894, Barlow again discussed the 
 relationship of infantile scurvy and rickets* and expressed 
 his belief that these were cases of true scurvy due to in- 
 adequacy of " living " food reacting on a child with a 
 rickety basis. The disease is of sudden onset, and may 
 come on at any period after four months, but chiefly occurs 
 between nine and eighteen months. The child is generally 
 rickety, but is fairly well clothed so far as subcutaneous fat 
 is concerned. From its common association with rickets 
 it was known as scurvy-rickets.. The symptoms and signs 
 are well marked, consisting of anaemia, haemorrhage from 
 the gums, extensive sub-periosteal hsemorrhages and intense 
 
 * " The Bradshaw Lecture on Infantile Scurvy and its Relation to 
 Rickets," by Thos. Barlow, British Medical Journal, Nov. loth, 1894. 
 
78 Rickets 
 
 pain in the bones and joints, so that the child fears the 
 shghtest movement. The names of scurvy-rickets and acute 
 rickets, which are applied to this disease, are unfortunate in 
 so far as the condition is one of true scurvy, which may or 
 may not occur in association with rickets. Barlow's disease, 
 unlike rickets, is not a disease of the poor ; indeed, it 
 chiejdy occurs among children who are well cared for, and 
 whose state of nutrition is good so far as fat and weight are 
 concerned. It does not occur in breast-fed children, differ- 
 ing again from rickets, which very frequently occurs in 
 children suckled at the breast. It chiefly arises in infants 
 of the better class who have been kept rigidly on one 
 proprietary miUs food, especially such as are mixed with 
 water or with condensed mUk, or who have been kept for 
 long periods on condensed milk alone, or pasteurised or 
 steriUsed cow's milk. In using the term " living " food, 
 Barlow adumbrated our present knowledge, which shows 
 that the disease is due to the absence of an accessory food 
 factor from the diet which is found in fresh meat and vege- 
 tables, and in natural unboiled milk and in fresh fruit juices. 
 Barlow's disease and scurvy are now generally believed to 
 be due to a deficiency of an accessory food factor named 
 the anti-scorbutic factor. This appears to be a crystalline 
 substance, capable of being destroyed at 120° C. or less. It 
 is found in fresh potatoes, onions, cabbages, apples, lemons, 
 limes and lime juice. It appears to be less stable than the 
 anti-nemritic factor and is only found in the fresh condition 
 of the vegetables and other foods. The condition is so 
 distinctive that for many years now it has been a well 
 recognised disease, but neither Barlow's disease nor ordinary 
 scurvy is a common condition in this country. A physician 
 may be in busy practice among the working class in the 
 East end of London for several years and may never meet 
 with a case of true scurvy. Probably, as has already been 
 suggested, the universal use of the potato is largely re- 
 sponsible for the comparative immunity of the country from 
 this disease at the present day. 
 
 In Europe there is only one nation which possesses a 
 
Food in relation to the Distribution of Rickets 79 
 
 cheap national food at all comparable with that possessed 
 by the great rice-eating nations of Asia or the date-eating 
 races of Arabia and Egypt. That nation is the Irish. In 
 Ireland the labouring classes have for more than two hundred 
 years been principally fed on potatoes, which were introduced 
 into this country late in the sixteenth or early in the seven- 
 teenth century. The potato contains very little nitrogen and 
 scarcely any fat. In former days the Irishman of the west 
 country drank largely of buttermilk, but this has to a great 
 extent been given up since the introduction of separated milk, 
 and tea has been substituted. Bread is also more largely 
 used than before. Formerly the only " meat " used, and that 
 only occasionally, was imported American bacon, but there 
 has been a tendency of late years to eat butcher's meat. The 
 potato remains the staple article of diet. In the west of 
 Ireland, and indeed over much the largest part of Ireland, 
 rickets is conspicuously absent, while in the wealthy and 
 prosperous industrial centre of Belfast, where the people are 
 thrifty and provident and the food is both varied and 
 wholesome, rickets is extremely prevalent. Among such a 
 people as the west country Irish, had there been any truth 
 in the theory that the cause of rickets was the absence of 
 fat-soluble A or some accessory food factor associated 
 with the fats, one would have expected to find it there. 
 
 The vitamin theory of disease is a fascinating one, and is 
 one of those facile hypotheses which will explain anything. 
 " The conception that vitamins provide the cells of the body 
 with the capacity — one might almost say the will — to work, 
 has this great merit, that it provides a working hypothesis 
 on which to found our treatment," says McCarrison, in an 
 important paper on the subject. " We should not," he con- 
 tinues, " restrict our vision of deficiency disease to such 
 ailments as beri-beri, rickets, and scurvy — conditions so 
 obvious and so severe that we cannot well overlook them — 
 we should consider every state of ill-health from this point 
 of view, so that we may be in a position to rectify nutritive 
 errors and to provide the body cells with the requisite 
 materials to enable them to fulfil their functions efficiently." 
 
8o Rickets 
 
 In the same paper difficulties are suggested. It is noted 
 that in monkeys, where the protein intake is adequate and 
 in proper proportion to carbohydrates and fats, the onset of 
 symptoms due to lack of vitamins is much longer delayed 
 and the loss of weight is not excessive, but where the 
 deficiency of vitamins is associated with great excess of 
 carbohydrates and still more with excess of fats, the onset of 
 symptoms is rapid and the loss of weight is great. In other 
 words, a properly balanced diet which contains a due and 
 proper share of all the constituents necessaty for the build- 
 ing up of the body is essential, not because it supplies 
 vitamins which are missing, but because it supplies the 
 necessary protein and fat — ^notably the protein — ^which tend 
 to be deficient in the diet of the poor. It is a matter worthy 
 of note that it is of little use giving malt and cod-liver oil to 
 young children who are suffering from lack of food. For 
 some years now malt and cod-liver oil have been supplied 
 fairly freely in many of the London County schools to 
 poorly fed children, with but very indifferent results. What 
 is of much greater help is a fair supply of milk, and if 
 this could be given twice daily in aU schools, half a pint in 
 the morning and half a pint in the afternoon, the greatest 
 benefit would result. Fat-soluble A, the name given to the 
 third factor, is also termed the growth factor. To the 
 absence of this substance, or some substance with a similar 
 distribution, the disease rickets is stated to be due. The 
 probability is that this statement is entirely erroneous, and 
 that while rickets is a disease of malnutrition, like most other 
 diseases, and the quahty and quantity of the food will 
 naturally materially affect its progress, that there are no 
 conditions of diet which will actually originate it. Rickets 
 has a superficial resemblance to scurvy, but has absolutely 
 no causal relationship with it, nor can it rightly be placed in 
 the same class as a deficiency disease. 
 
 Drummond* states that fat-soluble A is synthetised by 
 plant hfe and is present in most green leaves and in the 
 embryos of certain cereals. Such foodstuffs contain the 
 
 * " Some Aspects of Infant Feeding," by J. C. Drummond, Lancet, 
 Vol. n, 1918, p. 482. 
 
Food in relation to the Distribution of Rickets 8i 
 
 primary sources of the factor for the animal organism, 
 which apparently does not possess the power to synthetise 
 it. In the embryos of seeds this substance occurs in loose 
 combination with protein, but when liberated, as it is during 
 digestion, it shows similar solubilities to the fats and lipoids 
 and accompanies these substances during absorption. The 
 exact part this factor plays in the metabohsm of the body is, 
 Drummond states, quite unknown, but it is believed that a 
 liberal supply is necessary for the growing animal. When 
 formed in excess the factor is stored as depot fat or in 
 association with it. It is stated that young animals, when 
 deprived of this factor in their diet, do not show immediate 
 signs of disease, because the organism draws on its store 
 contained in this reserve supply. In the new-born infant, 
 as win be seen later, this is an entirely erroneous obser- 
 vation. Fat is a tissue which is conspicuously absent 
 in the new-born — ^indeed the deposit of fat in the sub- 
 cutaneous tissue in large amount and the signs of rickets 
 frequently appear in the infant at the same time, some six 
 or nine months after birth. 
 
 The following table shows the distribution of these 
 accessory food factors in various foodstuffs : — 
 
 Foodstuff. 
 
 Milk 
 
 Butter 
 
 Cream 
 Separated Milk 
 
 Egg yolk 
 
 Egg white ... 
 
 Beef fat 
 
 Lard... 
 
 Margarine 
 
 Vegetable oils 
 Cod-liver oil 
 Wheat (whole grain) 
 Rice (polished) 
 White bread 
 Wholemeal bread ... 
 Cabbage (fresh) 
 
 Spinach 
 
 Oranges 
 
 Onions, Apples 
 Lemon juice 
 
 Fat-soluble A. 
 
 + + 
 
 + -h -I- 
 
 + + 
 
 -I- + + 
 
 + ■ + 
 
 + + + 
 + 
 
 -I- 
 -I- + 
 + + 
 
 Water-soluble B 
 
 or anti-beri-beri 
 
 factor. 
 
 + + 
 
 + 
 + + 
 
 + + 
 
 + + 
 + 
 + 
 
 Water-soluble C 
 
 or anti-neuritic 
 
 factor. 
 
 -f- 
 
 + ? 
 
 + 
 
 J 
 
 ? 
 
 + + 
 + + 
 
 + + 
 + + 
 
 -I- 
 -I- 
 -I- 
 + 
 + + 
 
 4- = rough content value ; — = absence. 
 
82 Rickets 
 
 Particularly noteworthy is the statement that lard is of 
 no efficacy as regards the supply of the growth factor. 
 This is in conflict with all chnical experience. The 
 administration of bacon fat to the young child has been 
 found one of the most efficient and most digestible methods 
 of introducing fats. For centuries in Europe, throughout 
 the Middle Ages, the pig was almost the sole source of meat 
 used by the common people. 
 
 In experiments on animals no mention is made, as a 
 rule, of the manner of supplying fats in the diet. The 
 method of administration of fats is clinically of the 
 first importance in infant welfare centres. It must be 
 remembered that the milk of the mother is a most perfect 
 emulsion and one which does not readily separate out. 
 Underfed infants in welfare centres do not digest fat well 
 unless it is very perfectly emulsified, and the great success 
 of many of the patent preparations is largely due to the 
 very perfect degree of emulsion which has been produced 
 by mechanical means. Emulsification by hand by means 
 of tragacanth is not nearly so efficient. No record of the 
 value of the various fats in the metabolism is of much 
 use unless the method of administration is given in careful 
 detail. 
 
 The statement that certain diseases are due to the 
 absence of important accessory food factors, other than the 
 ordinary constituents of the food used in the building up of 
 the cell, is now passed beyond the stage of mere theory and 
 is accepted by nearly all as the actual cause of scurvy and 
 beri-beri. But extravagant claims have been made as a 
 result of these discoveries, and it has been suggested that 
 practically aU disease has its origin in this one factor. 
 Suggestions have even been made to hasten forward legisla- 
 tion for the regulation of foodstuffs on grounds which must 
 be considered wholly insufficient to warrant any such 
 drastic measures. Extravagant dietaries are prescribed for 
 children on the strength of ill-considered newspaper articles, 
 and raw vegetables, raw salads and raw fruits are frequently 
 given to children to the exclusion of meat and more easily 
 
Food in relation to the Distribution of Rickets 83 
 
 assimilable mixed diets, not with the idea of giving to the 
 body the constituents necessary for its nutrition and growth, 
 but to supply hypothetical vitamins. 
 
 Nature is a tolerant mother and children thrive under 
 food conditions which would often seem to be attended 
 with the gravest risk. The best results are not obtained 
 by these eccentric diets. Experience has shown that it is 
 well, especially in the case of children, to throw the net as 
 widely as possible and to include all the varied articles of 
 diet, both animal and vegetable, for which mankind is 
 adapted. Meat and fish are from a very early date essential 
 constituents of the dietary if the best results as regards 
 growth and physical and mental development are to be 
 obtained. As has already been pointed out, in tropical 
 countries where the diet is frequently greatly restricted to 
 one article, such as rice, the danger of the onset of deficiency 
 disease is a real one, but it has yet to be shown that with the 
 immensely varied diet of even the poorest in England, that 
 a deficiency of vitamins is a factor of importance in the 
 production of disease. 
 
 In the case of rickets, the evidence supporting the 
 claim that it is a deficiency disease due to diets, which 
 are unbalanced in that they contain too little of those 
 substances rich in a so-called anti-rachitic factor, which 
 is either identical with fat-soluble A, or has a similar 
 distribution, and too much of those substances deficient 
 in this respect,* is still entirely wanting, and there are 
 many facts, as will be seen in discussing the aetiology of 
 the disease, which tend to disprove any such connection. 
 According to this view, it will be noted that an unbalanced 
 diet is one deficient in vitamins, differing from the old 
 accepted view of an unbalanced diet as one in which the 
 proportion of the great food factors, proteins, carbohydrates, 
 fats, water, and salts, is badly balanced and insufficient to 
 support the demands of the normal metabolism and growth 
 of the body. 
 
 * " Report on the Present State of Knowledge concerning Accessory 
 Food Factors," Medical Research Committee, London, 1919, p. 91. 
 
84 Rickets 
 
 The amount of these hypothetical substances required 
 for the proper growth of the body is apparently extremely 
 small, and even experimentally, and with the most complete 
 laboratory methods it is extremely difficult to exclude them 
 from artificial diets.* Again, they are exceedingly widely 
 spread throughout the vegetable and animal kingdoms, and 
 it is difficult to believe that in the ordinary child's diet, where 
 the complaint is usually made that the child eats anything 
 and everything from the table, that the loss of a vitamin or 
 vitamins is a common existing cause of disease in this 
 country. It is not of course claimed that the diet for the 
 child in England, and still less in Europe generally, is 
 adequate or that ignorance in the rearing of the young infant 
 does not exist. But it might reasonably be expected that 
 such diseases would be prevalent among those nations where 
 the diets were restricted mainly to one staple article, such as 
 rice, and where such ignorance was much more common 
 than at home. When it is claimed that deficiency of fat, 
 or of some active principle commonly associated with fat, is 
 the actual exciting cause of rickets, it is difficult to reconcile 
 this with the almost complete absence of the disease from 
 rice-eating nations, who constitute the majority of the people 
 on the globe's surface, and from such a nation as the Irish, 
 who live largely on potatoes, where the fat content of the 
 diet is conspicuously low. 
 
 That many bodies exist in the milk of the mother, apart 
 from the constituents actually necessary for the building up 
 of the tissues of the child and for the supply of energy, has 
 long been considered probable. It is difficult to explain 
 otherwise the comparative immunity which the breast-fed 
 child enjoys from the ordinary zymotic diseases, than by the 
 action of some ferment conveyed in the milk conferring on 
 the child an immunity which the mother herself has 
 acquired. 
 
 Like all who claim that the food factor is the essential 
 cause of rickets, McCarrison notes that environment plays 
 an important part, want of fresh air and sunlight hastening 
 
 • Loe. cit., p. 13. 
 
Food in relation to the Distribution of Rickets 85 
 
 that functional depression of cells initiated by the vitamin 
 deficiency. In this factor of faulty environment lies not only 
 an important part but the essential agent in the production 
 of rickets, without which the disease cannot be produced. 
 It is the one constant common factor which explains 
 the history of its development as a national disease, the 
 age at which it occurs in the individual child and its 
 very definite geographical distribution. As will be seen 
 more fuUy later, the constant conditions which are present 
 when rickets is prevalent are : (1) the breathing of a vitiated 
 atmosphere in close and confined dwellings ; (2) the 
 exclusion of sunlight ; (3) the lack of opportunity of 
 exercise ; (4) damp climates and long winters, notably in 
 the colder northern temperate zones. 
 
 Where such conditions prevail rickets will develop in 
 spite of the best of breast feeding. These evil factors 
 produce their chief effect in the young infant immediately 
 it begins to lead a separate existence after birth, at a time 
 when fresh air and free oxygenation of the blood are most 
 essential. Under such circumstances nature rapidly 
 produces the lymphatic rachitic child, with shallow, quick 
 breathing, holding in strict reserve all its activities, so that 
 no undue demands are made for fresh air and sunshine and 
 abundant movement, which are all so essential to the proper 
 growth and development of the young iiifant. 
 
 Among Asiatic peoples there is an ignorance of the 
 ordinary principles of healthy infant feeding, as we under- 
 stand them, which exceeds anything which can be found in 
 Europe. Lactation is prolonged and the addition of starchy 
 pap at any early period to the diet is the rule. Gastro- 
 intestinal infections are intractable and severe and produce 
 a high mortality ; marasmus and deaths from starvation are 
 quite common, but for all practical purposes rickets is absent. 
 On the other hand, rickets is almost wholly confined to a 
 comparatively narrow belt running across America and 
 Europe — a zone which is the wealthiest in the world and 
 into which all the richest and choicest products of the 
 earth are poured in their natural state. To-day, the child 
 
86 Rickets 
 
 and the wife of the collier live on a dietary much greater in 
 food value and more extensive in variety than did even the 
 wealthy of say three hundred or four hundred years ago. 
 Notwithstanding, rickets is rampant among the colliers' 
 children to-day, while in these older times it was hardly 
 known, if the evidence from the examination of the teeth, 
 jaws and skeletons of ancient burials is to be believed. 
 
 There is no true race degeneracy, but, at the same time, 
 the concentration of enormous populations in large towns in 
 defective dwellings in slum areas, has led to the development 
 of aberrations and modifications of growth which have a 
 wide effect on the commimity, producing much secondary 
 disease and preventing the attainment of the normal standard 
 both as regards physical and mental development, which 
 might reasonably be expected if better conditions prevailed. 
 
CHAPTER VII 
 
 The Early Signs and Symptoms of Rickets 
 
 Sir William Jenner, in his well known lectures on rickets, 
 delivered at the Hospital for Sick Children, Great Ormond 
 Street, in December, 1859, prefaced his remarks by describing 
 in detail four great diathetic diseases of children, viz., 
 rickets, tuberculosis, scrofulosis and syphilis.* By the term 
 diathesis, at that time and up to comparatively recent years, 
 was meant a constitutional predisposition towards certain 
 diseases affecting the individual from birth or from an early 
 period of post-natal existence. Rickets, tuberculosis, and 
 scrofulosis, were held at that time to be diseases of mal- 
 nutrition, but, as Jenner pointed out, this term is vague, and 
 all diseased action by which unhealthy structure is formed 
 in the place of healthy may be called malnutrition. It is in 
 this sense that rickets is a disease of malnutrition, for while 
 it is most commonly associated with a dietary, deficient in 
 quantity and defective in quality, it is frequently found 
 where no exception can be taken to the feeding in either of 
 these respects. Again, it is commonly seen where the fault 
 in the feeding lies in the direction of excess, both as regards 
 variety and quantity. In any case, wasting is not an essential 
 characteristic of rickets. On the contrary, there is a con- 
 servation of the processes of metabolism, and the rachitic 
 child on an insufficient and inadequate diet, is frequently 
 unduly fat, and is pale and flabby. 
 
 All these diathetic conditions, Jenner taught, tended to 
 end in actual diseases, which were apt to be exceedingly wide- 
 spread and to produce large deviations from the healthy 
 
 * " Clinical Lectures and Essays on Rickets, Tuberculosis, Abdominal 
 Tumours and Other Subjects," by Sir William Jenner, Bart., G.C.B., 
 London, 1895. 
 
 87 
 
88 Rickets 
 
 structure in certain particular organs and tissues. With the 
 discovery of the tubercle bacillus as the cause of tuberculosis 
 and the spirochsete as the cause of syphilis, the consideration 
 of the soil as a factor in producing disease for a time fell into 
 the. background, and such terms as scrofula and struma were 
 but seldom used. When Jenner used the term diathesis it 
 is clear that he did not necessarily mean a congenital or 
 inherited tendency, for, while speaking of the rachitic 
 diathesis, he describes it as part of the process of the actual 
 disease and states, " I have never seen congenital rickets," 
 and again, " I know of no facts to prove that rickets is 
 hereditary." Tubercle, he considers, may be hereditary, 
 while the syphihtic diathesis is usually so. 
 
 The term scrofulosis, as used by Jenner, is very suggestive 
 of a stage in the development of the rachitic state. If this 
 be excluded, there are three morbid conditions left which 
 show great resemblance, in that they frequently affect the 
 very young child at the period of greatest growth, and that 
 the chief pathological changes tend to occur in the structures 
 and tissues in which growth is most active. Rickets is not 
 necessarily a true diathetic disease in the sense that the child 
 is born with a constitution which tends to develop some 
 definite form of disease. Neither can congenital syphihs be 
 rightly spoken of as a diathesis in so far as there is an actual 
 infection and not a mere tendency to invasion. 
 
 In rickets, all children if exposed to certain conditions 
 develop the disease, and racial characteristics seem to have 
 but little influence. I can find no confirmation in practice 
 for the generally expressed behef that Jews enjoy an immunity 
 from the disease. Rickets is the result of certain definite 
 causes, without which the condition cannot be produced, 
 and these causes are exceedingly constant and widespread, 
 affecting large sections of the community. 
 
 In making statistics in social work on the causes which 
 produce certain morbid processes, the greatest caution is 
 needed in drawing the inference that because the condition 
 affecting the child exists in the parent it is therefore 
 hereditary. When the causes are widely spread, it is 
 
The Early Signs and Symptoms of Rickets 89 
 
 exceedingly difficult to discriminate between the part which 
 heredity plays and that which truly belongs to environment. 
 In tuberculosis, however, certain children, certain families, 
 and certain races, seem more liable to infection than others 
 when exposed to similar conditions. There is still much 
 truth in the old description of the tubercular diathesis as a 
 clinical picture. In every children's hospital two types of 
 patient are weU known. 
 
 The tuberculous subject is frequently a charming child, 
 with a tail thin figure, straight and slender limbs, and a 
 delicate and transparent skin. The ends of the long bones 
 are very small and the layer of cartilage between the diaphysis 
 and the epiphysis is thin and regular. The complexion is 
 clear, the eyes are bright, the eyelashes long, and the hair 
 glossy. The child is forward and clever ; it cuts its teeth 
 early and talks and walks at an early period. Not only are 
 the teeth cut at the usual period but the enamel is generally 
 well formed and the teeth are but little liable to decay. It 
 is siirprising how frequently in the tuberculous subject the 
 teeth are large and well shaped and very firmly set in the jaw. 
 Clinically, it is difficult to believe that such a constitution is 
 the direct result of the actual invasion of the child's system 
 by the tubercle bacillus. It is often seen in children who 
 are brought up with the greatest care as regards feeding and 
 general nourishment. While such a child seems to fall an 
 easy prey to the tubercle bacillus, it is undoubtedly true 
 that if the actual environment remains good and the child is 
 not unduly weakened by acute disease, it may grow into a 
 healthy adult without ever showing signs of any actual 
 tubercular focus and may outgrow the tendency. 
 
 The rachitic child, on the other hand, tends to look dull 
 and heavy. The head is square and the skin is coarse and 
 pasty and is frequently harsh and dry. The hair is often 
 scanty. Knock knee and bowing outwards of the legs are 
 common, and the ends of the long bones are markedly 
 thickened in the neighbourhood of the growing cartilage. 
 Walking and speech are delayed and the child is late in 
 cutting its teeth. As will be seen in detail later, the teeth 
 
90 Rickets 
 
 of the racliitic child are stunted and the enamel is often 
 very imperfectly laid down. The tendency to early decay 
 of the teeth is one of the conspicuous features of rickets. 
 The child has an old-fashioned air which gives an appear- 
 ance of precocity, quite different from the bright, alert look 
 of the tubercular subject. 
 
 There is a general impression that the rickety child is 
 precocious, but in reahty it is essentially a backward child. 
 In considering the development of one thousand children, 
 examined in schools in the East end of London, it was 
 found that of eight hundred who showed signs of rickets : — 
 
 Per cent. Per cent. 
 Walking or speech was delayed in ... 48-0 
 
 Both being delayed in 29-0 
 
 Walking alone delayed in 12-5 
 
 Speech alone delayed in 6-5 
 
 Neither speech nor walking delayed in ... 52-0 
 
 The period constituting delay is taken as eighteen months, 
 so that those cases of delayed development did not walk or 
 speak till after the age of eighteen months.* To-day rickets 
 remains the most widely spread disease in London among 
 children. Tuberculosis is also common in young children, 
 but it is of a different variety from the adult form, pulmonary 
 tuberculosis being but rarely seen, while tubercle of the 
 glands, bones and joints is frequently present. 
 
 Rickets is a general disease affecting the nutrition of the 
 whole body. It results in retarded growth and development- 
 The teeth are cut late and the child is slow in walking and 
 in speaking. The ossification of the bones is delayed and 
 perverted, and the bones consequently become soft and the 
 muscles and ligaments which support the joints become 
 wasted and relaxed. In many cases there are profound altera- 
 tions in the central nervous system and in the lymphatic 
 glands, and to a less extent in the liver and spleen. The 
 disease is essentially one of the first few years of the child's 
 life and more particularly of the first two years. 
 
 One or two landmarks in the growth of the infant during 
 this time may be shortly referred to. At birth the average 
 * " On the Incidence of Rickets in School-children," by J. Lawson Dick. 
 School Hygiene, May, 1916. 
 
The Early Signs and Symptoms of Rickets 91 
 
 child weighs seven and a half pounds. At five months the 
 weight should be fourteen pounds, and at eighteen months 
 twenty-one pounds. The relatively enormous growth of the 
 brain which takes place during the first few years of the 
 child's life is a factor of the greatest importance in studying 
 the results of any nutritional defect at this period. Any 
 state of impaired nutrition which acts continuously at this 
 early period wiU have far-reaching effects on the develop- 
 ment and structure of the central nervous system. The 
 disease is partially recovered from, but there is apt to be a 
 permanent arrest or perversion of the growth and develop- 
 ment of the brain itself. If the weight of the adult brain be 
 taken as 100, the brain of the child may be represented at 
 various ages thus : — 
 
 At birth, weight of brain = 30 per cent. 
 
 At the end of the 1st year ,, „ =50 „ 
 
 4th „ „ „ = 75 „ 
 
 Hth „ „ „ = 92 „ 
 
 19th „ „ „ =100 „ 
 
 Now, as Sir Arthur Keith has pointed out, there is a 
 mechanism which controls the growth of the skull so that it 
 adapts itself to the needs of the rapidly growing brain. 
 The rapid increase in the size and weight of the brain during 
 the first few years is reflected in an equally rapid increase 
 in the circumference of the child's skull over the same 
 period. This rapid growth may be expressed at various 
 periods thus : — 
 
 Circumference of the head at birth =13 inches 
 
 „ nine months = 17 
 
 „ „ one year = 18 
 
 „ „ five years = 20 „ 
 
 It will be noted that during the first year there is a very 
 large increase in the cranial growth, viz., five inches, while 
 in the four succeeding years there is a further growth of 
 two inches, and there is a comparatively slight enlargement 
 afterwards up to adult life. The first year of life is the 
 time of all others when the whole environment of the child 
 should make for health, while in practice it is the period 
 when all the evils of a pernicious environment are concen- 
 
92 Rickets 
 
 trated on the young infant, with lasting damage to the 
 individual and to the community which is subjected to such 
 an environment. 
 
 In the East end of London the feeding of the young 
 infant at this period is, on the whole, very fair, much better 
 indeed than is generally supposed, but the conditions arising 
 as the resiilt of overcrowding of families of four, five and 
 six individuals in one, two or three rooms, with the conse- 
 quent loss of fresh air and sunlight, which are so essential for 
 all vital processes, and the want of the opportunity for 
 exercise and proper cleanliness, are all brought to bear in full 
 force on the young infant up to the end of the second year. 
 By that time much irreparable damage has been done. 
 
 To allow of moulding of the child's head during birth 
 and of free expansion of the brain afterwards, the skull has 
 at first a fair amount of mobility between its component and 
 adjacent parts. There are six fontanelles in the child's skull 
 at birth. The anterior fontanelle lies between the antero- 
 superior angles of the parietal bones and the superior angles 
 of the ununited halves of the frontal bone ; the posterior is 
 situated between the postero-superior angles of the parietal 
 bones and the superior angle of the occipital bone, while the 
 lateral fontanelles, two on each side, are irregular in shape 
 and are situated at the inferior angles of the parietal bones. 
 The lateral and posterior fontanelles close during the first 
 few months of infancy. The closure of the anterior 
 fontanelle forms an important clinical landmark. It closes 
 between the eighteenth and the twenty-fourth month, and 
 any delay beyond that period should be looked upon as 
 abnormal. In rickets it may remain open till the third or 
 fourth year or even to the sixth year. 
 
 A systolic bruit, the so-called rachitic souffle, is 
 frequently to be heard in the region of the open anterior 
 fontanelle, and it was at one time claimed that this was a 
 sign pathognomonic of rickets. It is, however, found in 
 many conditions besides rickets and may occur in the 
 normal child. Anaemic states may produce the souffle and 
 it is also fotmd in hydrocephalus. 
 
The Early Signs and Symptoms of Rickets 93 
 
 At from three to four months the child should be able 
 to hold up the head, and at nine months the development of 
 the spinal muscles and of the body muscles generally allow 
 of the child sitting up, while at from twelve to eighteen 
 months the child should begin to walk. Owing to the pro- 
 found debility usually present in rickets, these muscular 
 efforts are commonly much delayed. 
 
 In early infancy syphilis and rickets have many charac- 
 teristics in common. Both are peculiar in that their effects 
 axe indefinitely prolonged, unlilce most diseases which have 
 a period of invasion, acute stage, and convalescence, within 
 a short space of time. Both syphiUs and rickets tend to run 
 on for years, and the system is profoundly affected at its 
 period of most rapid growth. In both a widespread process 
 of rebuilding or reconstruction takes place, which leaves 
 stigmata recognisable especially in the skeleton, skull and 
 teeth. Both diseases show a predilection for certain sites. 
 Thus, both tend to affect the enamel of the permanent teeth, 
 and especially that part of the enamel laid down in the first 
 few months of the infant's life. In syphilis, the central 
 incisors and the first molars of the permanent dentition tend 
 to be contracted and peg-shaped, while the enamel of the 
 incisors shows a hypoplastic condition resulting in the 
 characteristic notch of Hutchinson's teeth. In rickets, the 
 central and lateral incisors, the tip of the canines and the 
 crowns of the first molars are frequently affected with 
 hypoplasia. Again, syphilis and rickets tend to affect the 
 centres where active ossification is proceeding. Thus, in 
 both there is a tendency to bossing of the skull, and both 
 frequently affect the sites of greatest growth at the ends of 
 the long bones, though this is peculiarly characteristic of 
 rickets. 
 
 There are, however, essential differences. Congenital 
 syphilis is due to the infection of the ovum by the spirochseta 
 pallida. Rickets is a disease which is not congenital, and 
 up to the present no specific micro-organism has been 
 found. Syphilis is a disease commonly seen at infant 
 clinics, such as the various child welfare centres now 
 
94 Rickets 
 
 springing up all over the country. It is rarely noticed in 
 children of school age. It produces a profound toxaemia, so 
 that both the ante-natal and post-natal mortality is very 
 large, and comparatively few survive to adult life. Rickets, 
 on the other hand, tends to end in recovery, and while 
 commonly seen in baby centres, the stigmata produced by 
 the disease are still exceedingly common in later years 
 among school-children. 
 
 In any primary school of our larger industrial towns 
 valuable statistics as regards rickets could be found if a 
 careful investigation were made of all the children, but it 
 would be useless to attempt to collect statistics as regards 
 syphilis from any one school by means of an ordinary 
 inspection ; the number of cases would be too small. So 
 common is rickets in the slum areas of our large towns, 
 that it may be broadly stated, that practically all children 
 living under these conditions have to struggle through a 
 rickety phase of their existence, when the whole tide of 
 growth is profoundly disturbed, producing permanent 
 damage to the body tissues and skeleton, and especially to 
 the sensitive tissues of the brain and nervous system. 
 
 Rickets and syphilis are distinct pathological entities. 
 Parrot's theory that rickets is simply a manifestation of 
 syphilis cannot be accepted, but it is probable that in 
 certain cases syphilis is a factor predisposing to the onset of 
 rickets. So closely do the two diseases resemble each 
 other in their effects, that it is frequently difficult to tell to 
 which disease a certain morbid process owes its origin. 
 This is notably the case with cranio-tabes and enlargement 
 of the spleen. 
 
 Elsasser, in " Der Weiche Hinterkopf," pubhshed in 
 Stuttgart in 1843, first described the condition of cranio- 
 tabes. It is a very characteristic defect found in young 
 infants, usually developing before the sixth month. Softened 
 areas appear in the cranial bones, in the vicinity of the 
 lambdoidal suture, especially in the parietal and occipital 
 bones. The squamous portion of the temporal bone is not 
 infrequently affected. Much more rarely they appear in the 
 
The Early Signs and Symptoms of Rickets 95 
 
 anterior part of the parietal bones, still more rarely in the 
 frontal bones in the region of the coronary suture. 
 
 In the examination of 100 cases of cranio-tabes, 
 Carpenter found the bones of tbe skull affected in the 
 following order of frequency : parietal bones alone affected, 
 58 per cent. ; parietals affected with squamous-temporal or 
 occipital or both, 35 per cent. ; occipital bones alone 
 affected, 2 per cent. The large number of cases in which 
 the parietal bones are affected is noteworthy, while the 
 occipital bone is affected much less frequently than is 
 generally supposed. The softened areas can best be felt by 
 holding the infant's head between the palms of the hands, 
 so that the index and middle fingers fall over the occipital 
 bone, and palpate the skull for the areas of thinning in the 
 bone, which often give way imder the pressure of the finger, 
 producing the characteristic feehng of parchment-like 
 crackhng. More rarely does the condition develop after the 
 sixth month. According to Jacobi, it may be found in forty 
 per cent, of cases of rickets if carefully looked for. To find 
 the condition in this large number of children the skull 
 must be palpated with the greatest care and skill, and very 
 minute areas of softening must be noted. 
 
 These softened areas may be due to thinning of the 
 bone to a parchment-hke texture, or there may be actual 
 openings in the bony skull, where only the pericranium and 
 dura are left to cover in the space, without the intervention 
 of bony tissue. These areas vary in size from one line to a 
 half or three quarters of an inch in diameter. They may 
 be rounded or oval in shape and are frequently irregular. 
 On the internal surface of the cranium the borders of these 
 areas are usually formed by a heaping up of the surrounding 
 bone, which shelves rapidly down to the gap. It is as if the 
 pulp of the finger had been kept continuously maintaining 
 a gentle pressure on the young bone, preventing the process 
 of ossification occurring under the linger and allowing an 
 accumulation of bone to take place round the margin not 
 directly under pressure. These heaped-up edges of bone 
 are frequently very vascular. In the distribution of cranio- 
 
96 Rickets 
 
 tabes there is usually an approach to symmetry, though the 
 defect may be more marked on one side than on the other. 
 At times there is no opening but merely a thinning of the 
 bone producing a depression ; not infrequently at the 
 bottom of this depression there is a small opening. 
 
 Cranio-tabes is not pathognomonic of any one diseased 
 condition. Sometimes it seems to be a simple delay in the 
 process of ossification within normal limits. Elsasser be- 
 lieved that the condition was essentially rickety in its origin. 
 Other observers, however, have pointed out that syphilis is 
 very common in cranio-tabes. Thus, in one bundled cases 
 of cranio-tabes. Barlow* found undoubted syphilis present in 
 forty-seven, and concludes that the existence of well marked 
 cranio-tabes is strong ground for suspecting a syphilitic 
 taint. Dealing with a similar number of cases, Carpenterf 
 found that in seventy-four per cent, the diagnosis of syphihs 
 was certain. The fact that it is a very early sign, usually 
 appearing before the sixth month and tending towards 
 spontaneous cure, has been held to support the view that 
 syphilis is the exciting cause, for it is at this early period 
 that syphilis is especially operative. After the sixth month 
 rickets is much the more common condition and tends to 
 develop, while cranio-tabes at this period tends towards 
 recovery, so that Gohn,J in an examination of 1,164 children 
 found that 34-6 per cent, had cranio-tabes and that this 
 percentage was higher under three months. Wieland 
 showed that softening of the cranial bones is present in 
 about twenty per cent, of infants at the time of birth. This 
 congenital softening, according to Wieland, § has none of the 
 histological features of true rickets. 
 
 It may be concluded that cranio-tabes is pathognomonic 
 
 * " Relationship of Cranio-tabes to Rickets and Congenital Syphilis," 
 by Dr. David B. l^es and Dr. Thomas Barlow, " Transactions of Patho- 
 logical Society of London," Vol. XXXII, i88i. 
 
 t " Cranio-tabes in Young Children. A Clinical Enquiry into its Origin, 
 illustrated by loo Cases," by George Carpenter, " St. Thomas's Hospital 
 Reports," Vol. XIX, 1889. 
 
 J " Zur Pathologic der Rachitis," von Dr. Michael Cohn, " Jabrbuch fUr 
 Kinderheilkunde," Band XXXVII, p. 189. 
 
 § Wieland. " Ergebnisse der inneren Medizin und Kinderheilkunde," 
 Band VI, p. 64. 
 
The Early Signs and Symptoms of Rickets 97 
 
 of neither rickets nor syphilis ; it may occur in both and 
 probably as a direct consequence of either disease. By many 
 it is held to appear in healthy children. (Friedenleben, 
 Comby.) Generally, however, it is encountered in badly 
 nourished infants. In most of our pathological museums are 
 specimens where the disease is widely spread along all the 
 sutures extending to the anterior part of the parietal and to 
 the frontal bones. In these severer cases the tendency to a 
 wide symmetrical distribution is usually marked and is very 
 suggestive of congenital syphihs. When the condition 
 occurs early, say at or before the third month, and is well 
 marked, the probability is that the disease is due to a 
 syphihtic taint. Frequently the condition is associated with 
 undue and continued pressiire. Thus, it is commonly 
 associated with the deformity of the head known as 
 plagiocephaly. 
 
 Plagiocephaly is a condition in which there is a de- 
 formity of the skuU produced by sustained pressure, which 
 may be due to a faulty decubitus either during intra-uterine 
 life or in the first few months after birth. One side of the 
 frontal region, as a rule, is flattened, and one prominent, 
 corresponding with a flattened and a prominent parieto- 
 occipital region posteriorly. The head is obhquely oval, 
 and the long antero-posterior axis is deviated to one or 
 other side, corresponding with the prominent frontal and 
 oecipito-parietal regions. It has been stated to be essentially 
 the deformation of the degenerate. Such a statement re- 
 quires much modification. Asymmetry of the head is so 
 common as to be the rule, and in so far as plagiocephaly is 
 a condition due to physical pressure applied to the cranial 
 bones at the period when the cranial bones are soft, and the 
 growth of the bone is exceedingly rapid, the causes are very 
 varied and may be far removed from degeneracy. When 
 the condition is of intra-uterine origin, it may be associated 
 with large size of the head in a perfectly healthy large child 
 without other abnormality, or it may be due to the expansion 
 of the head following hydrocephalus. In either case it may 
 be a useful deformation, favouring the passage during labour 
 
98. Rickets 
 
 of a head which would otherwise be disproportioned to the 
 pelvic canal through which it had to pass. Or again, it 
 may occur when the head is of normal size, owing to vmdue 
 pressure of the promontory in a contracted pelvis. 
 
 In the commonest form, when the child lies in utero in 
 the ordinary left occipito-anterior position, the left frontal 
 region is flattened, corresponding to a flattened right occi- 
 pito-parietal region. In this case the pinna of right ear is 
 prominent and stands away from the head, while the left 
 ear is closely applied. It is as if two hands had been 
 placed over these two regions, the left frontal and the right 
 occipito-parietal regions, compressing this oblique diameter 
 of the head till in its growth a corresponding bulging takes 
 place in the other oblique diameter, that is, over the right 
 frontal and the left occipito-parietal regions. When con- 
 genital the deformation of the skull is not due to rickets in 
 the child, though it may be due to the pressure of the 
 promontory, which may take place as the result of rachitic 
 deformity of the maternal pelvis. 
 
 Plagiocephaly may also be due to the decubitus of the 
 child after birth, when it is usually associated with rickets. 
 If the child be dehcate and weakly, and especially if the 
 bones of the skifll are softened by the early onset of the 
 rachitic state, the head, from the pressure on the pillow as it 
 Hes in the cot, may become deformed. Usually, the child is 
 placed on the right side, and again, the commonest deformity 
 is flattening of the right parieto-occipital and left frontal 
 regions. Cranio-tabes is frequently associated with this con- 
 dition, and while it usually affects both sides, it predominates 
 as a rule on the side of the parieto-occipital depression. 
 Cranio-tabes is frequently congenital, and, as Parrot pointed 
 out, when this is the case it tends more frequently to affect 
 the anterior part of the skull round the anterior f ontanelle and 
 along the line of the sagittal suture. Assuming that pressure 
 due to the weight or rapid growth of the brain, associated 
 with undue softening of the bones, are the usual causes of 
 cranio-tabes, it can readily be understood that in the ordinary 
 head presentation of the child the front part of the skuU is 
 
The Early Signs and Symptoms of Rickets 99 
 
 likely to be affected as well as the posterior part, while in 
 the child after birth the posterior part is likely to show the 
 more marked changes. 
 
 The depressions and elevations seen on the inner aspect 
 of the skull in cranio-tabes represent the exact mould of the 
 convolutions and sulci of the brain. The pressure of the 
 rapidly growing brain and the counterbalancing pressure 
 on the outside, in the one case of the soft parts of the pelvis, 
 and in the other of the pillow as the child lies in the cradle, 
 determine the exact spot where the delay in ossification or 
 the thinning of the bone takes place. In the congenital form, 
 as already noted, the process may be a simple delay in the 
 ossification due to pressure ; after birth many of the cases 
 where softening, and later re-absorption of newly deposited 
 bone occur, are the result of rickets, and are directly due to 
 the same cause, viz., pressure. 
 
 Elsasser attached great importance to this condition as 
 a cause of convulsions, frequently ending in the death of the 
 child. It has been blamed for producing lar37ngeal spasm, 
 and Kassowitz believed that it was an active factor in pro- 
 ducing tetany. Pressure on the softened areas is, however, 
 well borne, and the danger of compression of the head is 
 probably purely imaginary. As a rule, after the sixth or 
 eighth month, cranio-tabes ends in rapid recovery, with the 
 renewal of ossification. 
 
CHAPTER VIII 
 
 The Early Signs and Symptoms of Rickets 
 
 {Continued) 
 
 In describing rickets some general statements are commonly 
 made which have been originally expressed by some authority 
 and, as a result of constant reiteration, have come to be 
 looked upon as estabhshed facts without any criticed exam- 
 ination into their accuracy. Thus, it is commonly stated that 
 rickets is not usually found in children nursed on the breast 
 unless lactation is unduly prolonged. Now it is true that 
 artificial feeding is a serious handicap to a child, and is Ukely 
 to predispose to rickets, but it is no less true, that given 
 certain conditions — the conditions which prevail in slum 
 dwellings in our larger industrial towns — ^rickets will develop 
 with equal frequency in the breast-fed babies of healthy 
 mothers as in those who are artificially fed. In considering 
 the aetiology of rickets this is an important matter to realise. 
 The only advantage that the breast child has, is, that it will 
 probably suffer less severely than the child brought up under 
 similar unhygienic conditions, but artificially fed. 
 
 Another common statement is that deficiency of fat or 
 excess of carbohydrate is an important or even the essential 
 factor in producing rickets. This requires very careful 
 examination. Fat is, of course, an important item in the 
 infant's diet, but it is to be noted that in a large class of 
 patient, where the feeding is unexceptionable in this respect 
 and where the fat nutrition is excellent, rickets is frequently 
 well marked. 
 
 Wasting is by no means necessarily associated with 
 rickets. The state of nutrition of the child and its digestion 
 may be exceedingly good to all outward appearance. It 
 frequently has a good colour and is very plump and fat, 
 
The Early Signs and Symptoms of Rickets loi 
 
 though even then it may be noted that the child is some- 
 what dull and lethargic, and that the muscular system is 
 unduly soft and flabby. Frequently such children are 
 brought to the physician for the first time because they 
 have not cut any teeth by the tenth or twelfth month. 
 
 A badly balanced diet, in which there is an excess of 
 carbohydrate and a deficiency of protein and fat, is a very 
 common defect in the feeding of young children, but in 
 itself such a diet does not produce rickets. All the condi- 
 tions of a badly balanced diet are, as has been shown, present 
 to an extreme degree all over the East, prolonged lactation 
 frequently extending to two or three years, while the early 
 admixture of starchy foods with the breast feeding is the 
 rule. Such conditions are constantly cited as specially 
 pernicious and likely to produce rickets, and yet in China 
 and India, where these factors prevail to a degree altogether 
 unknown in Europe, rickets is for all practical purposes a 
 negligible quantity. 
 
 It is commonly stated that the first stage of rickets is 
 marked by the signs of gastro-intestinal irritation. There 
 is very Uttle evidence to support such a statement. There 
 is no doubt that the nutrition of the child fails and there is 
 an arrest, in the majority of cases, of the normal process of 
 growth ; obviously there is marked impairment of the 
 normal metabolism. But in rickets the signs of gastro- 
 intestinal irritation in its earliest stages are by no means 
 common. Neither vomiting nor diarrhoea is characteristic 
 of this stage of the disease. Both ssrmptoms are absent in 
 the great majority of cases. Von Hansemann* rightly 
 pointed out that almost aU children bom during the late 
 part of the year, and dying during the following spring, 
 show evidence of rickets, though these are the months 
 when gastro-enteritis is not prevalent, whUe those bom in 
 spring (April and May), and dying in the autumn, are free 
 from rickets, though they have passed through the period 
 when gastro-enteritis is exceedingly common, and, in itself, 
 causes many deaths. 
 
 * " Ueber die Rachitis als Volkskrankheit," Berlin. Klin. Woch, No. 9, 1906. 
 
I02 Rickets 
 
 Rickets is essentially a chronic disease and is very 
 insidious in its onset. About the third or fourth month the 
 child is found not to be thriving. It becomes less lively, 
 and at five or six months, instead of rejoicing in activity it 
 prefers to be quiet and motionless. The skin, in place of 
 being clear and healthy, tends to become somewhat dull 
 and pasty. Profuse sweats are apt to break out over the 
 head and neck and the upper part of the chest. This occurs 
 most markedly during slefep, and whether the infant falls 
 asleep at night or during the day. Very characteristic, at a 
 slightly more advanced age, is the action of the child in 
 tossing off the bed clothes, the body, feet and hands being 
 hot and dry, while the head and neck are bathed in per- 
 spiration, which saturates the pillow. The skin of the 
 forehead is often thin and white and the distended veins 
 show very markedly. Sudamina and miliaria are apt to 
 appear on the skin as the result of the excessive perspiration. 
 
 The jugular veins are full and the carotids are seen to 
 throb markedly — a point on which Glisson laid much stress. 
 Insomnia and nervous irritability are already well marked 
 signs. Usually it is stated that in rickets there is a pre- 
 monitory stage in which the child exhibits undue irritabihty, 
 restlessness, insomnia and sweating about the head and 
 neck, or marked debility with a tendency to lassitude. 
 These observations are inaccurate, for these symptoms 
 occur at the same time and proceed pari passu with the 
 changes in the cranial bones and in the growing ends of the 
 long bones. They are in no sense premonitory, but are the 
 result of the active progress of the disease itself. The point 
 is insisted on, for it is only by realising the insidious nature 
 of rickets, its wide distribution throughout the general 
 population, and the very early period at which the child's 
 metaboUsm is interfered with, that the importance of the 
 rachitic state and its effect on the growth of the manhood 
 and womanhood of the nation can be appreciated. Rickets 
 is not a congenital disease, but the changes begin, as a rule, 
 almost immediately after birth, or within the first few 
 weeks of extra-uterine Ufe. By the time that the wrists are 
 
The Early Signs and Symptoms of Rickets 103 
 
 swollen and tender, and the ribs beaded, and the forehead 
 is prominent, showing a thin white skin and distended 
 veins, and heavy sweats occur, the disease is weU advanced 
 and profound changes have already taken place throughout 
 the whole system. Most notable of all, the insomnia and 
 the irritabUity of the nervous system are signs of marked 
 impairment in the development of the brain itself, which 
 impairment is likely to have a lasting effect on the child's 
 future history. 
 
 It is true that it is not uncommon to find that rickets 
 begins after an attack of an acute and debihtating illness 
 such as measles, diarrhoea, or bronchitis. The confinement 
 over a prolonged period, to which the child is subjected, 
 may lead to an attack of rickets from which, but for the 
 acute illness, it would have been exempt, and the date of 
 onset of the rachitic state will naturally depend on the 
 period of occurrence of the acute illness. Thus, it may 
 begin, especially in better class famihes, at the age of six 
 months or one year, or eighteen months, or even later. 
 But, as a rule, where children are exposed to the conditions 
 which produce rickets, as they are, almost universally, in 
 the slum areas of our large towns, the disease appears soon 
 after birth, and that quite independently of the fact whether 
 the child is breast-fed or bottle-fed, and whether the supply 
 of milk is adequate or no. For it by no means follows 
 that because the parents live in two or three overcrowded 
 rooms, in the slums of our industrial towns, that the feeding 
 is necessarily inadequate. In many cases it is so, but, as 
 we shall see in speaking of the East end of London, and 
 especially of the Jewish section of the population, the 
 feeding is much better than is generally allowed, and the 
 mothers are often in excellent health, and yet the child 
 suffers markedly from the disease. In such areas, the con- 
 ditions which produce the disease are ubiquitous, and, as a 
 result, nearly aU the children pass through a rachitic phase. 
 So insidious is the disease that its presence is usually not 
 noted unless there is an intercurrent illness, which takes the 
 child to the hospital. But the results are noted in the fact 
 
104 Rickets 
 
 that we unconsciously associate certain types of features and 
 of physical development with slum areas, and accept as 
 natural to these surroundings a tj^pe of growth which we 
 recognise does not occur in the wealthier section of the 
 community. 
 
 No disease begins at so early a period and none has 
 more far-reaching effects. The d*efects consequent on the 
 faulty deposition of calcium occurs at a much earUer period 
 than is commonly supposed. Thus in the teeth, as wiU be 
 seen later, it is common for the enamel which is calcified 
 in the first few weeks after the child's birth to show well 
 marked defects, which frequently continue from this period 
 to the end of the second year, giving rise to the hjrpoplasia 
 so characteristic of the disease. 
 
 The rachitic rosary may be an exceedingly early sign, 
 which is not infrequently met with as early as the third or 
 fourth month. Virchow made the observation that in 
 children d5dng in the second month a rachitic rosary was 
 plainly visible. To find the characteristic sweUings in the 
 region of the wrist and ankle joints, it is usually necessary 
 to wait for twelve or eighteen months, but, by the time 
 this takes place, the disease is already far advanced. 
 
 The only reUable information as to the period at which 
 these changes first begin is to be found on histological 
 examination. From this point of view Schmorl's* work is 
 of great value. Histological examination was made of the 
 ■ bones of 386 children dying between the ages of two months 
 and four years, and the signs of rickets were carefuUy 
 looked for. Out of the 386 cases, 345, that is 89 4 per 
 cent., showed evidence of rickets, while 41, or 10" 6 per 
 cent., showed no signs of rickets. 
 
 These results closely correspond to the percentage given 
 as the result of a clinical examination of the children in the 
 London County Council schools in the East end of London, f 
 
 * " Die Pathologische Anatomic der rachitischen Knochenerkrankung 
 mit besonderer Beriicksichtigung ihrer Histologie und Pathogeuese," G. 
 Schmorl, Dresden, " Ergebnisse der Innem Medizin und Kinderheilkunde," 
 Vierter Band, 1909, p. 403. 
 
 t " Defective Housing and the Growth of Children," by J. Lawson Dick. 
 London, 1919. 
 
The Early Signs and Symptoms of Rickets 105 
 
 Of Schmorl's 345 cases, showing evidence of rickets, 65 were 
 cases of commencing rickets, 136 were cases of active and 
 advanced rickets, 80 showed rickets in the process of 
 healing, and 64 were actually healed cases. 
 
 The following table, from Schmorl's paper, shows the 
 incidence of rickets in the various months of the child's 
 hfe:— 
 
 Number of 
 Children. 
 
 Ages in Months. 
 
 Rickety Cases. 
 
 Cases free from 
 Rickets. 
 
 33 
 
 2-3 months. 
 
 20 = 6o-6 per cent. 
 
 13 = 39-4 per cent. 
 
 34 
 
 4-6 „ 
 
 33 = 97 
 
 1=3 
 
 53 
 
 7-9 
 
 50 = 94 
 
 3=6 
 
 75 
 
 10-12 
 
 73 = 97-3 
 
 2 = 2-7 „ 
 
 59 
 
 13-18 .. 
 
 58 = 98-3 
 
 I = 1-7 
 
 33 
 
 19-24 .. 
 
 30 = 90-9 
 
 3=9-1 
 
 65 
 
 25-36 „ 
 
 57 = 87-7 
 
 8 = 12-3 
 
 34 
 
 37-48 .. 
 
 24 = 70-6 „ 
 
 10 = 29-4 
 
 This table shows that histologically bony changes can 
 be seen as early as the second month, and that from the 
 fourth to the eighteenth month nearly all the children 
 showed evidence of rickets. In another table, Schmorl 
 showed the several stages of rickets according to the age of 
 the child : — 
 
 Age in 
 
 Commencing 
 
 Active 
 
 Healing 
 
 Healed 
 
 Total No. 
 
 Months. 
 
 Rickets. 
 
 Rickets. 
 
 Rickets. 
 
 Rickets. 
 
 of Cases. 
 
 
 per 
 
 
 
 
 
 
 cent. 
 
 per 
 
 
 
 
 A 
 
 4 = 100 
 
 cent. 
 
 per 
 
 
 4 
 
 3 
 
 12 = 75 
 
 4 =25 
 
 cent. 
 
 
 16 
 
 4-6 
 
 19 = 57-6 
 
 7 = 21-2 
 
 7 = 21-2 
 
 per 
 
 33 
 
 7-9 
 
 17 = 34 
 
 23 =46 
 
 10 = 20 
 
 cent. 
 
 50 
 
 10-12 
 
 7 = 9-5 
 
 45 = 61 -7 
 
 20 = 27-4 
 
 I = 1-4 
 
 73 
 
 13-18 
 
 4 = 6-9 
 
 32 = 55-2 
 
 15 = 25'8 
 
 7 = 2-1 
 
 58 
 
 19-24 
 
 2 = 6-6 
 
 10 = 33-4 
 
 II = 36-6 
 
 7 = 23-4 
 
 30 
 
 25-36 
 
 
 13 = 22-9 
 
 14 = 24-5 
 
 30 = 52-6 
 
 57 
 
 37-48 
 
 
 2 = 8-3 
 
 3 = 12-5 
 
 19 = 79-2 
 
 24 
 
 This table shows that the bony changes may be seen as 
 early as the second month, and that from the second to the 
 sixth month commencing cases prevail. Between seven 
 
io6 Rickets 
 
 and nine months active rickets is already present. From 
 the tenth month commencing cases begin to fall very 
 decidedly in number ; from one to two years they are few in 
 number, while no fresh cases begin between the ages of two 
 and four years. The disease is most active between the 
 periods of seven months and the end of the first year. The 
 accompanjnng chart (see Fig. 2, p. 107) is a graphic re- 
 presentation, constructed by Dr. Findlay, of a table of 
 Schmorl's, showing the frequency with which active and 
 healing rickets is met with at different periods of the year.* 
 
 The chart brings out the fact previously noted by von 
 Hansemann, that rickets tends to be active during the spring 
 and the late autumn, and is much less so during the summer, 
 while in the summer months there is a much greater 
 tendency towards healing than in the early and late parts of 
 the year. It will be noted that during the third quarter 
 of the year, the number of cases of commencing rickets is 
 at its minimum, while the number of healing cases is at its 
 maximum. This contrasts markedly with the incidence of 
 diarrhoea. 
 
 During the year 1914, out of 12,945 deaths resulting 
 from diarrhoea throughout England and Wales : — 
 
 1,444 deaths occurred during the first quarter. 
 1,362 „ „ „ „ second quarter. 
 
 7,352 „ „ „ „ third quarter. 
 
 2,787 „ „ „ ,, fourth quarter. 
 
 These deaths occurred in the general population, but 
 two-thirds took place in the first year, and three-quarters in 
 the first two years, so that they may be taken as fairly 
 representative of infantile mortality. It will be noted that 
 in the third quarter alone, a considerably larger nmnber of 
 deaths occurred than took place during the other three 
 quarters added together. That is, during the period of the 
 year when intestinal infections are most prevalent, com- 
 mencing rickets is at its minimum, and cases which have 
 been active during the first months of the year proceed 
 
 * " Introductory Historical Survey to a Survey of Social and Economic 
 Factors in the Causation of Rickets," National Health Insurance, 
 Medical Research Committee, London, 1918. 
 
Fig. 2. 
 
 SHOWING PERCENTAGE OF CASES EXAMJNED 386 IN ALL WITH 
 ACTIVE AND HEALING RICKETS FOR EACH MONTH OF THE YEAR. 
 
 COMPILED AFTER SCHMORL. 
 
 Jan. Feb. Mar. Apr. May June July Au^. Sep. Oct. Nov. Dec. 
 
 «»0 
 
 V 
 
 N 
 
 
 
 
 
 
 
 
 
 
 
 80 
 70 
 
 
 \ 
 
 V 
 
 
 v.- 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 N 
 
 ^ 
 
 
 
 
 
 f 
 
 - 
 
 60 
 
 
 
 
 
 
 
 \ 
 
 
 
 -, 
 
 \ 
 
 
 50 
 
 
 
 
 
 
 
 \ 
 
 r- 
 
 — ••' 
 
 ''^/ 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 ^ 
 
 
 
 
 
 AO 
 
 
 
 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 1 
 
 
 
 
 
 
 ■510 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,tf' 
 
 > 
 
 
 
 
 
 l- 
 
 — o 
 
 
 
 
 
 ,.J'' 
 
 
 
 
 
 
 
 
 
 
 
 
 ArHifet ffinlet^f'fi 1 
 
 
 
 
 
 Jthaling » 
 
 
 
 
 
 
 
 
 
 r-' 
 
 ,-' 
 
 V 
 
 
 
 
 
 
 TSSJK 
 
 
 
 
 107 
 
io8 Rickets 
 
 rapidly towards cure. This is quite incompatible with the 
 statement that rickets has its origin in an intestinal toxaemia. 
 
 Schmorl's observations on the early date at which 
 rickety changes can be discerned in the bones of young 
 infants are of great interest. In the infant and young 
 child aU forms of bone disease tend to begin at the growing 
 end of the diaphyses of the long bones. Since Parrot's 
 original observations, it has been recognised that in con- 
 genital S3rphihs inflammatory conditions at these sites are 
 very common, and the chief difficulty in diagnosis Ues in the 
 similarity of the appearances which some of these infantile 
 bone lesions present to those of rickets. In syphilitic 
 infants it is common to find certain areas in the skull 
 tender and shghtly swollen, and the long bones in the region 
 of the epiphyses often suffer in a like manner. These 
 lesions are frequently multiple and may make aU movements 
 of the Hmbs so painful that paralysis may be suspected. 
 Careful examination will often detect tender swellings of the 
 periosteum, near to the junction of the epiphyses and some- 
 times on the shafts. These swellings are of considerable 
 size, much larger, and at the same time more inflamed than 
 those of rickets. 
 
 As Hutchinson points out, if this form of multiple 
 periostitis is seen within six months of birth, it is almost 
 certainly due to syphilis.* In rickets much the same areas 
 are affected, but the nature of the histological change is 
 different and the process is much less acute than in syphilis, 
 though it is also of an inflammatory character. 
 
 One of the earhest and most striking signs of rickets is 
 the early appearance of muscular weakness and wasting. 
 The manner in which the child, when undressed, hes 
 placidly across the mother's knees is very characteristic. 
 There is but httle effort to raise the head or to move the 
 arms and feet as the normal child strives to do. The 
 distended abdomen is flaccid and deep palpation is easy. 
 At an early period in the disease the whole of the muscles of 
 the limbs and of the body are largely thrown out of action 
 
 * " Syphilis," by Jonlithan Hutchinson, London, 1889, p. 83. 
 
The Early Signs and Symptoms of Rickets 109 
 
 and the child moves as little as possible. There are two 
 main reasons for this. First, the respiration of the child is 
 embarrassed at a very early age, and the rickety child avoids 
 all robust movements, such as the normal infant rejoices in, 
 which would be likely to excite the respiratory act. From 
 an early period the rickety child is a silent child. It does 
 not expend its energy in crying, for it is wholly occupied in 
 getting sufficient oxygen into its lungs to supply its present 
 needs. The mechanical act of respiration is a laboured 
 effort which exhausts the child's energies. The only time 
 it is fretful is when it is moved ; when left alone it is placid 
 and silent. The physical condition of the child demands 
 that it should conserve its energies. AU voluntary muscular 
 effort is thus limited, and in consequence the muscles tend to 
 become soft and flabby. 
 
 The second reason for the very marked muscular wasting 
 which occurs is found in the widespread changes which 
 are already taking place in the bones. As Hilton* points 
 out, when the interior of a joint is in a state of in- 
 flammation or of irritation, the influence of this condition 
 is carried to the spinal marrow, and thence reflected to 
 the various muscles of the joint through the medium of the 
 associated motor nerves, the muscles being supplied by 
 the same nerves that supply the interior of the joint. 
 Similar changes occur when these inflammatory changes 
 are in the epiphyses and in the region of the joints, and, 
 as has just been observed, the condition in syphilis may 
 be so extreme as to resemble a paralytic state within the 
 first few months of the child's life. In the rickety infant the 
 process is not so acute, but at a much earlier date than is 
 commonly supposed the muscles tend to be thrown out of 
 action by the inflammatory changes which are taking place 
 at the actively growing bony centres, especially at the 
 junction of the bony ribs with their cartilages and at th^ 
 ends of the long bones. At a later date, say eighteen 
 months or two years, when the wrists and ankles are 
 distinctly swollen and tender to pressure, one occasionally 
 
 * " Rest and Pain," by John Hilton, London, 1887, p. 183. 
 
II o Rickets 
 
 finds a very similar form of pseudo-paralysis to that already 
 described as occurring in syphilis. 
 
 So marked is the muscular debihty that it has been 
 suggested that there is an actual structural alteration peculiar 
 to rickets in the musculature. Thus, Bing* describes the 
 following changes, viz., great thinning of the muscle fibres 
 associated with tendency to disappearance of the transverse 
 striation, while the longitudinal striation is markedly ac- 
 centuated. There is also excessive and diffuse multiplication 
 of the muscle nuclei and replacement of the finer connective 
 tissue by coarser fibres ; there is a complete absence of fatty 
 tissue. From these observations, Bing suggests that the 
 histological changes are peculiar to rickets and that they 
 differ from the other myopathies of children. That there is 
 a great loss of function and wasting throughout the whole 
 muscidar system is true, but that there are any profound 
 structural changes in the muscular fibres seems unHkely, 
 when the readiness with which even severe cases recover, 
 immediately the environment is altered, is considered. The 
 other suggestion, that there is an enfeeblement or arrest of 
 development of these parts of the central nervous system 
 controlling muscular tone seems more Ukely, and is in 
 accordance with what we know of the action of rickets on 
 the nervous system. Aschenheim and Kaumheimer ex- 
 amined the muscles of eight rachitic children and three 
 without rickets, and found in all the rickety cases that there 
 was a diminution in the amount of calcium corresponding 
 to the severity of the disease. 
 
 This early interference with the proper tonicity and 
 nutrition of the muscles is a ssmiptom of great importance. 
 Nowhere is it of greater importance than in relation to 
 abdominal tension. 
 
 Many morbid conditions are recognised as due to 
 alterations in abdominal tension and are credited with 
 producing varied and far-reaching results. Glenard's 
 
 * Bing. " Histopathologische und electrodiagnostishe Untersuchungen 
 bei rachitischen Kindern mit pseudo-paxetischen und atonischen Muskel- 
 storungen." Med. Gesellsch. Basel., Dec. 6th, 1906. 
 
The Early Signs and Symptoms of Rickets 1 1 1 
 
 disease, or enteroptosis, occurs in two classes of cases ; one, 
 where the normal support of the abdominal wall is lost in 
 consequence of repeated pregnancies or recurring ascites, 
 and a second and more important group in younger persons, 
 where the prolapse of the viscera is associated with a 
 motley group of nervous symptoms, frequently classed as 
 neurasthenia. 
 
 It is not generally recognised how important this one 
 factor of abdominal tension is in the maintenance of health 
 throughout the whole period of Ufe from infancy to old age. 
 Probably no better criterion of physical fitness at any period 
 of life could be obtained than by estimating the value 
 of this one factor of abdominal tension. In the young 
 rickety infant one of the first effects of the muscular debihty 
 is the loss of tonicity of the abdominal muscles, and the 
 consequent characteristic distension of the abdomen which 
 is so common a feature of the disease. 
 
 Under normal conditions the muscles of the abdominal 
 wall constitute, as it were, a great resilient tube or belt, in 
 which not only is there a continuous elastic support from 
 the tonicity of the muscles, but each individual contraction 
 and relaxation has an influence in helping on the circulation 
 in the great vessels within the abdomen, and in maintaining 
 in their proper position the hver and spleen and the whole 
 gastro-intestinal tract. The continuous elastic pressure on 
 the intestines prevents hquid accumulations and flatulent 
 distension, and aids the action of the involuntary muscular 
 fibre which allows of the three or four motions daily in the 
 healthy child. 
 
 It is very different with the rickety child. The laxity of 
 the abdominal muscles rapidly produces the " pot-belly " of 
 rickets. The muscular wall of the intestine soon shares in 
 the general muscular atony and the bowels become dis- 
 tended and lethargic, and there is an unhealthy stagnation 
 of gases and fluids within the abdomen. Constipation 
 rather than diarrhoea is an early feature of the disease. The 
 faeces are usually small in quantity and are light in colour. 
 Not infrequently, especially if cow's milk is given, the 
 
1 1 2 Rickets 
 
 stools are liimpy and pasty and may be coated with mucus. 
 Alternating with this the motions may become loose and 
 very offensive, and it is this irregularity of the bowels, con- 
 stipation alternating with occasional loose motions, which 
 is characteristic of rickets in its early stages. Very frequently 
 however, the bowels give rise to no trouble. At a somewhat 
 later stage the child frequently finds relief from abdominal 
 discomfort by lying on its face during sleep. 
 
 The circulation of the blood and Isnnph within the 
 abdomen is greatly aided by the healthy contraction and 
 tone of the muscles. In rickets the obstruction is chiefly in 
 the capillary circulation, and lymph stasis leads to a fibroid 
 hyperplasia which, according to Ewart,* accounts for the 
 slighter forms of interstitial proliferation found in the liver 
 and spleen. 
 
 The effect of the abdominal atony on the respiratory act 
 is very profound. Normally, in the act of inspiration the 
 chest expands and the contraction of the diaphragm tends 
 to protrude the abdominal wall. The elastic recoil of the 
 healthy abdominal wall is an important factor in the 
 expiratory act. In the rickety child there is little or no 
 movement in the abdominal wall, and this important aid to 
 respiration is lost. At the same time, it is to be noted that 
 the upper pait of the chest moves but httle, and the dia- 
 phragm is chiefly responsible for carrying on the respiratory 
 act. In typical cases, the only region showing active 
 respiratory movement is the inferior costal region, but in- 
 stead of the normal inspiratory expansion occurring, the 
 mechanical effect of the contraction of the diaphragm is 
 reversed, and a marked recession of the chest takes place 
 during contraction, followed by expansion during expiration. 
 This is the reverse of the normal act. The lower aperture of 
 the thorax is moulded, as it were, over the inert abdominal 
 contents, and the contraction of the diaphragm in place of 
 protruding the abdomen in the normal way produces a 
 
 * " The Abdominal Atony of Rickets, its Significance and its Treat- 
 ment," by Wm. Ewart, M.D., Cantab., F.R.C.P., British Medical Journal. 
 1906, II, p. 920. 
 
The Early Signs and Symptoms of Rickets 1 1 3 
 
 direct drag on its attachments to the yielding ensiform and 
 six lower rib cartilages. 
 
 The origin of the diaphragm is at the circumference and 
 is alike on both sides. It arises : (1) by fleshy slips from 
 the inner surface of the ensiform cartilage ; (2) from the six 
 lower rib cartilages by a series of serrated shps which inter- 
 digitate with the attachments of the transversalis abdominis ; 
 (3) from two aponeurotic arches between the last rib and the 
 spinal column, one being placed over the quadratus 
 lumborum and the other over the psoas ; (4) from the 
 lumbar vertebrae by two crura or pillars, the right from the 
 upper three or four lumbar vertebrae and the interposed 
 discs, and the left from the first and second lumbar vertebrae 
 and the adjacent discs. 
 
 From this origin the fleshy fibres are inserted into the 
 trefoil tendon in the centre of the muscle. This tendon 
 consists of a right, a left, and a middle lobe. In the 
 descent of the diaphragm the parts of the tendon move 
 unequally. Thus the central lobe, above which the heart is 
 placed, moves least, while the lateral lobes, above which the 
 lungs are situated, move freely. The extent to which the 
 central tendon descends in full inspiration is estimated by 
 Hasse * at one inch for the right lobe, four-fifths of an inch 
 for the left lobe, and two-fifths of an inch for the hinder 
 part of the middle lobe. The fibres from the ribs ascend 
 vertically, and while the vault of the diaphragm is maintained 
 by the abdominal viscera, the contraction of the muscle 
 elevates and expands the upper ribs to which it is attached. 
 In the rickety subject the diaphragm acts at a double dis- 
 advantage : (1) in place of the abdominal viscera being 
 depressed and the abdomen somewhat protruded during 
 inspiration, allowing the natural recoil of the abdominal 
 walls to aid the act of expiration, the abdomen remains 
 immobile, and the diaphragm loses the advantage of the 
 elastic give and recoil of the abdominal wall ; (2) the 
 softeiied ribs have not sufficient rigidity to act as an efficient 
 support for the muscular fibres, and the diaphragmatic con- 
 
 * Archiv. fiir Anatomie, 1886, p. 199. i 
 
114 Rickets 
 
 traction actually draws on its attachments, pulling in the 
 lower ribs, as already noted, instead of expanding the chest 
 in the lower costal region. 
 
 Rokitansky believed that the changes in the formation 
 of the chest in the rachitic child were due to the recession 
 of the ribs in the act of inspiration produced by the dia- 
 phragm in its contraction, associated with want of power in 
 the inspiratory muscles attached to the outside of the ribs* 
 Jenner attacked this view, and ascribed the malformation 
 of the chest solely to the result of atmospheric pressure 
 acting on the softened long ribs, producing the prominent 
 keel-shaped sternum and the longitudinal furrow on either 
 side of it, and also the transverse depression now known as 
 Harrison's sulcus. There is but little doubt that atmo- 
 spheric pressure is the main factor producing these changes, 
 but clinical observation of the rickety child shows that the 
 reversed action of the diaphragm is also an important factor. 
 In place of the diaphragm acting from a resistant fulcrum, 
 constituted by the ensiform cartilage in front, and the two 
 crura and the aponeurotic arches behind and the six lower 
 rib cartilages laterally, this part of the lever is greatly 
 weakened and shows but little rigidity. At the same time, 
 the central tendon of the diaphragm is maintained in a 
 more or less stationary position by the resistant abdominal 
 mass, which does not move up and down as in health, and 
 the pull of the muscle is deviated from the insertion of the 
 muscle to its origins. If the diaphragm acts forcibly and 
 quickly, as in sobbing, this recession of the most flexible 
 part of the thoracic parietes is most plainly seen, and is a 
 factor of considerable importance helping to produce the 
 collapse of the lower and posterior portions of the lungs, 
 which is so dangerous a feature when the child is attacked 
 by such diseases as bronchitis, whooping cough, or measles. 
 
 By these concerted actions the lower ribs are moulded 
 over the liver, and the inert abdominal viscera and Harrison's 
 sulcus is produced, a transverse furrow which begins at the 
 level of the xiphisternum and passes from thence outwards 
 and slightly downwards. The very early and considerable 
 
The Early Signs and Symptoms of Rickets 1 1 s 
 
 thickening, which takes place at the costo-chondral junc- 
 tions, is possibly an attempt on the part of nature to buttress 
 the rib at its weakest point. Similarly, when the action of 
 the powerful muscles of inspiration attached to the outer 
 surfaces of the ribs is considered, the loss of their activity 
 must be a contributory factor in producing the characteristic 
 deformity of the chest. 
 
 From a very early date, with the weakness of the muscles 
 is associated great weakness of the ligaments and the other 
 supporting structures of the joints. The relaxation of the 
 joints seems to last for a very long period and is responsible, 
 in a large measure, with the muscular weakness, for the onset 
 at the period of adolescence of such conditions as flat foot, 
 genu valgum and varum, and the various forms of lateral 
 curvature. Even after apparent complete recovery, in the 
 adult there may be a certain degree of genu recurvatum or a 
 capacity for extending the knee beyond a straight line. A 
 similar condition not infrequently affects the elbow joint. 
 Double joint is a very characteristic and well known sign 
 of rickets, which is frequently looked on as an accomplish- 
 ment rather than as an infirmity, which it really is. These 
 children can assume extraordinary attitudes, and can often 
 place the limbs in unnatural positions, owing to the muscular 
 enfeeblement and laxity of the ligaments. In severe cases, 
 for instance, the child may rest for hours in the sitting posture 
 with the legs extended and with the body bent forwards, so 
 that the face rests on the knees. 
 
 Rickets is an insidious disease, frequently beginning, as 
 Schmorl has shown, in the second month, but not usually 
 recognised till the sixth or eighth month, by which time it is 
 already well advanced. The nervous symptoms appear very 
 early. The child becomes dull, peevish and irritable. There 
 is, in well marked cases, a general tenderness of' the whole 
 body and the patient courts rest and resents being handled 
 or interfered with. The sweating of the head and neck 
 during sleep is a characteristic early sign. 
 
 The state of the general nutrition in rickets has already 
 been touched upon. In eight hundred rachitic children in 
 
ii6 Rickets 
 
 the East end of London, it was found that eighty per cent, 
 were of good or of very good nutrition, while in only twenty 
 per cent, could the nutrition be said to be distinctly poor. 
 The child, especially if fed upon the breast, frequently looks 
 well nourished and healthy. At other times the infant does 
 not increase in weight satisfactorily and the muscles are soft 
 and flabby. But marked wasting is by no means a constant 
 sign, even in severe rickets, and in deaths from marasmus 
 there is generally no sign of rickets. Wasting in the young 
 infant of from a few days old up to the end of the second 
 or third month is a much more common sign of hereditary 
 syphilis than it is of rickets, especially in the syphilitic form 
 of pseudo-paralysis. In such a case the child looks cachectic 
 and has an old expression. The skin is dusky and shrivelled 
 and the eyehds and lips may be fissured. Coryza, hyper- 
 trophy of the hver and skin eruptions are common in syphilis. 
 Such a series of symptoms is uncommon in rickets, especially 
 at this early stage. The very fat, flabby and pale-com- 
 plexioned child is well known in rickets. Frequently in 
 these cases nothing abnormal is suspected till delay in 
 teething or in walking draws attention to the fact that the 
 child is not progressing as it should. 
 
CHAPTER IX 
 
 Chang-es in the Bones of the Vault of the Cranium and 
 in the Bones of the Upper and Lower Extremities 
 visible to the Naked Eye 
 
 Changes in the skeleton visible to the naked eye. 
 
 As has already been seen, these begin insidiously and at a 
 very early age, and Schmorl, as the result of actual micro- 
 scopical examination, found that the bony alterations might 
 begin as early as the second month. Frequently they are 
 overlooked in the early stages by both the parent and the 
 physician, and in the milder cases they have to be system- 
 atically looked for ; but when this is done they are usually 
 fairly obvious. The skeleton, as a rule, is affected as one 
 organ by the disease, but the structural alterations may be 
 more marked at certain parts. In the young child the 
 changes show a definite sjmimetry. They affect the long 
 bones mainly in the growing ends of the bones, in and 
 around the layer of cartilage l5dng between the diaphysis 
 and the epiphysis, where the bone is growing in length by 
 ossification in cartilage, and at the circumference of the 
 shaft where the bone is increasing in thickness by ossification 
 in membrane (periosteum). 
 
 In the fiat bones of the skull the errors in growth tend 
 to manifest themselves at the growing borders in the 
 neighbourhood of the sutures, and at the centres of ossifica- 
 tion in the region of the natural eminences of these bones, 
 where sweUing and softening of the osseous tissue are usually 
 well marked. 
 
 Changes in the fiat hones of the vault of the cranium. 
 
 The most marked and the earliest alterations appear in 
 the fiat bones forming the vault of the cranium. The 
 
 117 
 
1 1 8 Rickets 
 
 tendency to delayed closure of the fontanelles and sutures 
 has already been noted ; in place of closing on or about the 
 age of two years, the anterior fontanelle may still be widely 
 open, and may not close until the third or fourth year, or 
 even later. Normally, the most rapid growth in the cranial 
 vault is focussed round the anterior fontanelle, and for this 
 reason closure does not take place in the healthy child till 
 about the end of the second year. In rickets there is a 
 general holding-up of the growth, not only of the skeleton 
 as a whole, but also of the nervous system, and for this 
 reason the closure of the fontanelle is much delayed, allow- 
 ing a longer period for adaptation to the needs of the more 
 slowly developing brain. 
 
 When rickets begins early, the cranial changes are not, 
 as a rule, very notable clinically till the fifth or sixth month. 
 It win be remembered that this period tends to coincide 
 with the disappearance of cranio-tabes, which is so common 
 and so evanescent a change in many childish ailments. 
 Frequently in mild rachitic cases there is only a sUght 
 sweUing in the neighbourhood of the parietal and frontal 
 eminences and along the edges of the bones bordering the 
 sutures. These changes may be very sUght and may pass off 
 without producing any characteristic deformity. When the 
 alterations are more persistent in the frontal region, the 
 forehead tends to become large and square. It is both 
 wide and high. The frontal eminences show bossing, 
 forming what is known as the Oljonpian type of forehead, 
 very commonly seen in the rachitic child to-day. 
 
 In many diseases, especially those which affect growth 
 and development, there is a tendency to reproduce a certain 
 t3T)e. This is conspicuously true of acromegaly, where all 
 the eases look as if they were members of the same family. 
 Similarly in a disease like rickets, which may pervade a 
 whole nation, these very deformations may come to form 
 a national type. Later, in discussing the history of rickets, 
 reasons will be shown for believing that, before the disease 
 actually developed in England, it was already well estab- 
 Ushed on the Continent, notably in the low-lying country of 
 
Changes in the Bones 119 
 
 Flanders, and in the great commercial and industrial centres 
 of the Hanseatic League. Indeed, the high square fore- 
 head or front Olympien came to form a national ideal of 
 dignity and beauty, and is constantly depicted as such by 
 the Flemish school of painting. 
 
 Not only, however, is the frontal region affected, but a 
 similar overgrowth takes place in the parietal region. The 
 bossing in the region of the parietal eminences is often 
 exceedingly well marked and is a much commoner and 
 more persistent sign than the frontal bossing. In placing 
 the hands on the heads of school-children for the purposes 
 
 Fig. 3. — Infant skull showing position of parietal bossing and the 
 thickening along the coronal and sagittal sutures, the character- 
 istic cranial signs of rickets. 
 
 of palpation, this is the> sign which is much the most 
 frequent and is often very conspicuous. The borders of the 
 parietals may show thickening and the sagittal suture may 
 come to lie in a groove or hollow. (Fig. 3.) On the 
 other hand, as already pointed out, the process may lead to 
 softening and thinning of the borders of the bones, and if 
 the changes occur in the first few months cranio-tabes may 
 develop in the region of the posterior border of the parietals. 
 It will be observed that the alterations described in the 
 frontal bones and in the parietals closely resemble those met 
 with in congenital syphilis. When these , changes occur 
 early it is not always easy to distinguish between syphilis 
 and rickets. In the syphilitic lesion there is a more acute 
 
120 Rickets 
 
 inflammation and the swollen areas are more tender. When 
 the frontal bosses and the parietal bosses are both well 
 marked, constituting the natiform Skull or the caput 
 quadratum of Parrot, the condition, as Parrot correctly 
 pointed out, is usually syphilitic. In pure rickets the 
 natiform head is by no means common. In the rachitic 
 subject, when the frontal bossing is well marked, the high 
 intellectual-looking forehead is apt later to become con- 
 soUdated into the forbidding, overhanging type of forehead 
 so characteristic of many slum dwellers. In these cases the 
 parietal bossing is not well marked and the head may 
 assume the doliocephaUc type. In the commoner class the 
 parietal bones are chiefly affected and the deformation of 
 the frontal region is but little marked or is entirely absent, 
 and the skull tends to assume the brachycephalic type 
 characteristic of rickets. It is worthy of note that in the 
 rachitic state the disease seems to concentrate either on the 
 parietal or the frontal region, but not on both at the same 
 time, while in syphilis the tendency is for both frontal and 
 both parietal bones to be simultaneously affected. 
 
 Throughout the skeleton rickets manifests itself chiefly at 
 the points where growth is proceeding most rapidly. In the 
 flat bones of the vault of the skull it is most marked at two 
 parts, viz., the centres of ossification and the rapidly growing 
 borders. Of all the bones of the cranial vault, the parietal 
 bone is the chief centre of growth, and therefore it is not 
 surprising to find that it is usually the bone most markedly 
 affected in rickets. If the disease is severe and continued, 
 more advanced changes occur. Towards the borders of the 
 bone the outer surface becomes more vascular, somewhat 
 swollen and slightly roughened, and the outer table loses its 
 shiny appearance. This roughened surface becomes some- 
 what elevated above the level of the adjacent smooth bone 
 by the formation of a light, finely porous and friable bone 
 which, in the dry specimen, has very much the appearance 
 of pumice stone. 
 
 This change is usually very definitely symmetrical and 
 progresses from the margins of the bone towards the centre of 
 
Plate I. 
 
 Frontal bone of an infant showing well marlsed rickety ciianges. The 
 greater part of the bone is thickened and is converted into a light, 
 dry, finely porous and friable tissue. This porous, spongy bone has much 
 the appearance of fine pumice stone and is slightly raised above the 
 level of the smooth compact bone which still remains. The change 
 is symmetrical and progresses from the circumference of the bone 
 towards the centres of ossification which, with an area round, are free 
 from the disease. The inner surface of the bone shows the same 
 changes, somewhat less advanced. — Hnntcritm. 
 
 [To face p. 120. 
 
Changes in the Bones lai 
 
 ossification, which, however, with a variable space round it, 
 usually reta.ins its smooth compact appearance (see Plate I). 
 In severe cases the inner surface of the bone may also be 
 roughened, though the changes are usually much more 
 marked on the external aspect. On both surfaces the 
 openings for blood vessels are more numerous and larger 
 than in health. When the inner surface is much roughened, 
 remains of the smooth compact bone of the inner table may 
 stiU be seen in areas corresponding to the spaces between 
 the cerebral convolutions. At a later stage the disease may 
 involve both the outer and inner tables, and the diploe, and 
 the thickness of the bone may become very greatly increased. 
 The bone throughout its thickness is frequently converted 
 into a uniform finely cancellous tissue, in which there is no 
 distinction between tables and diploe. At times the thicken- 
 ing may be very considerable, even from four to six lines, On 
 the inner surface of the bone there are large grooves for the 
 meningeal arteries, and the apertures for the blood vessels 
 are especially large and nuiperous. In the dried specimen 
 the bones throughout are finely cancellous, the cells being 
 small and irregular in form and lined by tortuous lamellae. 
 The bone is hght and brittle in texture and may, in the 
 dried specimen, be easily converted into a coarse powder. 
 
 At a still later stage a reparative process occurs, by means 
 of which this loosely cancellous bone becomes consolidated. 
 The walls of the various cells become thickened till their 
 cavities are greatly reduced, and in place of the bone being 
 light and porous it tends to become solid and heavy. 
 
 In the rickety skull there i§ frequently an appearance as 
 if the cranial capacity were considerably increased. Apart 
 from hydrocephalus, this is , practically never the case. 
 Either the capacity of the skull remains normal, or when 
 the thickening is very great it may be considerably encroached 
 upon. 
 
 Several stages then can be noted in the progress of the 
 disease in the membrane bonel of the cranial vault, viz. : — 
 
 1. a general softening and swelling of the bone chiefly affect- 
 ing the outer table. Frequently, the process never goes 
 
122 Rickets 
 
 beyond this stage, and there may or may not be slight 
 bossing over the centre of ossiiication as a result. In 
 young infants, up to the sixth month, certain areas may, 
 as a result of pressure, become thin and atrophied, and 
 cranio-tabes may be produced : 
 
 2. as a result of an extension of the disease, new light can- 
 
 cellous bone is formed, which projects slightly beyond 
 the level of the outer table and tends to replace it. 
 This is usually associated with some roughening of the 
 inner table, but at this stage the disease is usually more 
 marked on the outer surface : 
 
 3. in severe cases the whole thickness of the bone may be 
 
 involved, so that the distinction between inner and outer 
 tables and diploe is lost, and the structure throughout is 
 uniform, light, and porous : 
 i. a reparative process occiurs whereby the bones become 
 consoUdated and indurated, not only by recalcification, 
 but also by the formation of new lamellae thickening the 
 walls of the ceUs till these are reduced to minute pores. 
 
 It is important to remember that when this process of 
 consolidation takes place it is remarkably persistent and 
 may not disappear throughout life. It is quite commonly 
 seen in the adult, in the heavy forbidding forehead, and the 
 overhanging eyebrows of the slum dweller who has suffered 
 somewhat severely from the disease and over a prolonged 
 period. 
 
 The bones of the face also participate in the rachitic 
 process. Both maxillae are liable to be affected, but the 
 most notable changes take place in the superior maxillae. 
 These alterations are peculiar in that their manifestation is 
 delayed, as a rule, till a considerably later period, usually 
 about the period of second dentition. These changes are 
 part of a connected process associated with such conditions 
 as post-nasal obstruction due to adenoids, mouth breathing, 
 and chest deformation, and will be best dealt with when 
 speaking of alterations in the function of respiration in 
 rickets and their effects on the growth of the upper jaw and 
 the bones of the face. 
 
 Changes in the long bones. 
 Jules Guerin, in his celebrated observations on the 
 pathology of rickets, in 1837, described two stages : (1) a 
 

 Plate II. 
 Longitudinal section of rachitic femur,, slightly reduced. 
 r. Greatly thickened and irregular layer of iiitertnediary cartilage. 
 
 2. Long process of cartilage extending into the osteoid tissue. 
 
 3. Islands of cartilage surrounded by osteoid tissue. 
 
 4. Osteoid tissue merging into the fibrous and partially calcified trabeculse 
 
 of the medulla. 
 
 5. Greatly thinned and expanded periosteal bone with formation of 
 
 osteoid tissue under periosteum. 
 
 [To face p. 1 2-^. 
 
Changes in the Bones 123 
 
 period of effusion and proliferation associated with rare- 
 faction ; (2) a period of deformation and of organisation of 
 the tissues which have undergone proliferation.* 
 
 In the first stage the bone is easily bent and is soft, so 
 that it may be cut with a sharp knife. If a section of the 
 bone be made in its long axis, splitting the bone into two 
 halves, it will be noted that there is considerable prolifera- 
 tion of the medullary tissue, which is softer and redder than 
 normal. The medullary cavity tends to be actually increased 
 by the enlargement of the areolar spaces and by the rare- 
 faction and absorption of the compact bone. At the same 
 time, there is a swelling of the intermediate semi-transparent 
 bluish zone of cartilage, between the diaphysis and the 
 epiphysis. On examination by the naked eye, this is seen 
 to be increased in thickness and to have a reddish colour, 
 owing to abnormal vascularisation. It is markedly irregular, 
 and at times long processes of partially calcified cartilage 
 can be seen extending upwards into the osseous spongy 
 tissue, or there may be isolated islands of cartilage sur- 
 rounded by new bone (see Plate II). A double process is 
 going on. 
 
 At the same time that there is a rarefaction of the pre- 
 existing healthy bone, there is a formation of osteoid tissue, 
 especially in the region of the zone of ossification at the 
 epiphysial ends. This takes place on an exaggerated scale. 
 All the scaffolding, as it were, for the new growing bone 
 is erected in excess, but the actual building of the bone faUs 
 far short of the preparations made. The enlargement of the 
 ends of the long bones and the beading of the ribs are due to 
 this overgrowth of the layer of cartilage and to the formation 
 of ill-formed, spongy bone. 
 
 In mild caSes, the periosteum and the sub-periosteal 
 layers may exhibit no marked structural alteration, but when 
 the disease is a little more intense these tissues usually show 
 changes. The periosteum is much thickened and soft and 
 
 * Jules Guerin. " M^moire sur les caractftres gen^raux du rachitisme," 
 Bull, de I'Acad. du mid., 13 Juillet, 1837, et Compt. rend, de I'Acad. des 
 Sciences, 1839. 
 
124 Rickets 
 
 shows increased vascularity. It is less easily stripped off 
 than in the normal subject, and when so stripped it is rough 
 and irregular, bearing numerous spicules and fragments of 
 ill-formed osseous tissue on its inner aspect. The compact 
 bone beneath the periosteum may be greatly thinned and is 
 often replaced by concentric layers of soft spongy bone. 
 This new bone, or osteoid tissue, is imperfectly calcified and 
 readily allows of curvatures of the bone, and even of 
 fractures if a sudden force is applied to it. 
 
 The two processes, then, which are characteristic of rickets 
 are, as Guerin pointed out, a process of medullisation and 
 the formation of spongy bone. These processes, as a rule, 
 proceed together in the same bone, though the meduUi- 
 sation is the first change which occurs. In this process the 
 medulla or bone marrow increases in volume and becomes 
 redder than normal. It is much softer than natural and 
 there is much fluid not contained in the blood vessels. 
 Following the increase of the medulla, the cancellous spaces 
 in the shaft and towards the end of the bone become en- 
 larged, so that the medullary cavity as a whole actually 
 becomes expanded. Under the periosteum the laminae of 
 the compact bone are spHt up and a rarefaction of the 
 compact bone begins, and it tends to be replaced by spongy 
 bone or osteoid tissue. While this spongy bone is formed 
 under the periosteum, it is mainly found between the 
 medullary cavity and the epiphyses at the diaphysial end of 
 the long bones. This tissue is soft and spongy, with many 
 fine spaces, and cuts easily with a knife, a grating sensation 
 being imparted to the edge of the knife, owing to the im- 
 perfect calcification which has taken place. 
 
 In the long bones, as in the flat bones of the skull, the 
 rachitic process tends to end in repair. The medulla loses 
 its red colour in the shaft of the bone and becomes less 
 abundant. The spongy tissue becomes paler and the excess 
 is in part absorbed, and in part becomes consolidated. New 
 lamellae are formed in the spaces of this spongy tissue, which 
 gradually becomes transformed into a dense compact bone, 
 harder and denser than normal bone, so that it has an ivory- 
 
Changes in the Bones 125 
 
 like appearance on section. This new bone is especially 
 abundant in the concavity of the bend in the shaft of the 
 bone, but in the tibia it frequently encroaches very largely 
 on the medullary cavity, owing to the deposit of new dense 
 compact ebumated bone on the medullary aspect of the 
 shaft. 
 
 The following sites are the parts of the skeleton most 
 frequently and most vigorously attacked by rickets. The 
 anterior extremity of the ribs seems to be the part for which 
 rickets has the chief affinity. Next, in early cases, come the 
 bones of the vault of the cranium, and after this the inferior 
 extremities of the femur, radius and ubia, and the tibia and 
 fibula. Following this in order come the superior extremity 
 of the humerus, the vertebrae and the iliac bones, while the 
 sternum is but rarely affected. 
 
CHAPTER X 
 Microscopic Anatomy of the Bony Changres in Rickets 
 
 Microscopic changes in the bone in rickets. 
 
 The work of Virchow, published in 1853, on the minute 
 anatomy of the changes which take place in normal ossifica- 
 tion and in the rachitic process, constitutes an important 
 landmark in the study of this disease.* It has formed the 
 model for most of the subsequent work which has been 
 done on the subject. Most observers have not been able to 
 break away from his authority or to extend the scope of 
 the enquiry, and the study of the pathology of rickets has 
 largely Umited itself to an examination of the changes 
 which take place in the bone and cartilage, and but little 
 attention has been paid to the important structural alter- 
 ations which occur elsewhere throughout the body. 
 
 Already, in the fifth week of the life of the infant, 
 Virchow found that, as the result of rickets, there was a 
 retardation of the process of bone formation, and an unequal 
 and irregular growth in the region of the line of calcification 
 of the cartilage. 
 
 The first notable change takes place in the meduUa. The 
 medulla or marrow normally fills up the hollow of the shaft 
 of the long bones and occupies the cavities of the cancellated 
 structure, and it also extends into the larger Haversian 
 canals. The medullary cavity and the cancellae are lined by 
 a medullary membreuie which, however, cannot be detached 
 as a continuous structure. In the healthy adult, the marrow 
 which fills the cavity in the shaft of the long bones differs 
 
 * " Das nonnale ICnoclienwachstum und die rachitische Storung 
 desselben," von Rud. Virchow, Archiv. fUr Paihologische Anatomic und 
 Physiologie undfUr KHnische Medicin. Fflnften Bandes, viertes Heft, 1853. 
 
 126 
 
Microscopic Anatomy of the Bony Changes 127 
 
 from red bone marrow, and is of the character of ordinary 
 adipose tissue, the fat cells being supported by a kind of 
 retiform tissue, while between them, cells similar to those 
 found in the red marrow occur. In the cancellated ends of 
 the long bones, in the ribs, and notably in the cranial diploe, 
 the medulla is of the nature of red marrow, which contains 
 very few fat ceUs. 
 
 In the foetus and in the young infant, the marrow filling 
 the general medullary cavity in the shaft of the long bones, 
 unlike what is found in the adult, is of the nature of red 
 marrow, and the cells have the power of aiding in the 
 building up and the absorption of bone. In the adult, 
 the marrow cells lose their osteogenic function, and the 
 medullary tissue probably takes no part in the formation of 
 new bone. Soon after birth fat cells begin to be deposited 
 in the meduUa of the shaft, but at birth they are con- 
 spicuously absent. It is another illustration of the erroneous 
 observation that the new-bom infant is a storehouse of fat. 
 
 When the rachitic process begins the fatty element of 
 the marrow tends to rapidly disappear. ProUferation takes 
 place in the cells of the medullary spaces. According to 
 Marfan, this increase takes place chiefly in the nucleated red 
 blood corpuscles and in certain large multi-nucleated cells 
 (eosinophile myelocytes), while the still larger giant cells or 
 myeloplaxes, which, according to Kolliker, play such a large 
 role in the absorption of bone in the process of normal 
 ossification, do not appear to be more abundant than in 
 health. In rickets these giant cells do not seem to take 
 much part in the process of rarefaction which is a con- 
 spicuous feature of this disease. 
 
 The blood vessels of the medulla are dilated, and in them 
 may be seen small infarcts consisting of clumps of red 
 blood corpuscles, or there may be minute haemorrhages with 
 traces of pigment. If the disease is acute, medullary cells 
 appear under the periosteum, where they are not usually 
 found, though osteoblasts in large numbers occupy this 
 situation in health. 
 
 In the process of normal bone formation, several layers 
 
128 Rickets 
 
 may be noted in the cartilage at the end of the long bones 
 lying between the shaft or diaphysis and the epiphysis. 
 Furthest away from the actual line of ossification there is a 
 comparatively quiescent layer of ordinary hyaline cartilage. 
 Next to this, and nearer to the line of ossification, there is a 
 layer of actively proliferating cartilage where the cells are 
 swollen and are rapidly dividing. In the zone where 
 ossification is taking place normally, these cells arrange 
 themselves in rows and are somewhat flattened transversely 
 to the long axis of the bone. In the trabeculse between 
 these columns of cells, a process of calcification goes on 
 leading to the formation of primary or temporary bone. 
 
 In normal bone capillary loops come from the vessels 
 of the bone marrow and are, as it were, held up by this layer 
 of calcified cartilage. Gradually, however, as these vascular 
 loops covered with medullary cells approach the calcified 
 cartilage, certain of the cell columns break down and the 
 blood vessels pass into the cell columns between the calcified 
 trabeculffl, carrying the osteoblasts with them. These apply 
 themselves to the trabeculae and begin to form new bone 
 on the remains of these calcified cartilaginous processes. 
 This is a regular and ordered process, and is very different 
 to what takes place in rickets, where the blood vessels 
 penetrate far and wide into the partially calcified cartilage. 
 
 In rickets three stages of the disease are generally 
 described — ^the incipient stage, the florid stage, and the 
 period of healing. The first essential part of the rachitic 
 malady is a holding up and delay of the normal process of 
 ossification. The enlargement at the epiphysial end of the 
 long bones at first sight appears to be due to the excessive 
 production of cartilage. It is true that an overgrowth of 
 cartilage does take place, but in the main the enlargement is 
 due to the fact that ossification is much delayed and pro- 
 ceeds very slowly, so that the cartilage does not become 
 converted into the properly calcified and more compact 
 bone. The layer of cartilage between the epiphysis and the 
 diaphysis, where it abuts on the capillary loops extending 
 from the marrow, has failed to undergo the usual provisional 
 
Plate III. 
 
 Longitudinal section through the junction of a rib and its cartilage from a 
 rickety child of eighteen months, X, lo, Kassowitz. 
 
 PL, Pleural side. 
 
 A, Normal cartilage. 
 
 B, Proliferation zone deeper than normal. 
 
 c, Columnar zone, enormously increased and showing islands and processes 
 of osteoid tissue deposited round the blood vessels spreading from the 
 spongy layer and fi om the perichondrium. 
 
 SP, Spongy tissue with wide spaces filled with grumous material, containing 
 many cells. 
 
 V, Blood ves.sel. 
 
 [7'i) face p. ;2y. 
 
Microscopic Anatomy of the Bony Changes 129 
 
 calcification, or at most has been calcified very irregularly. 
 As a consequence the capillary loops, instead of being 
 arrested at this calcified area, penetrate readily into the 
 cartilage and spread far and wide, splitting it up in all 
 directions. The osteoblasts which are carried in with these 
 blood vessels immediately proceed to the formation of new 
 bone, but the process is only partial. A tissue which has 
 morphologically the appearance of true bone is laid down 
 in the form of thick irregular laminae, but the laminae do not 
 become properly calcified. This is the osteoid tissue which 
 plays so important a part in rickets. 
 
 But the cartilage is not only invaded by the vessels from 
 the medulla. From the periosteum an abundant over- 
 growth of vessels takes place, penetrating the epiphysial 
 cartilage. These split up the cartilage and end in a network 
 of small vessels, running for the most part parallel to the 
 plane of ossification. This vascularisation of the cartilage, 
 which is normally present in the foetus, is quite abnormal 
 after birth. The free supply of blood vessels from the 
 medulla and from the periosteum, splitting up the cartilage 
 and carrying with them the medullary cells right into the 
 substance of the cartilage, is quite irregular and is one of the 
 early and reliable signs of the disease. As a consequence, 
 the cartilage becomes excavated in all directions, and a 
 medley of all the processes of ossification results. Ir- 
 regular masses of imperfectly formed bone lie in the midst of 
 the much expanded cartUage layer on the one hand, while on 
 the other, islands or processes of partially calcified cartilage 
 extend far into the osteoid tissue, which has been laid down 
 (see Plate III). 
 
 Not only, however, is there a holding up of the normal 
 ossification, but a process of rarefaction precedes and 
 continues pari passu with the formation of osteoid tissue. 
 This rarefying process is greatly in excess of what takes place 
 in healthy growing bone. The medullary cells are the active 
 agents promoting the absorption of bone, but, according 
 to Marfan, in rickets this process is not carried out by the 
 myeloplaxes which produce absorption in normal ossification. 
 
13° Rickets 
 
 As a result of the rarefying osteitis in rickets there is an 
 enlargement of the areolar spaces of the spongy bone and 
 of the cancellated spaces of the medullary cavity. Osteoid 
 tissue, that is tissue which has the morphological structure 
 of bone, but which is imperfectly calcified or entirely uncalci- 
 fied, is formed in two ways, firstly, by the absorption of lime 
 salts from old bone which has been previously calcified, and 
 secondly, by the laying down of new bone which has never 
 been calcified. The increase in bulk of the cartilage and the 
 formation of the osteoid tissue which takes place, especially 
 towards the diaphysial end of the bone, together form the 
 swelMng noted at the epiphysial end of the long bones 
 and also the beading at the costo-chondral junction of 
 the ribs. 
 
 Meanwhile, in the shaft of the bone changes are also 
 taking place. The medulla, which has acquired the character 
 of red marrow, passes, as has been seen, under the periosteum 
 and into the Haversian canals. As a result of this intrusion 
 rarefaction takes place and the Haversian canals are enlarged, 
 and the layers of compact bone underneath the periosteum 
 become first of aU softened and the laminae become de- 
 tached. If the disease is at aU severe, the compact bone is 
 decalcified and softened and may be entirely removed and 
 be replaced by osteoid tissue newly laid down. In severe 
 cases the compact layer of bone under the periosteum may 
 be very thin, and it can readily be understood that such a 
 bone is liable to fracture from very shght violence. So that 
 even under the periosteum of the shaft, osteoid tissue is 
 found, and it is especially abundant where perforating 
 vessels pass through the compact bone from the periosteum 
 to the medulla. As the disease progresses the marrow tends 
 to become much more fibrous, and laminae of bone or 
 masses of osteoid tissue may be present in this fibrous 
 marrow. 
 
 In the flat bones of the skuU the swelling of the parietal 
 or frontal eminences is due to the formation of soft and 
 spongy osteoid tissue, which may subsequently become 
 entirely absorbed if the rachitic state be slight. If the 
 
Microscopic Anatomy of the Bony Changes 1 3 1 
 
 rickets be severe and prolonged, the spongy bone tends to 
 become organised and consolidated by becoming completely 
 calcified, and by the laying down of fresh laminae in the 
 areolae, so that the former spongy tissue is converted into 
 hard and dense bone. When this latter change takes place 
 it is wonderfully permanent, and is quite commonly seen to 
 persist in the dense thickened skull bones of the adult of 
 forty years. This is especially noticeable when the recon- 
 struction takes place in the thickened bone of the frontal 
 region. 
 
 In rickets the interference with the bmlding up and 
 moulding of the bone is very marked. But at no time does 
 the process, as it were, get out of hand. The confusion 
 which occurs is at times very marked, but there is always a 
 very ready tendency to recovery even in advanced cases. 
 When this takes place new laminae are laid down in the 
 areolae of the spongy bone, and these new laminae and the 
 spongy bone become completely calcified. Faulty bone is 
 removed by a process of absorption and considerable curves 
 in the bone may become straightened out. When the 
 curvature of the bone is well marked, or the disease severe 
 and prolonged, the give in the bone may not be corrected, 
 and in the rebuilding of the bone strong buttresses are often 
 thrown out strengthening the concavity of the arch. 
 
 In the florid stage of the disease there may be minute 
 infarcts within the capillaries and smaller vessels or there 
 may be minute haemorrhages. But the process is more 
 controlled than are the changes which occur in the same 
 situations as the result of scurvy. In scurvy the cartilage 
 has the appearance of having been driven with some violence 
 into the softened bone, so that the laminae and trabeculae 
 lying underneath the cartilage are splintered and strewn 
 about in all directions.* Haemorrhages are common, and, 
 especially under the periosteum, are liable to be extensive 
 and severe. How far the scurvy is responsible for the bead- 
 ing of the ribs it is difl&cult to say. That it has some 
 influence in producing the condition seems probable from 
 
 * Hess, " Scurvy Past and Present," 1920. 
 
132 Rickets 
 
 the histological picture, which differs considerably from that 
 produced by rickets. It must be remembered, however, that 
 while Barlow's disease is a true scurvy, it frequently occurs 
 in a rachitic subject. The probability is that the change is 
 essentially rachitic in these cases, but that super-added to it 
 there are the more acute changes which occur in scurvy. In 
 the ordinary way, it may be safely inferred that if the child 
 has a well marked rosary the condition is due to rickets. 
 Scurvy is a well defined disease and is a comparatively rare 
 condition in this country. It is an acute affection which 
 definitely menaces the hfe of the child, and to include under 
 the term scurvy various forms of anaemia and conditions of 
 ill-health due to defective and deficient feeding and to faulty 
 nourishment is not warranted by what is known of the 
 disease. It is due to the continued want of a specific 
 accessory food factor essential to the maintenance of health, 
 and if the deficiency be severe enough to produce scurvy 
 the s57mptoms are very distinctive and the menace to the 
 child's hfe is a very real one. 
 
 The nature of the bony changes in rickets. 
 
 The chemical study of the bones in rickets has not added 
 greatly to our knowledge of the disease. The following 
 table, taken from Vierordt shows, what is now well estab- 
 hshed, that there is a marked deficiency in the proportion of 
 inorganic salts in the bones in this disease, but that the 
 proportion of the different salts is the same as in normal 
 bone.* 
 
 There are two chemical theories explaining the process 
 of normal calcification and ossification. The first is that 
 chemical precipitants are formed in the tissues from nucleo- 
 proteins, possibly by a process of autolysis. Autolysis is a 
 process occurring in cell degeneration whereby, probably 
 as the result of enz37mes, a form of self-digestion occurs 
 within the cell. The chemical precipitant, it is suggested, 
 may be phosphoric acid formed by breaking up of the 
 
 * " Chemical Pathology " by H. Gideon Wells, Ph.D., M.D., Phil- 
 adelphia and London, 1920. 
 
Microscopic Anatomy of the Bony Changes 133 
 
 nucleo-proteins of the cartilage cells, which combines with 
 the calcium from the plasma. The administration of phos- 
 phorus has long been a recognised form of treatment for 
 rickets, and is considered by many of the nature of a specific. 
 
 
 Normal bone 
 
 of a two 
 
 months old 
 
 child. 
 
 Rachitic bones. 
 
 
 Tibia. 
 
 Uhia. 
 
 Femur. 
 
 Tibia. 
 
 Hu- 
 merus. 
 
 Ribs. 
 
 Verte- 
 brae. 
 
 Tnorganic matter . . . 
 Organic matter 
 
 65-32 
 34-68 
 
 64-07 
 35-93 
 
 20-6o 
 
 79-40 
 
 33-64 
 66-36 
 
 18-88 
 
 8l-I2 
 
 37-19 
 62-91 
 
 32-29 
 67-71 
 
 Calcium phosphate... 
 Magnesium phosphate 
 Calcium carbonate ... 
 
 Soluble salts 
 
 Collagen (or ossein)... 
 Fat 
 
 57-54 
 1-03 
 6-02 
 
 0-73 
 
 33-86 
 
 0-82 
 
 56-35 
 I-OO 
 
 6-07 
 
 1-65 
 
 34-92 
 
 I-OI 
 
 14-78 
 
 0-80 
 
 3-00 
 
 1-02 
 
 72-20 
 
 7-20 
 
 26-94) 
 0-81/ 
 4-88 
 1-08 
 
 60-14) 
 
 6-22) 
 
 15-60 
 
 2-66 
 0-62 
 
 81-22 
 
 
 ... 
 
 The second view, elaborated by Wells, is that ossification 
 depends on physico-chemical factors and variations in the 
 carbonic acid content of the blood. Wells points out that 
 all tissues about to become calcified undergo retrogressive 
 changes, such as hyaline degeneration as in cartilage, or 
 necrosis. Thus these tissues tend to assume a similar 
 physical character. Further, in the areas about to become 
 calcified the circulation is feeble, and the blood plasma 
 soaks slowly through the tissues as through a foreign sub- 
 stance. These hyaUne structures, besides showing an affinity 
 for calcium, also show an affinity for pigment and iron. 
 This is conspicuously seen in the enamel of the teeth in the 
 brown lines of Retzius. Hofmeister believes that normally 
 the blood which comes to the cartilage has a higher degree 
 of saturation with calcium salts and carbonic acid gas than 
 the fluid is able to maintain as it slowly permeates the 
 cartilage, and that when this carbonic acid content is 
 diminished calcium salts are precipitated. 
 
 Wells implanted various tissues into the abdominal 
 
1 34 Rickets 
 
 cavities of rabbits, and found that tissues rich in nucleo- 
 proteins showed no tendency to take up calcium in greater 
 amounts than did tissues poor in nucleo-proteins, which 
 speaks against the theory that phosphoric acid derived from 
 nucleic acid combines with the calcium. On the other hand, 
 a piece of boiled cartilage placed in the abdominal cavity 
 rapidly became thoroughly impregnated with calcium and 
 salts, which seemed to be deposited, as regards carbonate and 
 phosphate, much as in ordinary bone. Wells favours the 
 second view, that changes in the physical characters of the 
 tissues and variations in the carbonic acid content of the 
 blood are the chief agents in rickets preventing the lajdng 
 down of calcium salts at one time and causing their 
 absorption at another. 
 
 The crude views which have been put forward from time 
 to time that rickets is due to the absorption of calcium salts 
 from the bones by free acids, or other acid molecules circu- 
 lating in the blood, have been largely abandoned in so far 
 as they are contrary to everything that is known of the 
 chemistry of the blood. Nor are the changes in rachitic 
 bone at all comparable to the changes which are produced 
 by a simple removal of calcium salts, such as would occur 
 from placing the bone in an acid medium. 
 
 Neither are calcium poor foods now held to be an active 
 agent in the production of rickets. Stoeltzner has shown 
 that while young animals fed on food deficient in calcium 
 show defective bone formation, the defect is simply a 
 quantitative one, and that the pseudo-rachitic bone shows a 
 notable affinity for calcium salts and undergoes rapid 
 calcification when these are supplied.* 
 
 It has been maintained that in rickets there is a simple 
 arrest of or a delay in the metabolism, but, as has already been 
 shown, there are essential anatomical differences between 
 the osteoid tissue laid down in this disease and that laid 
 down in health, which could not be explained by a simple 
 holding up of the normal process. 
 
 * " Pathologie und Therapie der Rachitis," vou Dr. Wilhelm 
 Stoeltzner. Berlin, 1904. 
 
Microscopic Anatomy of the Bony Changes 135 
 
 Virchow first expressed the view that the changes in this 
 disease were essentially of an inflammatory nature, and that 
 they are due to an irritative process of the nature of a rare- 
 fying osteomyeUtis. Kassowitz and Ziegler have strongly 
 supported this view. That the changes are essentially 
 inflammatory in their nature seems certain, when the changes 
 in the bone marrow ceUs and in the connective tissue basis 
 of the medulla are considered, and also the active sweUing 
 and proliferation which occurs in the cartilage cells. 
 Furthermore, there is the evidence of the hypersemia and 
 the proliferation of blood vessels in the medulla, and the 
 invasion of the cartilage, not only from these vessels but 
 from the periosteum. Now there are all degrees of irritation 
 and of inflammatory response, and in rickets the process is 
 essentially a sluggish one, distinguishing it very markedly 
 from the acute processes which occur as the result of 
 experiments in animals, notably dogs, and in animals under 
 confinement. There is an absence of acute cellular 
 infiltration and of fibrinous or purulent exudates, and 
 haemorrhages are not common. Ziegler believed that the 
 inflammatory process chiefly affected the endosteum, or 
 membrane which lines the medullary space, and the areolar 
 spaces of the cancellous bone. 
 
 The probability is that the process is of a double nature, 
 and that an inflammatory response to an irritant runs pari 
 passu with a delay of all the normal processes of ossification, 
 and indeed of most of the metabolic processes throughout 
 the body. Marfan* lays great emphasis on the early changes 
 which take place in the medullary tissue and in the cells of 
 the cartilage, more especisdly of the former. As already 
 pointed out, the marrow cells in the medullary space and in 
 the areolar spaces of the cancellous tissue at the ends of the 
 long bones divide rapidly and the whole tissue becomes 
 unduly vascular. Fibro-vascular bundles invade the car- 
 tilage, the Haversian canals and the interstices of the 
 compact bone extending, as has been shown in well marked 
 cases, right up under the periosteum. The ossifying 
 
 * Marfan, loc. cit., pp. 324-332; 
 
136 Rickets 
 
 cartilage participates actively in the irritative process, for the 
 cartilage cells also swell and divide abnormally. Like all 
 inflammatory processes, these irritative changes tend to end 
 in the formation of new fibrous tissue, and in time, in place 
 of the actively proliferating, very vascular meduUa, there is a 
 tendency for the marrow to become harder and more fibrous 
 than normal, and for osteoid tissue to be deposited in the 
 trabeculse. 
 
 But, before this further change takes place, there is also 
 a notable arrest of the normal process of bone formation. 
 New bone is not laid down, and the process of decalcifica- 
 tion and absorption of old bone, which normally occurs, 
 stiU continues and is probably exaggerated. In place of 
 new bone formation, there is an excessive la5n[ng down by 
 the osteoblasts of osteoid tissue, resembling new bone 
 morphologically but with well marked difference in the 
 form and arrangement of the laminae. This imperfect 
 tissue is deposited chiefly in the vicinity of the growing 
 centres of the long bones, and, owing to the irregularity of 
 the cartilaginous overgrowth in this region, cartilaginous 
 tissue appears in the spongy bone and spongy bone in 
 the cartilage. As the process of absorption of old bone 
 continues in other situations, for example, tmder the peri- 
 osteum, so it tends to be replaced by this imperfect 
 osteoid tissue. 
 
 These changes wiU again be discussed in speaking of the 
 aetiology of rickets, and it is important to remember the 
 double nature of the process, consisting of a slow, indolent 
 inflammatory change, with an arrest, more or less complete, 
 of the normal ossification. 
 
 Such then, are some of the changes occurring in the bone 
 in rickets. Frequently, these changes in the skeleton are 
 treated as if they embraced in themselves the whole path- 
 ology of the disease. That this is far from the truth will be 
 shown in the following chapters, where marked pathological 
 variations will be found to occur in the teeth, skin, eyes and 
 nervous system, and very notably throughout the lymphatic 
 system. The changes in the nervous system have not yet 
 
Microscopic Anatomy of the Bony Changes 137 
 
 been demonstrated, but by analogy, and from the very 
 definite line of nervous symptoms produced, such changes 
 may be reasonably. inferred. 
 
 Rickets is an insidious disease and has far-reaching 
 effects on the whole economy of the growing child. 
 
CHAPTER XI 
 
 Common Deformations produced in the Long Bones and 
 Certain Deformities appearing^ at Adolescence and 
 their Relation to Rickets. Late Rickets 
 
 Given this general softening of the skeleton, associated with 
 the loss of ligamentous and muscular support, many of 
 the secondary deformities which occur in the bones can be 
 shown to be produced by the mechanical effects of pressure. 
 What form these deformations will take, depends on the 
 direction in which the force is applied, and whether the 
 child is attacked before the period of walking or afterwards. 
 A vigorous, healthy child does not for long maintain the 
 attitude of rest when it is awake. It shifts its position 
 frequently and delights in action and in sudden movements. 
 The rickety child habitually assumes and maintains this 
 attitude of rest, the result being that the normal physio- 
 logical attitude of rest tends to become fixed, and later to be 
 exaggerated. 
 
 The femur is, as a rule, curved forwards and outwards 
 throughout its length, an exaggeration of the slight normal 
 curve of this bone. Before the child walks in the rachitic 
 state, this curvature tends to be increased by the weight 
 of the legs and feet as it sits on the mother's lap and the 
 feet hang pendant. On walking, the weight of the trunk 
 naturally tends to aggravate the curve. If an adult femur 
 be examined, when the bone has undergone a process of 
 induration and consohdation, and the disease has become 
 arrested and partially cured, the appearances are very 
 characteristic. The condition, in the great majority of cases, 
 is symmetrical. Usually, the bone is hard and dense and 
 may be heavier than normal. The growth of the bone in 
 length is diminished, and this, with the bending of the shaft, 
 
 138 
 
Vi',' 
 
 Plate IV. 
 
 Rachitic femur (left) from a person of nearly adult age. Upper epiphyses 
 completely united and the lower almost united. Upper and middle 
 thirds of the bone are curved forwards and are laterally compressed. 
 Linea aspera at this curved portion projects far backwards. Bone is 
 hard and heavy. Surface of neck is rough as also is the surface of the 
 lower third of the femur. — Hniilcyicui. 
 
 [To hue p. r;o. 
 
Common Deformations 1 39 
 
 tends to produce the shortened stature characteristic of 
 rickets. The surface of the femur, especially in the upper 
 portion of the shaft between the two trochanters, is fre- 
 quently roughened, and there may be a similar roughening 
 on the anterior surface of the lower third of the shaft. In 
 the midst of this rough surface, above and between the 
 condyles, there is often an area where the compact bone is 
 clear and glistening, and when this is the case a similar 
 area is present on the other femur, showing that the 
 approach to symmetry is very close. The femur is fre- 
 quently much flattened laterally, especially in the region of 
 the greatest degree of curvature, and the anterior surface of 
 the bone forms, as it were, the arc of a bow. Posteriorly, 
 the concavity of the bone is filled in by a buttress of 
 osseous tissue, thrown out to strengthen the bone where it 
 is weakened by the arch. In the femur this is usually along 
 the luiea aspera, and a distinct ridge of bone fiUs up the 
 concavity of the curve and forms the chord of the arc. 
 (PI. IV.) At other times this chord may not be seen on an 
 examination of the external aspect of the bone. In the 
 tibia, to make the compensatory strengthening support 
 visible, a longitudinal section must be made, when it will 
 be found that there is great thickening of the bone in its 
 concavity, but this thickening takes place in the cancellous 
 tissue of the shaft, so that the medullary cavity is much 
 encroached upon. 
 
 Another characteristic deformity of rickets is an altera- 
 tion of the angle at which the neck of the femur is set on 
 the shaft. In the normal subject this varies with age. In 
 the young child the neck of the thigh is so oblique that it 
 forms almost a gentle curve from the axis of the shaft ; in 
 the adult the angle is an open one, about 125° ; as age 
 advances the neck tends to drop and to approximate a right 
 angle, and at the same time its compact wall becomes 
 thinner and its cancellous tissue more expanded, so that 
 there is an increased tendency to fracture of the neck of the 
 femur in old subjects. 
 
 In the rachitic subject, the head and neck of the femur 
 
HO Rickets 
 
 are frequently somewhat small and slight, and the angle at 
 which the neck is set on the shaft tends to be less obtuse 
 than normal, that is, the rachitic bone tends to approximate 
 in this respect the bone of aged persons. This is the natural 
 result of the pressure of the weight of the trunk in the erect 
 attitude, and is the condition to which the term coxa vara is 
 applied. Coxa vara, however, is only said to be present 
 when the deformity is sufficiently severe to produce 
 symptoms. It may be a congenital condition, when it is 
 quite unassociated with rickets and may be found in several 
 members of the same family. Most commonly it is acquired 
 and occurs at the period of adolescence, usually between the 
 ages of thirteen and seventeen years. It may be unilateral or 
 bilateral. While a tendency to this condition undoubtedly 
 occurs as a result of rickets, coxa vara of a degree sufficient 
 to produce symptoms is much less common than might be 
 anticipated, considering the frequency with which the 
 deformity in a mild form is seen in the rachitic femur. 
 Fiorani first described this condition as occurring in fifteen 
 cases of rickets, in 1881,* and the deformity is now well 
 recognised. 
 
 Hoffa has seen it as early as eighteen months. 
 
 Whitman, in an analysis of seventy-two cases, found 
 that, as regards the age of incidence, they were grouped as 
 follows t : — 
 
 Over 17 years 6 
 
 Adolescents, 12-17 years 40 
 
 Later childhood, 5-11 years 23 
 
 Early childhood, less than 5 3 
 
 In about one-third of these cases there was a distinct history 
 of rachitis. Outward curvature of the shaft is sometimes 
 compensated by a downward direction of the neck. In the 
 rare intractable cases, which do not recover spontaneously, 
 the usual symptoms of coxa vara appear, viz., shortening of 
 the limb, rotation outwards of the Umb and eversion of the 
 
 * " Sopra una forma speciale di zoppicamento." Gazz. degli ospedali. 
 i88i. 
 
 t " A Treatise on Orthopaedic Surgery," by Royal Whitman, London, 
 1919. 
 
Common Deformations 141 
 
 foot, and adduction associated with limitation of abduction. 
 The great trochanter is prominent, partly due to elevation of 
 that process above Nekton's line, and partly to muscular 
 atrophy. Its incidence is apt to be associated with pain, and 
 a Hmp or a waddling gait. The diagnosis is, as a rule, made 
 on X-ray examination. HofEa states the diagnosis between 
 the congenital and rickety forms can be made out from the 
 direction of the epiphysial line between the head and neck 
 of the femur. In the rickety form it is oblique, while in the 
 congenital form the direction is vertical. Spontaneous cure 
 may generally be anticipated in rickets. The treatment of 
 coxa vara in rickety cases is usually associated with the treat- 
 ment of the other deformities in the Umb, such as genu 
 valgum, or curving of the tibia, leaving the coxa vara to 
 right itself. Occasionally, in early infancy, individual cases 
 benefit by forcible abduction, the limb afterwards being 
 retained in the position of extreme abduction. In rare 
 cases, linear osteotomy of the shaft, or the removal of a 
 wedge of bone at the level of or below the trochanter minor 
 may be required, when the deformity is severe and persistent. 
 The tibia and fibula frequently give way at a very early 
 date. One of the early signs in connection with the tibia is 
 the swelling which takes place at the lower extremity in the 
 region of the epiphysial line, just above the malleolus. This 
 is usually more marked on the tibial side, but the fibula may 
 be similarly swollen, and the characteristic knotting just 
 above the malleoli, with the tumefaction of the wrist, forms 
 a very characteristic sign of the developed rachitic state. 
 These swellings are not, as a rule, apparent so early as the 
 beading of the ribs. Most commonly it is first appreciable 
 from the twelfth to the eighteenth month, and the character- 
 istic curving of the tibia is noticed somewhat later. In 
 patients belonging to the hospital class, the bending of the 
 tibia is usually noticed about the age of two years, or a httle 
 afterwards. Naturally, the children of better-class parents 
 are brought to the surgeon at an earlier date than those of 
 the poorer class. As a rule, the deformity commences at a 
 much earlier age. Even before the child begins to walk. 
 
142 Rickets 
 
 the normal curvature of the tibia outwards tends to be 
 exaggerated by the child sitting cross-legged, so that the 
 outer malleolus bears on the floor. The characteristic 
 curve is outwards and forwards. The outward curve is very 
 constant and often very pronounced, and is most commonly 
 seen at the junction of the lower and middle thirds, though 
 it sometimes occurs in the upper third. As in the femur, 
 there is usually flattening of the bone from side to side, 
 resulting in the production of a knife-like edge. The 
 forward curve most commonly affects the lower third of the 
 bone or the junction of the lower and middle thirds, and 
 the sabre-like edge of the tibia in this region is a sign 
 pathognomonic of rickets. 
 
 On rare occasions the tibia may give way so as to pro- 
 duce a curve inwards. The fibula follows the changes in 
 the tibia. Congenital sj^hilis may also induce bending 
 of the tibia, and may give rise to some difficulty in diagnosis. 
 As a rule, the rachitic curve appears before the third year ; 
 in congenital syphilis it may appear at any time up to the 
 ninth year. In S5rphilis the curve is usually purely anterior, 
 and the crest of the tibia is smooth and rounded, while the 
 surfaces of the tibia are convex. In rickets, on the other 
 hand, the convexity is usually antero-extemal and the edge 
 of the tibia sabre-like, while the surfaces of the bone are 
 either flat or concave. Frequently, the bowing of the tibia 
 and fibula is associated with flat-foot, but genu valgum 
 does not, as a rule, co-exist with it. Slight degrees of bow- 
 legs are exceedingly common and generadly tend towards 
 spontaneous cure. 
 
 Genu recurvatum, in which the knee is habitually over- 
 extended, may be found associated with many conditions 
 such as club-foot, infantile paralysis, and deformities of one 
 limb, but is especially common when the muscles and 
 hgaments are relaxed, as in rickets. In children with loose 
 joints a slight degree of over-extension is very common, and 
 may be combined with a varying degree of knock-knee. In 
 an interesting paper on adolescent or late rickets, Mr. 
 Glutton shows an excellent X-ray photograph of the con- 
 
Common Deformations 143 
 
 dition, where the deformity is produced by curvature of the 
 lower end of the femur with the convexity forwards, and 
 of the upper end of the tibia with the convexity back- 
 wards. These changes are produced by an overgrowth in 
 the neighbourhood of the epiphysial line, which, as is 
 usually the case, is more marked on the diaphysial side of 
 the epiphyses. In some cases the tibia alone shows the 
 characteristic curve and, in slighter cases, genu recurvatum 
 may simply be the result of the relaxation of the liga- 
 mentous and muscular supports of the joints without actual 
 curvature of the bones. 
 
 In the upper hmb the most characteristic sign of the 
 rachitic state is the enlargement of the wrist, which takes 
 place especially over the expanded lower end of the radius. 
 As a rule, there is a furrow between the wrist and the hand. 
 The shafts of the ulna and radius tend to show a slight 
 curve, the convexity of which is backwards. This condition 
 is most marked near the wrist and is simply an exaggeration 
 of the normal curve of these bones. Later, in the sitting 
 posture, the child throws part of the weight of the body on 
 the arms, and as a result of the pressure both bones are apt 
 to become somewhat twisted and curved outwards, especially 
 in the neighbourhood of the wrist. 
 
 The rickety hand is relatively long and slender. Koplik 
 described a beaded condition of the fingers, which he 
 attributed to thickening of the shafts of the phalanges, so that 
 the shafts of the bones were greater in circumference than 
 the ends of the bones near the inter-phalangeal joints.* 
 This appearance, however, as was pointed out by Siegert,"f 
 is rather due to the elongation and narrowing of the joints 
 and the adjacent parts, owing to relaxation of tendons and 
 ligaments, which leaves the middle of the phalanges relatively 
 but not actually enlarged. 
 
 Frequently the humerus is but little deformed, and the 
 epiphysial enlargement is much less marked at the elbow 
 
 * " The Rachitic Hand," by Henry Koplik. Archiv. of Pediatrics. 
 Vol. XXI, 1904. 
 
 t Siegert : " Verhandl. d. Gesellschaft f. Kinderheilk." (Cassell), 
 XX, 1903, p. 240. 
 
144 Rickets 
 
 than at the wrist. The shaft may be somewhat curved out- 
 wards and forwards, as in the femur. Later, the humerus 
 tends to be bent outwards at the insertion of the deltoid, due 
 to the weight of the arm acting on the softened bone when 
 it is raised to a horizontal position by that muscle. 
 
 The scapula is apt to be somewhat swollen and softened, 
 especially along its borders, though it is frequently un- 
 affected. The clavicles are often markedly affected. As 
 usual, the characteristic bending of the bone is an exagger- 
 ation of the normal curvature. The inner two-thirds is 
 curved forwards more than is normally the case and is also 
 bent somewhat upwards. This is most marked just outside 
 the attachments of the pectorahs major and the sterno- 
 cleido-mastoid muscles. The second curve is backwards, 
 near the articulation to the acromion process, and the 
 characteristic projection of the acromial end of the clavicle 
 is often a very marked sign in the shoulder girdle of the 
 rickety child. These curves are apt to be especially marked, 
 owing to the force brought to bear on the clavicle when 
 the weight of the trunk is thrown on the upper extremities. 
 
 Three deformities in the lower limbs have been men- 
 tioned, coxa vara, genu recurvatum, and genu varum, all 
 common conditions which, however, are but incidents in 
 the progress of the disease, and do not, as a rule, call for 
 operative measures, in so far as they show a strong tendency 
 to natural cure. Three conditions — scoUosis, genu valgum, 
 and flat-foot or pes valgus — are very directly associated 
 with rickets, and are important in that they often demand 
 direct surgical treatment, and are the common deformities 
 for which children are first brought under medical care. 
 Each of these conditions may arise during the active stage 
 of the disease, that is, in the first three or four years, and 
 may even appear before the child learns to walk, but by far 
 the greatest number of cases originate during the period 
 of adolescence, euid at the time of occupational strain, from 
 twelve to eighteen years of age. 
 
 As with most rachitic deformities, several factors are 
 concerned in their production, and these may be placed 
 
Common Deformations 145 
 
 under four headings : (1) increased strain due to tlie limbs 
 having to support an excessive weight ; this agent is specially 
 operative at the time of occupational strain, after school age, 
 when continuous work is first undertaken ; (2) diminished 
 resistance, due to the softened condition of the bones ; 
 (3) loss of muscular tonicity and power. This third factor 
 is of great importance, as has already been seen in speaking 
 of abdominal tension, and not sufficient allowance has been 
 made for it in the production of morbid states. The 
 authority of Sir Wilham Jenner is largely responsible for 
 this. In his celebrated work on rickets, he discounts the 
 effect of muscular action. " In excluding muscular action," 
 he states, " from all direct share in the production of curva- 
 ture of long bones, I am, so far as I know, unsupported by 
 any authority." Now the action and interaction of opposing 
 muscles is of the first importance in the development of the 
 long bones, and is largely responsible for the very shape and 
 nature of the surfaces of these bones, and when these are 
 thrown out of action in varying degrees in the young infant, 
 this loss of action greatly affects the development of the 
 bone ; (4) the irregular thickening of the layer of cartilage 
 which lies between the diaphyses and epiphyses of the 
 long bones. This factor may in itself determine certain 
 deformities, such as genu valgum, before the child learns to 
 wallc. The thickening may be considerably greater on one 
 or other side of the joint, and this, with the increased 
 formation of osteoid tissue which takes place as the result 
 of the exaggerated growth of cartilage, tends to deflect the 
 limb away from the side of greatest thickening. 
 
 The reason for the occurrence of genu valgum in one 
 patient and of genu varum in another has been much dis- 
 cussed. Normallyy the axes of the femoral shafts converge 
 shghtly towards the knee, so as to form, on the outer side, 
 an angle of 165° with the long axes of the tibia. It may, 
 therefore, be said that a slight degree of knock-knee is 
 natural, and it can readily be understood that, if there is 
 a bias in that direction when the child begins to walk, 
 the natural tendency will be for the defect to become 
 
146 Rickets 
 
 exaggerated. But, as a matter of fact, the condition of genu 
 varum and bow-legs are more common than knock-knee. 
 Sir William Arbuthnot Lane, who has done much to 
 re-introduce the old Cartesian mechanical theory in the ex- 
 planation of morbid processes, believes that the determining 
 factor is the position assumed by the lower extremities in 
 the attitude of rest, while the child is in the erect attitude. 
 
 Put concretely, it depends on whether a plumb-Une 
 dropped from the head of the femur tends to fall to the 
 inside or to the outside of the knee. Abduction of the foot, 
 Lane points out, is the position of rest in the erect posture, 
 while that of adduction is the attitude of activity. Abduction 
 is the position habitually assumed when muscular activity is 
 poor.* The rickety child tends to stand with both hips and 
 knees flexed through an angle of 10° to 20°. If the heels are 
 in apposition, and the inner margins of the feet include a right 
 angle, the plumb-line falls considerably inside the centre of 
 the knee joint, and most of the superjacent weight is trans- 
 mitted through the internal condyle, and the patella tends 
 to be displaced inwards upon the internal condyle. The 
 bones, therefore, become deviated outwards at the knee and 
 genu varum results. If, however, the child retains its lower 
 limbs in such a position that the inner margins of the feet 
 are parallel, so that the toes point directly forwards, the 
 plumb-line falls outside the central point of the knee, and 
 the weight is chiefly transmitted through the external con- 
 dyle, and the outer tibial tuberosity and the bones at the 
 knee are displaced inwards and forwards, producing rickety 
 knock-knee. 
 
 Such an explanation applies to many cases but by no 
 means to all. Both genu varum and genu valgum are quite 
 common before the child assumes the erect attitude, and 
 before the weight of the body is imposed on the two columns 
 which support it in walking. In utero and at birth the limbs 
 of the child are naturally bowed outwards. There is a general 
 
 * " A Brief Statement of the Causation of Several of the Simple and 
 Rachitic Deformities that Develop during Young Life," by W. Arbuthnot 
 Lane. British Medical Journal, 1889, Vol. I, p. 174. " Guy's Hospital 
 Rep." 1883, Vol. XI. 
 
Common Deformations 147 
 
 curve from the hip to the ankle, more obvious below the 
 knee. At the third or fourth month the healthy child, when 
 lying on its mother's knee, loves to stretch the two limbs 
 out, and gradually the tibiae become closely applied and 
 run parallel to each other. This muscular tension is of the 
 greatest value in moulding the shape of the limbs and in 
 keeping the joints well knit. In rickets, the tone of the 
 whole limb is affected by the loss of muscular action. Not 
 only are the muscles soft and flabby, but the ligaments 
 which support the joints are lax and long, allowing easy 
 separation of the joint surfaces. The bones tend to retain 
 the outward curve longer than normal. 
 
 When the rickety child sits up, and it must be re- 
 membered that the act of walking is considerably delayed, 
 so that the sitting and crawling period tends to be unduly 
 prolonged, the favourite attitude is sitting on the floor with 
 the knees bent outwards and the legs drawn up towards the 
 body. Frequently, the legs cross near the ankle. Often 
 the hands are placed on the floor, so that the weight of 
 the body is partly borne on the arms. In this position 
 there is a marked tendency to separation of the external 
 condyle of the femur from the articular surface of the 
 external tuberosity of the tibia, and at this early period the 
 two joint surfaces may easily be separated passively and 
 may be brought together again with an impact. While 
 the pressure is diminished on the outer side of the knee, 
 there is increased pressure between the internal condyle 
 and the articular surface of the internal tibial tuberosity. 
 There is unnatural growth taking place in the epiphysial 
 layer of cartilage in both the femur and the tibia, usually 
 sufficiently marked to be visible to the naked eye on 
 section. This growth in thickness is irregular, and in the 
 cross-legged and sitting posture, owing to diminished 
 pressure, tends to be greatest on the outer side of the 
 bones, and the formation of new osteoid tissue is also 
 greater, leading to an enlargement of the external condyle. 
 Between the internal condyle and the inner tuberosity of 
 the tibia the bone is compressed and the growth of cartilage 
 
148 Rickets 
 
 is relatively diminished, while the internal condyle becomes 
 flattened, and may become very markedly so if the condition 
 becomes exaggerated. If now the child struggles on to its 
 feet while the bones are still soft and yielding, a bias has 
 been given to the direction in which deflection will occur, 
 and the weight of the body increases the bowing outwards. 
 This is especially likely to happen if, before assuming the 
 erect attitude, the child shuffles along the floor in the sitting 
 posture with the aid of the hands, while the outer malleoh 
 bear upon the floor. 
 
 If, on the other hand, the weak rachitic child crawls on 
 the hands and knees, as it not unfrequently does for a pro- 
 longed period, with the inner malleoh bearing on the floor, 
 the reverse action takes place. There is a tendency to 
 separation of the inner condyle from the internal tuberosity, 
 leading to diminished pressure and increased growth, while 
 there is increased pressure and diminished growth on the 
 outer side. At the same time, the internal lateral ligaments 
 of the knee become unduly stretched. Normally, the inner 
 condyle of the femur is fully half an inch lower than the 
 outer in the adult when the bone is placed perpendicularly, 
 but when the bone slants, as it naturally does, both condyles 
 are on the same level. In the crawling position in rickets, 
 the growth of the internal condyle is exaggerated, while that 
 of the external condyle is diminished, and a condition of 
 genu valgum is produced, which increases when the child 
 assumes the erect attitude. The increased growth of the 
 condyles chiefly affects the diaphysial side of the cartilage, 
 and in the rickety form of knock-knee the femur is chiefly, 
 and may be exclusively, at fault. When genu valgum and 
 genu varum develop before the child walks, the epiphysial 
 overgrowth is the important factor in determining the con- 
 dition, and when the child walks it is still of importance. 
 It will be readily understood that a very shghtly increased 
 unilateral overgrowth towards the internal or the external 
 condyle may be sufficient to give the bias which will 
 determine the deflection to one or other side when the 
 child walks. 
 
Common Deformations 
 
 149 
 
 Flat-foot is a deformity which not infrequently follows 
 as a result of rickets. It is a common complaint that the 
 ankles are weak in the young rachitic child. The foot may 
 constantly turn over in walking and there is frequently undue 
 mobility at the ankle. The tibialis posticus, the tibiaHs 
 anticus, the long flexors of the toes and the short flexors on 
 the sole of the foot are deficient in tone. As the muscles 
 tire, the weight of the body tends to be thrown on the 
 ligaments, which become relsixed and weakened. The 
 attitude of abduction, which is the attitude of rest, persists, 
 and after a time becomes fixed. The posterior division of 
 the tarsus, consisting of the os calcis and astragalus, is 
 rotated inwards and downwards, while the part of the foot 
 in front of the mediotarsal joint is rotated downward and 
 outward in the direction of abduction. In such a case the 
 arch may never form properly, and if already formed it 
 may become depressed. Such a condition in the young 
 child is frequently present without much pain, and, as a rule, 
 though it may be recognised that the child has weak ankles, 
 sjnnptoms of flat-foot do not supervene tiU the period of 
 adolescence. Whitman* gives the following analysis of 
 1,000 cases, showing the rate of incidence of flat-foot at 
 various periods : — 
 
 Age of Incidence. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 10 years or less 
 
 68 
 
 SO 
 
 98 
 
 10 to 15 years 
 
 lia 
 
 87 
 
 199 
 
 15 to 20 „ 
 
 144 
 
 83 
 
 227 
 
 20 to 25 ,, 
 
 94 
 
 53 
 
 147 
 
 25 to 30 „ 
 
 68 
 
 41 
 
 109 
 
 More than 30 years ... 
 
 132 
 
 88 
 
 220 
 
 Seeing then that flat-foot does not usually occur till the age 
 of adolescence, and that the active stage of rickets belongs 
 essentially to the first two or three years of the child's life, 
 the question arises as to the manner in which the disease 
 is responsible for the production of this late deformity. 
 
 * " Orthopaedic Surgery," Whitman. London, 1919. 
 
ISO Rickets 
 
 In the same way scoliosis and knock-knee, though, as 
 has akeady been noted, they frequently occur in the 
 young rachitic child between the ages of one and four 
 years, are essentially deformities which appear during 
 adolescence. 
 
 There are two periods during which bony growth is 
 exceedingly active and in which deformities of the bones 
 are especially liable to occur. The first period is from birth 
 up to the age of three or four years, and the most active 
 morbid conditions which seriously affect the skeletal growth 
 at this early period are syphUis and rickets. Adolescence is 
 the second period of weakness, and may be considered as 
 extending over a lengthened period, from the age of twelve 
 years up to seventeen or eighteen years. During this period 
 the growth of bone, which has been relatively quiescent, 
 again takes on a new activity. Other factors are of import- 
 ance at this time. The sexual functions develop at this 
 period ; a considerable degree of mental strain is often 
 imposed on the child in the closing years of its school life, 
 and, what is exceedingly important, when the child leaves 
 school at the age of fourteen, it is for the first time subjected 
 to serious occupational stress. 
 
 In the first period rickets is known to be active, and it 
 can be readily understood that bony deformities result. 
 The association of this disease with the deformities pro- 
 duced during the years of adolescence and later is, however, 
 less readily comprehended. 
 
 This raises the question of late rickets. As long ago as 
 1860, Sir Wilham Jenner referred to a case of rickets arising 
 in a girl of nineteen years.* Dr. F. G. D. Drewitt showed a 
 boy, aged ten years, to the Pathological Society of London, 
 in November, 1890. The boy died two years afterwards, and 
 the post-mortem examination showed that the process was 
 undoubtedly one of true rickets.f Since then many cases 
 have been shown, and although the disease, in the form in 
 which it is met with in the young infant, is not common at 
 
 * Medical Times and Gazette, Vol. I, i860. 
 
 t " Transactions of the Pathological Society," Vol. XXXII. 
 
Common Deformations i s i 
 
 this late period, it has been shown to be more frequent than 
 was generally supposed.* 
 
 There is a considerable difference between the condition 
 of the skeleton in early infancy and that which exists at 
 adolescence. At the earher period the long bones are 
 membranous tubes supporting layers of young bone arranged 
 in Haversian systems, the greatest thickness of the bone 
 being at the centre of the shaft and rapidly diminishing 
 in thickness towards the extremities. The resulting bony 
 and membranous tube is hour-glass shaped, and each end 
 is capped by a cartilaginous pad in which the chief growth 
 in length of the bone takes place. In the later period of 
 adolescence the bone has already assumed its adult form, 
 and even were the child exposed in the same degree as in 
 early infancy to the conditions which produce rickets, which 
 is improbable, the florid type of the disease is much less 
 likely to occur. The epiphyses, however, have not yet joined 
 the shaft of the bone and the cartilaginous layer is still 
 present, and X-ray examination of many cases has shown 
 that active rickets does occur at this time. But these cases 
 are relatively infrequent, and the acute form of the disease 
 is not sufficiently common to explain the large number of 
 deformities which arise at this period. 
 
 Ogston, of Aberdeen, holds that knock-knee, flat-foot 
 and scoliosis are the most common deformities arising from 
 adolescent rickets, and fiat-foot, he believes, is seldom due 
 to anything else but rickets, f 
 
 The question arises whether this is a new disease or a 
 recrudescence of the rachitic state which has persisted since 
 infancy. 
 
 In considering the effect of rickets on the health of the 
 community, it is of the first importance to remember that 
 while rickets is essentially a curable disease, it is, at the 
 same time, a disease which retains a tenacious hold of the 
 
 * " Adolescent or Late Rickets," by H. H. Glutton, Lancet, Vol. II, 
 1906, p. 1268. " A Case of Recrudescent Rickets," by Robert Jones, 
 Liverpool Medico-Chirurgical Journal, No. 30, January, 1896, p. 480. 
 
 t " Tbe Surgical Treatment of Rickets," by Alex. Ogston, M.D., CM., 
 British Medical Journal , Vol. II for 1888, p. 1148. 
 
152 Rickets 
 
 individual, and that the recovery is, in the great majority of 
 cases, only partial. The adult stage of the rickety infant is 
 permanently handicapped in many ways. The youth is apt 
 to be short and stunted in his growth, or he may be tall 
 and thin and weedy. He is hkely to be long-chested with 
 stooping shoulders, and to have a sallow complexion. 
 Such individuals lack the spring of healthy youth. The 
 muscles and hgaments are stUl weak and relaxed, and the 
 joints show undue mobijity. These are the children who 
 develop scoHosis at school, and flat-foot and knock-knee 
 when the extra demand on their energy is made by 
 adolescence ; or these conditions may develop somewhat 
 later, when occupational strain comes to bear on their 
 enfeebled constitution. In the late war, mihtary service 
 was the test which revealed the existence of this large class 
 of debilitated individuals, which forms to-day a heavy 
 charge on the community. 
 
 As has been shown, a reparative process occurs in the 
 bone of the young rickety subject, whereby it is consoUdated 
 and may be rendered unduly dense and heavy. In such a 
 condition florid rickets is not likely to occur, but in the 
 majority of cases this reparative process is imperfect and 
 the bone remains unduly Ught and capable of further giving 
 way when undue strain is placed upon it. 
 
 Not infrequently the three deformities, scoHosis, knock- 
 knee and flat-foot are associated together in the same 
 subject. At other times, the first part of the support to give 
 way is the foot, and flat-foot develops, to be followed by 
 genu valgum at a later date. 
 
 It is not claimed that aU three deformities are necessarily 
 rachitic. If a boy of fourteen or sixteen years is placed 
 continuously at heavy work, such as a bricklayer's labourer, 
 or if a girl be allowed to carry heavy weights before the 
 osseous and hgamentous structures of the spine and the 
 lower Umbs are sufficiently developed and consohdated, 
 failure of some part of the skeletal support is Hkely to 
 occur. But this is by no means the most important 
 factor. Among girls, scoHosis is met with much more 
 
Common Deformations 153 
 
 frequently in the well-to-do than in the labouring classes 
 of the community. 
 
 Rheumatism is another condition which may produce 
 any of these deformities, apart from rickets ; but it is not a 
 common cause. In young adults chronic synovitis, by 
 leading to weakening of the ligamentous structures, occa- 
 sionally in itself leads to the development of knock-knee. 
 But, allowing for all such conditions, the great majority of 
 these deformities occur in connection with the rachitic state. 
 The young adolescent does not assume faulty attitudes 
 without reason ; the position of rest is sought and unduly 
 maintained because the child's muscles and ligaments have 
 been weakened by present or pre-existing disease. 
 
 Three propositions then may be stated with reference to 
 the occurrence of late rickets, viz. : (1) that rickets may 
 arise ci& novo at puberty, though this is not common ; 
 (2) that a recrudescence of a previously existing disease is 
 much more common, and that adolescent rickets is prac- 
 tically the same disease as the infantile form, modified in 
 some respects by the age of the patient and by the tendency 
 to partial recovery which has taken place ; (3) that without 
 a fresh outbreak of the disease, many of the weak and de- 
 bihtated subjects of early rickets first break down when 
 the extra strain of adolescence and continuous occupation 
 is imposed upon them ; that is, the recovery from the 
 disease has only been partial and a protracted weakness of 
 the muscles, ligaments, and bones has been left behind, 
 which leads to failure at the first period of stress. 
 
 To this last class belong by far the greatest proportion of 
 these failures in the supporting structures which are so 
 liable to occur at adolescence. 
 
CHAPTER XII 
 Deformities of the Thorax in Rickets 
 
 In the rachitic infant the thorax looks small in comparison 
 with the large head and the enlargement of the abdomen. 
 Normally, at birth, the circumference of the chest forms 
 almost a perfect circle, and the antero-posterior diameter 
 and the transverse diameter are equal. Towards the end of 
 the first year the transverse diameter exceeds the antero- 
 posterior, but the somewhat cylindrical shape is retained till 
 the end of the second year. 
 
 About the fifth year the permanent shape is attained, the 
 proportion of the transverse to the antero-posterior diameter 
 being as 7 is to 5. 
 
 In the young infant there is not much movement of the 
 ribs when the child is breathing quietly ; the respiration is 
 chiefly diaphragmatic, the abdomen being protruded slightly 
 with each inspiration, the elastic recoil of the abdominal 
 walls aiding the act of expiration. The child in health 
 breathes more quickly than the adult ; in rickets the re- 
 spiratory act is apt to be much hastened, and may, without 
 any affection of the lungs, reach from forty to eighty 
 respirations per minute. 
 
 To this quickening of the respiratory act the term 
 polypnoea has been applied. The respiratory rhythm is 
 frequently altered in rickets. Instead of a long inspiration 
 being followed by expiration, and this by a pause, as in the 
 adult, there is often a short expiratory grunt followed by an 
 inspiration, and that by a pause.* In place of being a 
 smooth modulated act, the respiratory rhythm becomes 
 jerky and spasmodic — a factor which has an important 
 
 * " On dirait, suivant I'expression de Rilliet et Barthez que I'enfant 
 crache son expiration." Marfan, loc. cit., p. 260. 
 
 154 
 
Deformities of the Thorax in Rickets 155 
 
 bearing on the production of deformation of the chest wall 
 Hutchison * suggests as a reasonable explanation of this 
 inversion of the rhythm that it facilitates freer oxidation of 
 the blood, for the pause after inspiration means that the 
 lungs are kept ivHl of pure air for a much longer period than 
 by the normal method. 
 
 Asymmetry of the chest is a common defect in rickets, 
 such as a tendency to flattening of the left apex with a 
 projection of the chest wall to the right side of the lower 
 part of the sternum where it meets with the true ribs. This 
 distortion of the chest is usually the result of a slight lateral 
 curvature of the spine, and indeed the slighter forms of 
 scoliosis can often be diagnosed more easily from the front 
 than by an examination of the spine itself ; which apex is 
 flattened and which shoulder is elavated varies with the 
 form of lateral curvature present. It is noteworthy that 
 impairment of the resonance at one or other apex with 
 flattening is in children more frequently due to distortion of 
 the chest than to tubercle. 
 
 Another of the slighter deformations of the chest is an 
 elevation of the manubrium sterni at the level of the sterno- 
 clavicular joints, so that the whole chest seems as if it were 
 tilted forward and raised. This is associated with a flat- 
 tening of the chest in the sub-mammary region, as if the chest 
 had been squeezed in by two hands placed on the infra- 
 mammary regions, resulting in a pressing forward of the 
 upper part of the chest and the upper portion of the sternum. 
 This is a deformity which is commonly seen in long-chested 
 delicate adolescents and may persist throughout life. 
 
 Beading of the ribs is an early and very constant sign 
 of well marked rickets. This consists in a nodular swelUng 
 at the junction of the cartilage with the bony part of the rib. 
 As a rule, the beading is more angular than globular, and is 
 usually much more marked on the surface of the rib which 
 is towards the pleura than on that which is external, where 
 it may easily be missed by the examining finger. 
 
 * " Lectures on Diseases of Children," by Robt. Hutchison. London, 
 1906. 
 
is6 Rickets 
 
 A very common result of pressure of these rachitic nodes 
 is the so-called " white patch " on the visceral surface of the 
 pericardium. This is usually situated on the left ventricle a 
 little above its apex, just where the heart impinges on the 
 nodule of the fifth rib.* 
 
 As already noted, not aU nodular enlargements of the 
 ribs are rachitic. In scurvy very definite enlargement of 
 the costo-chondral articulation is likely to develop. Scurvy, 
 though usually associated with rickets, is by no means 
 necessarily so. It not infrequently occurs in children who, 
 apart from the error of diet which is responsible for the 
 onset of scurvy, live a healthy life much in the open under 
 conditions which are not likely to produce rickets. Rickets 
 is essentially a disease of the poor slum-dweller ; scurvy is 
 frequently a disease of the well-to-do, where the child is kept 
 rigidly to some proprietary food which is deficient in the 
 anti-scorbutic factor. The histological appearances, as has 
 been shown, are quite different from those which appertain 
 in rickets. 
 
 In considering the production of rachitic deformities of 
 the chest wall four factors are of great importance : (1) at- 
 mospheric pressure ; (2) great softening of the bony portion 
 of the rib ; (3) weakness of the muscles of inspiration due 
 to (a) the general debility of rickets, (6) loss of purchase on 
 the softened bones ; (4) over-action of the diaphragm. 
 
 Jenner was the first to point out clearly the great and 
 predominant part played by atmospheric pressure in the 
 production of these deformities, but in bringing forward 
 this theory there can be httle doubt that he discounted too 
 much the effect of the loss of general muscular action and 
 tone, and in the case of the diaphragm, the relative over- 
 action, and still more important, the disordered action of this 
 muscle. 
 
 In ordinary nasal breathing in health, when the dia- 
 phragm contracts and the ribs are elevated by muscular 
 action, air rushes in through the glottis and expands the 
 
 * " The Wasting Diseases of Children," by Eustace Smith, London, 
 1878, p. 145. 
 
Deformities of the Thorax in Rickets 157 
 
 lungs, allowing them to follow the expanding chest wall. In 
 rickets, owing to the loss of muscular power and the soften- 
 ing of the ribs, the muscles have no power to pull up and 
 evert them, and the tendency to negative pressure pro- 
 duced by the contraction of the diaphragm, gives full play 
 to the atmospheric pressure which tends to crush in the 
 chest wall all round. The ribs give at their weakest part, 
 and as a result a longitudinal sulcus is formed just outside 
 the beads at the costo-chondral junctions. 
 
 In the rachitic child, and especially in the mouth breather, 
 the entry of air into the chest is defective, and the softened 
 ribs, unsupported by internal pressure, are not able to with- 
 stand the pressure outside. The result is, that if the chest 
 be looked at from behind, the ribs are much flattened. As 
 they leave the spine they pass horizontally outwards and 
 then bend sharply forwards at the angle, passing forward 
 and inwards to join their cartilages. 
 
 In cross section the chest assumes a triangular form, the 
 two posterior angles being formed by the angles of the ribs 
 and the anterior angle being formed by the sternum. 
 
 This gives rise to the appearance which Glisson describes 
 so accurately and which he likened to the prow of a ship, 
 the condition being commonly known as " pigeon-breast." 
 The bending forward at the angle of the rib is often very 
 acute, and it is quite common to find a green stick fracture 
 on one or more of the ribs at this situation and often on 
 both sides. This may be due entirely to atmospheric 
 pressure, but is probably more frequently due to handling 
 the child in hfting it. These fractures, like all fractures in 
 rickety children, heal quite readily. 
 
 The longitudinal groove on the antero-lateral surface of 
 the chest, lying just outside the nodules on the ribs, extends 
 from the second or third rib above to the ninth or tenth rib 
 below. It passes downwards and outwards. The groove 
 varies on the two sides, tending to be shorter on the right 
 side, owing to the liver supporting the ribs, and to be 
 shallower on the left side, at the level of the fourth and fifth 
 ribs, owing to the subjacent heart. This deep groove on 
 
iS8 Rickets 
 
 either side of the sternum tends to thrust the sternum for- 
 wards, producing the diiferent forms of " pigeon-breast." 
 
 Another groove commonly seen in rickets, which is 
 frequently known as Harrison's sulcus, is a transverse 
 constriction beginning at the xiphisternum and passing out- 
 wards and slightly downwards just below the sixth rib. As 
 a rule, it does not reach as far as the mid-axillary line. It is 
 mainly due to atmospheric pressure driving in the softened 
 ribs, on the one hand, and the liver, stomach and spleen 
 helping to bulge the lower ribs out, on the other. In many 
 of these cases, especially when the diaphragm acts spas- 
 modically, the muscle can be seen to draw in this sulcus 
 forcibly with each inspiration. An inverted action of the 
 diaphragm takes place, and instead of the diaphragm 
 obtaining its purchase from its parietal origin and pulMng 
 on the central tendon so as to flatten the diaphragm and 
 drive the abdominal wall forwards, the muscle contracts 
 over the inert abdominal mass and exercises traction on its 
 origin more forcibly than on the central tendon. As a 
 restdt the lower part of the thoracic parieties are moulded as 
 it were over the abdominal contents, while the lower border 
 of the chest wall is everted and lipping takes place along 
 this margin. 
 
 Most of the more marked forms of pigeon-breast are 
 associated with obstruction to the free entry of air, and this 
 obstruction, in the majority of cases, is due to adenoids. But 
 the same condition is frequently developed in the mouth 
 breather, who does not suffer from adenoids. 
 
 A rarer variety of chest deformity is observed where the 
 sternum, instead of being thrust forward is depressed and 
 drawn in, as it were, towards the spinal column. The 
 whole length of the sternum may be sunk in, producing the 
 gutter-shaped chest [thorax en gouUiire), but more com- 
 monly the lower part of the sternum is markedly retracted, 
 forming the funnel-shaped chest (thorax en entonnoir — 
 Trichterbrust). 
 
 In Barlow's disease, there is a great and sudden weakening 
 of the chest wall, due to the acute destructive changes which 
 
Deformities of the Thorax in Rickets 159 
 
 take place at the costo-chondral articulations. This rapid 
 weakening tends to result in a marked sinking in of the whole 
 length of the sternum, producing the gutter-shaped chest. As 
 long ago as 1894, Barlow stated : " During the development 
 of this disease the sternum, with the adjacent costal cartilage 
 and a small portion of the contiguous ribs, seemed to have 
 sunk bodily back en bloc, as though it had been subjected 
 to some violence which had fractured several ribs in front and 
 driven them back. This curious appearance, taken in con- 
 junction with the sub-periosteal and other haemorrhages, is 
 said to be diagnostic of the disease." Barlow's disease is an 
 acute condition, and the severity of the changes leads to 
 this sudden giving way of the front of the chest wall. In the 
 slower process, of rickets there is not the same tendency to 
 the formation of the gutter-shaped chest, although it may 
 occasionally be seen as a result of severe and continued 
 spasm of the glottis associated with embarrassed action of 
 the diaphragm. 
 
 When the rickety infant is attacked with whooping cough 
 the prognosis as regards recovery is usually very gloomy. 
 Death is exceedingly likely to supervene from broncho- 
 pneumonia associated with collapse of the lung. In this 
 condition the over-action of the diaphragm and the spasm of 
 the glottis are apt to lead to marked retraction of the lower 
 part of the chest, especially of the lower part of the sternum. 
 If recovery takes place a true funnel-shaped deformity is not 
 infrequently left behind, in which the xiphisternum and the 
 lower part of the mesosternum are deeply retracted. 
 
 The method of production of the funnel-shaped chest has 
 given rise to much discussion and many varied opinions. 
 The congenital form, which may affect any portion or the 
 whole of the sternum, and the variety due to occupational 
 pressure, as in the well known cobbler's hollow, have no 
 specific connection with rickets and need only be mentioned. 
 
 In normal respiration there are several factors which are 
 accurately correlated to each other, viz., the strength of 
 the thoracic parieties, the opening of the larynx, and the 
 action of the diaphragm and of the inspiratory muscles. 
 
i6o Rickets 
 
 Normally, the contraction of the diaphragm tends to 
 produce a negative pressure within the chest, and the 
 elasticity of the lungs is exactly met and overcome by the 
 inrush of air through the glottis. The balance, however, is 
 easily upset, for if the child sobs violently and contracts the 
 diaphragm with abnormal rapidity and force, the most 
 flexible part of the thoracic wall is drawn in during in- 
 spiration. If the orifice of the glottis be narrowed, the 
 recession of the lower part of the chest wall becomes 
 marked and may be very distressing, as in laryngismus 
 stridulus. 
 
 The funnel-shaped chest is particularly likely to be 
 developed in the rickety state, when there is a spasmodic 
 contraction of the diaphragin associated with narrowing of 
 the glottis. Normally, the xiphisternum and the cartilage 
 of the fifth, sixth, and seventh rib cartilages are braced up 
 by the insertion of the rectus abdominis into their outer 
 surfaces. In rickets this muscle tends to be peculiarly 
 flaccid and inert, and this support is lost. The diaphragm, 
 it must be remembered, is a muscle acting between two 
 mobile resistances, the thorax on the one hand, and the 
 abdominal contents on the other, each of which is liable to 
 many and frequently recurring variations. The contraction 
 is capable of producing a double effect on the thorax or on 
 the abdomen, according to the variations which occur in 
 the resistance of these two factors. 
 
 Thus, in rickets, when the muscle contracts over the 
 inert and immobile abdominal mass the central tendon 
 becomes, as it were, the fulcrum of the lever and the force 
 of the contraction acts on the chest wall, so that the soft 
 cartilages and ribs are drawn markedly in over the liver, 
 spleen and stomach, deepening Harrison's sulcus. Normally, 
 the anterior fibres of the diaphragm, which are directed 
 more horizontally towards the central tendon, oppose the 
 forward motion of the sternum, but in cases where there is 
 prolonged over-action of this muscle, as in rickets, the in- 
 verted pull of these fibres may very markedly retract the 
 xiphisternum. Occasionally the funnel-shaped depression 
 
Deformities of the Thorax in Rickets i6i 
 
 can be seen in the actual process of formation, recurring 
 with each inspiration and flattening out during repose. 
 Prolonged bronchitis may lead to excessive and spasmodic 
 action of the diaphragm, especially in the inverted form of 
 respiratory rhythm already spoken of, where the child grunts 
 out the expiration and follows this with a prolonged inspira- 
 tion and then a pause. 
 
 Jenner taught that in all these cases the cartilages were 
 softer than the bony parts of the ribs, and were driven 
 backwards by atmospheric pressure. This is difficult to 
 reconcile with the direct pull on the thoracic parietes so 
 often seen in these debilitated children, and with the fact 
 that in these severe rickety cases the bone is often softer 
 than the cartilage. 
 
 Certain difficulties in the diagnosis of chest diseases 
 may arise as the result of rachitic deformations. It has 
 already been pointed out that in the flattening of the apex 
 associated with lateral curvature, dullness may be produced 
 which bears no connection with tubercle. Again, in the 
 rachitic subject acute disease of the lung may produce 
 violent symptoms, very often out of proportion to the actual 
 extent of the disease. 
 
 Where, as usually happens, the ribs are, as it were, 
 moulded over the heart, the action of the heart may from 
 very slight causes act very violently, and the sound and 
 impulse may be so diffuse as to give rise to the impression 
 that there is serious organic disease where none exists. 
 Rickety distortion of the skeleton may also give rise to 
 abnormal conditions of the blood vessels closely simulating 
 aneurism. It is not uncommon in cases of scoliosis to find 
 abnormal pulsation between the second and third ribs on 
 the right side of the sternum, suggesting the possibility of 
 an aortic aneurism, and this mistake has not infrequently 
 been made. 
 
 This abnormal pulsation, visible either to the right or 
 to the left of the sternum, simulating aneurism, may be 
 due to deflection of the aorta consequent on rachitic mal- 
 formation of the chest. 
 
1 62 Rickets 
 
 Balfour describes several such cases, and believes that 
 they are by no means uncommon.* If the possibility of 
 such a condition is kept in view, the grave error of stating 
 that a patient has a serious disease, such as aneurism of the 
 aorta, when in reality he is only suffering from a rachitic 
 deformity of the chest, probably of little consequence, will 
 be avoided. 
 
 * " Clinical Lectures on Diseases of the Heart and Aorta," by George 
 Wm. Balfour, 3rd Edition, London, 1898, p. 386. 
 
CHAPTER XIII 
 
 Deformities of the Spine and of the Pelvis associated 
 with Rickets. 
 
 Glisson derived the name rachitis, which he gave to 
 this disease, from the fact that the spine was one of the 
 chief parts of the body to suffer. Not that the spine 
 is more markedly affected than other parts of the skeleton, 
 but because it lends itself to deformations which are often 
 permanent and ineradicable. 
 
 Antero-posterior curvatures of the spine. 
 
 The rachitic child is late in learning to walk, and for 
 a prolonged period tends to assume a habitual sedentary 
 position, in which the head and neck and thorax are bent 
 forwards. The spine assumes a long curve with the con- 
 vexity backwards, which culminates in a rounded projection 
 at the level of the junction of the last dorsal with the first 
 lumbar vertebrae. The anterior portion of the bodies of 
 the last two dorsal and the first two lumbar vertebrae are 
 compressed vertically and the fibro-cartilages project from 
 between them. The vertebrte are still largely cartilaginous 
 and are easily moulded, and there is a tendency to diminished 
 growth of the anterior portion of their bodies in the 
 concavity of the curvature, and to increased growth at the 
 convexity. Not only are the bones soft but the ligaments 
 and muscles which support the spine are relaxed. The 
 weakest part of the spine is about the last dorsal vertebra. 
 It is the centre of the spine and the centre of motion in the 
 back, and is exposed to the powerful leverage of the ver- 
 tebral column above and below it. The lumbar portion is 
 
 163 
 
164 Rickets 
 
 very flexible, while the dorsal, supported by its ribs, is 
 comparatively rigid. The part of the spine which forms 
 the greatest degree of convexity in rickety kyphosis is 
 rounded and has not the angular appearance which is 
 usually associated with Pott's disease. Usually, too, the 
 deformity is easily reduced, and for a long time remains a 
 faulty attitude rather than an actual deformity. About the 
 third year the spine tends to recover and no trace of the 
 condition may be left. Not infrequently, a certain degree 
 of lateral curvature is associated with the kyphosis. In 
 some cases the kyphosis does not develop till a later period. 
 This may happen in the young child who has just begun to 
 attend school, when the routine and confinement prove 
 injurious. The remedy is plenty of exercise in the open air, 
 good food, and a proper regulation of the time for study and 
 for recreation. 
 
 It has already been noted, in speaking of the develop- 
 ment of flat-foot and knock-knee, that long after the active 
 rachitic process is over various sequelae remain for many 
 years, notably weakness of the ligaments and muscles and a 
 degree of softening of the bones, allowing of bending and 
 deformation of the various columns which support the 
 weight of the body. This latent weakness is especially apt 
 to show itself at the period of adolescence in those who 
 have outgrown their stock of muscular and nervous strength. 
 Round shoulders and arching of the back in the upper dorsal 
 or cervico-dorsal region are exceedingly apt to develop. 
 The head is held in advance of the body, so that the chin 
 approximates the sternum. The chest is flattened and 
 concave, corresponding to the rounded back which carries 
 the shoulders forward, so that the arms hang away from the 
 body. The scapulae are apt to be somewhat winged and 
 prominent. Frequently such conditions are associated with 
 lateral deviation of the spine. In early cases the attitude 
 of the young rickety child in the sitting posture, with the 
 arched back, and the head, which the cervical vertebrae are 
 too weak to support, thrown well backwards, forms a very 
 characteristic picture. 
 
Spine and Pelvis Deformities 165 
 
 When the rickety child struggles to its feet, the spine 
 has now to adapt itself to the erect attitude. The head and 
 shoulders tend to weigh the body forwards, and this may be 
 counteracted by the production of forward bending of the 
 spine, or lordosis. The hollow, as a rule, is in the lower 
 dorsal and lumbar region, and by its means the weight of 
 the head and shoulders is thrown backwards and the weight 
 of the protuberant abdomen is counterbalanced. Except 
 in severe and protracted cases, the kyphosis and lordosis 
 both tend to correct themselves as the disease passes off 
 towards the age of four or five years, and as the child gains 
 strength as the result of exercise. No marked structural 
 alterations, as a rule, occur in the vertebras. 
 
 Lateral curvature of the spine, or scoliosis. 
 It is commonly stated that lateral deviations of the spine 
 are less common in rickets than the antero-posterior curva- 
 tvires. This is true if the study of scoliosis be limited to 
 the period during which the child is suffering from active 
 disease during the first two or three years of its life. But 
 these deformities by no means represent the total influence 
 of rickets in the production of spinal deformities. In the 
 young child, scoliosis, if less common than the antero- 
 posterior deformities, is of much greater importance, in 
 that it tends to last much longer, and to lead to more or less 
 permanent deformities. Scoliosis appears somewhat later 
 than kyphosis, usually between the second and the fourth 
 year. In the young infant it is frequently stated that the 
 mother, as she carries the child in the sitting posture on the 
 left forearm, tends to produce a curvature with the convexity 
 towards the left. While this is possible, it is not a common 
 factor in the production of scoliosis. In the young rachitic 
 subject, the convexity of the curve may be directed either to 
 the right or to the left. In the adolescent form of rickety 
 scoliosis, the curve with the convexity to the right is the 
 common variety. Slight degrees of lateral curvature in 
 young children are of much more common occurrence than 
 is generally supposed, and in early school life its presence is 
 
1 66 Rickets 
 
 often shown by the production of shght flattening at one 
 apex with shght prominence of the lower ribs on the 
 opposite side. This is due to early rotation of the trunk, 
 and the presence of slight degrees of lateral curvature may 
 often be more easily diagnosed from an examination of the 
 front of the chest than of the spine itself. At the age of 
 five years, these slighter forms of curvature may pass away 
 and leave no trace, but, if at all marked, they not infrequently 
 persist and may very slowly increase, or may begin to 
 advance rapidly at the age of puberty. 
 
 Scoliosis in later childhood and during adolescence. 
 
 In well marked and permanent cases of lateral curvature, 
 two deformities are to be noted : (1) a lateral deviation of 
 the spine to one or other side of the median line ; (2) a 
 rotation of the vertebrae round a vertical axis. When the 
 patient stands, the simple lateral curvature is most readily 
 noted, but when the body is bent forwards and the back 
 is viewed from behind, the torsion of the trunk becomes 
 the prominent deformity. It is not the lateral inclination 
 of the spine, as a rule, which induces the mother to bring 
 the child for treatment, it is usually a " high " shoulder or a 
 " high " hip that is first noticed. 
 
 The causes of lateral curvature of the spine are many 
 and varied, but when all cases dependent on such direct 
 causes as irregularity of the length of the hmbs, infantile 
 paralysis, diseases of the chest are excluded, and others 
 definitely due to occupational stress of an exceptionally 
 heavy nature, there remains a large class usually discussed 
 under the heading of " scoliosis of adolescents," which is 
 generally supposed to begin at puberty, but which has its 
 origin at a very much earlier period. These children lack 
 vigour and are much inclined to loll about. They are un- 
 able to bear any sustained fatigue, and when the stress of 
 adolescence comes, the weak muscles, ligaments, and bones, 
 are apt to give at the points of stress, and such conditions 
 as flat-foot, knock-knee, and scoliosis are likely to supervene. 
 Attacks of acute disease, chlorotic anaemia, tuberculosis, and 
 
Spine and Pelvis Deformities 167 
 
 various other conditions may predispose to the production 
 of these deformities, but by far the commonest and most 
 important cause is the rachitic state in early infancy, which 
 has left its mark in a profound debility and the weakening 
 of the supporting structures of the skeleton. 
 
 For various reasons girls suffer more than boys. They 
 are apt to be subjected for a longer period to the debilitating 
 influence of a confined and unhealthy environment, and the 
 demand made on their reserve of strength at the time of 
 puberty is considerably greater than in boys. A much larger 
 process of adaptation has to take place in the female skeleton 
 at this period than in the male, and the likelihood of a 
 breakdown is greatly increased. 
 
 While it is difficult to estimate the proportion of cases 
 in which rickets is responsible for the production of 
 scoliosis, the probability is that the larger proportion 
 of severe and intractable forms are directly due to this 
 disease. 
 
 Tubby has pointed out that scoliosis is very commonly 
 associated in young adults with nasal obstruction and 
 adenoids. The sequence of adenoids causing chest de- 
 formity in early childhood, with kyphosis at a slightly later 
 period, say from six to ten years, followed by scoliosis at the 
 age of puberty, is a very common one. Frequently the 
 removal, of enlarged tonsils and adenoids leads to a rapid 
 disappearance of the deformity and an immediate improve- 
 ment in the general health. As already stated, the high 
 shoulder or hip, or prominence of the scapula, are the 
 common conditions for which the mother seeks advice. 
 
 In the most common variety of scoliosis, the primary 
 curve is present in the dorsal region with the convexity to 
 the right, while there is a compensatory curve to the left in 
 the lumbar region and often a slighter compensatory curve 
 also to the left in the cervical region. The deformity pro- 
 duced by the twisting of the trunk, in a well marked case, is 
 as if a hand had been placed on the right infra-mammary 
 region in front and the other hand over the posterior 
 surface of the chest in the region of the angles of the left 
 
1 68 Rickets 
 
 ribs, and firm and continuous pressure had been maintained. 
 The result is that the angles of the ribs on the right side are 
 drawn backwards, so that the angles become more acute 
 than normal and project beyond the spinous processes. 
 From this sharp angle the rib on the right side bends 
 suddenly forwards. (See Fig. 4.) 
 
 On the left side the angle of the rib is much more open 
 and the ribs take a much wider sweep, so that from the 
 back this side of the chest is broadened and flattened. The 
 right shoulder is high and the left is depressed, and usually 
 the right hip is prominent while the left is flattened. 
 
 Fig. 4. — Illustrating the alteration in the shape of the ribs, and the 
 deviation of the transverse diameter of the thorax. 
 
 Deformities of the pelvis associated with rickets. 
 
 It has already been shown that rickets is peculiarly 
 dysgenic, in that it affects the young infant almost imme- 
 diately after birth and continues to produce its evil effects 
 during the period of most rapid growth, up to the end of 
 the second or third year. From that time forward there is 
 a marked tendency to recovery, but such recovery, even in 
 comparatively mild cases, is only partied, and sequelae are 
 
Spine and Pelvis Deformities 169 
 
 left which produce far-reaching results, especially at periods 
 of stress, such as puberty. 
 
 But rickets is extremely harmful to the young infant in 
 another direction, and that is in its effects on the bony 
 pelvis of the female, whereby it produces deformity of the 
 passages through which the child has to psiss, often en- 
 dangering the life of the infant and increasing the risk of 
 injury and of infection to the mother. It is weU known that 
 labour is more difficult and more dangerous, both to mother 
 and child, in civilised communities than it is among savage 
 people. It is also recognised that the more extreme degrees 
 of dystocia are most commonly met with in large industrial 
 communities. In England, degrees of deformity demanding 
 Caesarean section and craniotomy are comparatively rare, 
 but in certain districts on the Continent they seem to be so 
 frequent that these ultimate resources of the obstetric art 
 have to be constantly employed. 
 
 In 1911, Amand Routh pubhshed a series of 1,282 cases of 
 Caesarean section in Great Britain, representing a complete 
 list of all cases operated upon in Great Britain and Ireland 
 by obstetricians living on June 1, 1910.* In 1,058 of these 
 cases the indication for operation was pelvic contraction. 
 In the great majority of cases these high degrees of deformity 
 are due to rickets. The distribution of these cases is very 
 interesting, and the small number found in Ireland and 
 Wales as compared with the large number in Scotland is 
 very noteworthy, indicating the comparative infrequency of 
 the severer forms of rickets in these two countries. The 
 distribution is as follows : — 
 
 England 841 
 
 Scotland 375 
 
 Ireland 53 
 
 Wales 13 
 
 1,282 
 
 * " Caesarean Section in Great Britain and Ireland," by Amand Routh. 
 London, igii. 
 
I/O Rickets 
 
 The distribution in the various towns is also of interest, as 
 indicating where the most extreme varieties of rickets occur. 
 These are as follows : — 
 
 England — London 
 
 Manchester 
 
 
 . 383 
 . 155 
 
 Liverpool 
 
 Sheffield 
 
 
 . 96 
 . 92 
 
 Leeds 
 
 
 . 38 
 
 Birmingham 
 
 Wolverhampton 
 
 Newcastle 
 
 
 . 34 
 . 15 
 . 15 
 
 Bristol 
 
 
 . 13 
 
 Wales— Cardiff 
 
 
 . 13 
 
 Scotland — Glasgow 
 
 Edinburgh 
 
 Dundee 
 
 
 . 304 
 
 . 59 
 9 
 
 Aberdeen 
 
 
 3 
 
 Ireland — Dubhn 
 
 
 . 40 
 
 Belfast 
 
 
 ■9 
 
 Cork 
 
 
 4 
 1,282 
 
 It is noteworthy that in Glasgow the number of cases 
 is almost as great as that occurring in London. In Man- 
 chester the number of cases is much higher than in 
 Liverpool, though the population of these two towns is 
 approximately the same. Rickets is both less frequent and 
 less severe in Liverpool, an advantage which it enjoys 
 owing to its large river frontage on the Mersey. In 
 Birmingham, with a population somewhat greater than that 
 of Manchester, the number of cases is considerably less 
 than a quarter of what it is in that city. In Dublin, Belfast 
 and Cardiff, the number of cases is notably small. 
 
 It is difficult to get a true estimate of the frequency of 
 occurrence of contraction of the pelvis in the general 
 population. There are several varieties of deformity pro- 
 duced in the pelvis by rickets, but in aU the essential feature 
 is shortening of the conjugate diameter, that is, of the 
 antero-posterior diameter at the plane of the brim of the 
 true pelvis, which. runs from the centre of the promontory 
 
Spine and Pelvis Deformities 171 
 
 of the sacrum to the upper part of the posterior surface of 
 the symphysis pubis. A pelvis in which this diameter is 
 shortened is designated a " fiat " pelvis, and this is the 
 essential deformity produced by rickets. Normally, the 
 conjugata vera measures 4 J inches on the dry bony pelvis, 
 or, allowing for the presence of the soft parts, 4 inches. 
 When it is shortened to 3^ inches (8-5 cm.) contraction is 
 said to be present. 
 
 Winckel states that in Germany contraction of the 
 pelvis is found in from ten to fifteen per cent, of all par- 
 turient women, and in Munich, where he was professor of 
 gynaecology, he insists on the great frequency of rickety 
 deformity of the pelvis, notwithstanding the fact that in 
 that city, death carries off a large proportion of the rachitic 
 children who, in other regions, increase to such an enormous 
 extent the number of difficult labours from narrowing of 
 the pelvis.* 
 
 In the absence of direct measurements of the pelvis, it 
 is difficult to estimate the frequency of contraction, for in 
 many cases with contraction labour is accomplished without 
 undue difficulty. Systematic measurements have been con- 
 ducted in Germany more frequently than elsewhere, and 
 taking a diminution of IJ cm. to 2 cm., in an important 
 diameter, as constituting a contracted pelvis, it is estimated 
 that in Germany as a whole, 14 to 20 per cent, are to be 
 thus designated. If the contraction were to be considered 
 as being present only where serious dystocia resulted, the 
 proportion would only be from 3 to 5 per cent.f Thus, in 
 Vienna, among over 50,000 labours in the University Chnic, 
 between 1878 and 1895, it was estimated to be present in 
 2*5 per cent., and at Queen Charlotte's Hospital, London, 
 in 1,000 cases it was found in 4 per cent. Among women 
 bom in America contracted pelvis is rare, but among the 
 ahen population, and the negroes, high grades of contraction 
 are not infrequently met with. In Australia, New Zealand, 
 
 * " A Text-book of Obstetrics," by Dr. F. Winckel. Translated by 
 J. Clifton Edgar. Edinburgh and London, 1890. 
 
 t " The Principles and Practice of Obstetrics," by Joseph B. de Lee. 
 Philadelphia and London, 1918. 
 
172 Rickets 
 
 and South Africa, contraction of the pelvis to a degree 
 sufficient to interfere with labour is very rare. 
 
 Labour may be rendered difficult by changes in any one 
 of the three factors concerned in labour, viz. : (1) in the 
 powers, which include the uterus and the abdominal 
 muscles ; (2) in the child itself, such as increased size of the 
 head in hydrocephalus, and faulty presentations ; (3) in the 
 passages, including changes in the soft parts, such as rigidity 
 of the cervix, and in the bony pelvis, narrowing and deforma- 
 tion of the various diameters of the true pelvis through which 
 the child must pass. 
 
 Rickets is the common factor affecting the diameters of 
 the bony pelvis. There are several varieties of deformation, 
 but in all, as akeady stated, " flattening " or diminution of 
 the conjugate diameter is the essential feature. 
 
 Two factors are at work in producing these deformities — 
 abnormality in the development of the bones, and the 
 mechanical action of various forces upon the softened bones. 
 As a result of the rachitic state, there is, in the pelvic bones, 
 as in all the other bones of the skeleton, a tendency to 
 stunted growth. The sacrum is broader from side to side 
 and thinner from behind forward. The deformation of the 
 pelvis begins while the child is as yet in the sitting posture, 
 before it has learned to walk. 
 
 The weight of the body is transmitted through the spinal 
 column to the sacral promontory, and thence to the iMac 
 bones and the tuberosities of the ischii. Normally, the 
 anterior surface of the sacrum is concave from above 
 downwards and from side to side. In rickets the weight 
 of the body causes the sacrum to sink forward, so that the 
 promontory tends to approach the pubis. The concavity of 
 the transverse curve is flattened out by the weight of the 
 body acting on the softened bone. The upper part of the 
 sacrum being pressed downwards tends to cause the lower 
 end to be tilted backwards. This is resisted by the strong 
 sacro-sciatic hgaments, and as a result a sharp bending 
 forwards of the lower end is frequently brought about. 
 
 The iliac bones, which, in the youngj^child suffering 
 
spine and Pelvis Deformities 173 
 
 from rickets, may be thickened and swollen during the active 
 stage of the disease, are frequently, in the adult, more 
 delicately shaped than normal. The sinking of the pro- 
 montory of the sacrum is strongly resisted by the strong 
 ilio-sacral ligaments, resulting in a pull which tends to draw 
 together the posterior superior spines of the ilium. As a 
 result, the posterior part of the iliac fossa is often rendered 
 more abruptly concave by a curling inwards and forwards 
 of its posterior margin, while the anterior portion of the 
 crests and the iliac fossae tend to spread outwards, so that 
 the anterior superior ihac spines are further apart. The 
 softened ihac bones are further flattened by the weight of the 
 viscera. The pelvic arch is usually wider than normal, 
 and the tuber ischii may be everted, so that the transverse 
 diameter of the outlet may actually be exaggerated. When 
 the lower end of the sacrum tilts backwards, the antero- 
 posterior diameter of the pelvic outlet is also increased. 
 Thus, while the pelvic inlet is contracted, the pelvic outlet 
 is wide and gaping. 
 
 This action on the pelvis is important, for it means that 
 the conjugata vera is always shortened, and the brim of the 
 pelvis becomes oval, reniform, or heart-shaped. The trans- 
 verse diameter is not usually much affected, but it may 
 appear relatively enlarged and is sometimes absolutely so. 
 This is the ordinary form of simple flat rickety pelvis. 
 
 Another form is the generally narrowed fiat rickety 
 pelvis, which corresponds to the variety already described, 
 except that all the diameters are shortened instead of the 
 conjugate only. 
 
 The pseudo-osteomalacic pelvis is usually due to a very 
 severe form of rickets and is associated with grave forms 
 and degrees of contraction. The walls of the pelvis collapse 
 so that the sacrum and the lateral, walls approach one 
 another, giving rise to a small trefoil brim. Happily, such 
 a condition is not now common. 
 
 The scolio-rachitic pelvis is a commoner and therefore 
 more important variety, and is met with, as the name implies, 
 in cases where the deformity is associated with lateral cur- 
 
174 Rickets 
 
 vature of the spine. Lateral curvature in the lumbar portion 
 of the spine may by itself produce a certain amount of 
 asymmetry of the pelvis, one side being somewhat more 
 roomy than the other. Only slight degrees of contraction 
 can, however, be produced in this way. When, however, as 
 is usually the case, the scoliosis is associated with rickets, it 
 may produce an extreme degree of oblique deformity asso- 
 ciated with flattening. In these cases the inlet at the brim is 
 smaller on that side to which the convexity of the lumbar 
 scoliosis points, and the sacrum is pushed over to that side. 
 Owing to increased pressure on one wing of the sacrum, the 
 bone tends to be less well developed, and this may also affect 
 the iliac portion of the sacro-iliac joint. 
 
 The pelvis is tilted so that the more contracted side is 
 higher than the other, and the ischial tuberosity on this side 
 is also higher, while the pelvic arch points to the contracted 
 side. The conjugata vera runs obliquely backwards, the 
 transverse diameter is always shortened, and the oblique 
 diameters are unequal. 
 
 Towards the end of pregnancy, the existence of flat 
 pelvis may be suspected from the fact that the presenting 
 part cannot engage in the brim and therefore remains freely 
 movable, so that the child lies high and well forwards, 
 producing the condition known as pendulous belly. 
 
 Mechanism of labour in simple flat rickety pelvis. 
 
 Diuring labour, the head is pushed to the occipital side 
 of the pelvis, so that the bitemporal diameter of the head 
 engages in the diminished conjugate. The forehead now 
 dips so that the anterior fontanelle becomes more easily 
 palpable. The position of the head is transverse, and the 
 anterior parietal bone, most commonly the right, tends to 
 present so that the sagittal suture is nearer to the pro- 
 montory of the sacrum than to the pubis. This is what is 
 known as the Nsegele obhquity. The head now passes the 
 conjugate by the bitemporal diameter. In the commonest 
 head presentation, the right parietal forms the presenting part 
 and the left parietal bone rounds the promontory, frequently 
 
Spine and Pelvis Deformities 17S 
 
 receiving an indentation on its anterior part as it does so. 
 This mechanism is exceedingly important in these cases of 
 flat rachitic pelves, for it is in cases of this nature that there 
 is apt to be delay. To apply forceps in a case of flat pelvis, 
 with the head at the brim, is to court danger. Gross 
 haemorrhages into the skull, as the result of the application 
 of " high " forceps, are much more common than is generally 
 supposed, and it is in such cases that this accident is Hkely 
 
 Fig. 5. — Flat pelvis showing compression of the head in the narrowest 
 transverse diameter in a breech presentation. 
 
 to occur. The position of the head is transverse, and the 
 grasp of the forceps is likely to be in the occipito-frontal 
 diameter. Such a compression is dangerous to the child, 
 and tends to lessen the size of the head in the roomy trans- 
 verse diameter, and to make it bulge in the direction of the 
 contracted conjugate. 
 
 In such a case, where the position of the anterior 
 fontaneUe is found to be low, the indication is for turning 
 (see Fig. 5), which allows control of the labour and proper 
 moulding of the aftercoming head. 
 
CHAPTER XIV 
 Chang-es in the Bones of the Face in Rickets 
 
 The changes which take place in the flat bones of the vault 
 of the cranium have been described apart from those which 
 occin: in the bones of the base of the skull and the bones of 
 the face. 
 
 Sir Arthur Keith conveniently divides the skull into two 
 parts : (1) the flat bones of the vault of the cranium, which 
 grow according to the requirements of the brain, the in- 
 crease of growth taking place chiefly at the sutural borders, 
 notably at those of the paiietal bones. The anterior fon- 
 tanelle forms, as it were, a focus or centre about which the 
 most rapid growth takes place. In any errors these are the 
 parts where defective growth is most apt to show itself, and 
 in consonance with this, it is found that the chief changes 
 in rickets, as has already been shown, take place along the 
 interparietal or sagittal suture, and at the coronal and lamb- 
 doid sutures, and at the centres of ossification, especially 
 those of the parietal bones, producing the characteristic 
 parietal bossing ; (2) the base of the skull and the bones of 
 the face, which are not concerned in the adaptation to the 
 increasing size of the brain, but which have to do mainly 
 with the act of mastication and the movements of the jaws, 
 and with respiration. Even in wide deviations in growth of 
 the bones of the cranial vault, the base of the skull remains 
 remarkably constant and varies but httle. 
 
 In rickets, the chief changes which occur in the bones of 
 the face are found in the superior maxilla. There are two 
 relationships of this bone which' are of prime importance in 
 the production of these deformities, viz., the association 
 with the teeth and the function of mastication, and the 
 
 176 
 
Changes in the Bones of the Face 177 
 
 relationship to the nose and air passages and the function of 
 respiration. 
 
 A quarter of a century ago, Prof. Marfan, of Paris> 
 stated his behef that the co-existence of adenoids and rickets 
 were the chief factors in the production of the high arched 
 palate, which is the most characteristic deformation of the 
 superior maxilla. Writing in 1907, M. Marfan says : 
 " In 1896 I affirmed that the co-existence of adenoids and 
 rickets is the most potent factor producing the deformations 
 of the superior maxilla, and to-day I am able to affirm that 
 rickets is the true cause of the high vaulted palatine arch."* 
 
 Keith, on the other hand, believes that this deformity of 
 the palate is associated with a failure in the function of the 
 jaws as a grinding machine, leading to defective growth of 
 the bone, and he has recently pointed out some notable 
 changes which he believes are taking place in the modern 
 skull, using the term modern in the wider sense as dating 
 from the Roman Period, f These are : (1) the high arched 
 palate with irregularity and overcrowding of the teeth ; 
 (2) deepening of the orbit as if the lower external angle of the 
 orbit were pulled downwards and outwards ; (3) narrowing 
 of the entrance of the nose by the laying down of an edge 
 of bone along the lower margin of the nasal orifice ; 
 (4) thickening of the nasal bones, so that they are somewhat 
 more prominent than normal. Keith ascribes these changes 
 to errors of growth largely produced by modern habits, 
 especially the change to soft and well-cooked foods which 
 require but little mastication, in place of the rough and 
 coarse grain foods on which man formerly lived. 
 
 Now there can be no question that profound changes 
 have taken place in the modern skull within a remarkably 
 short space of time — much shorter than is allowed by 
 Keith — probably not more than between three and four 
 centuries. 
 
 * " Le rachitisme dans ses rapports avec la deformation ogivale de la 
 voiite palatine et I'hypertrophie chronique du tissu lymphoide du pharynx. ' ' 
 M. Marfan, La Semaine Midicale, i8th Sept., 1907. 
 
 t " Hunterian Lectures," Royal College of Surgeons, England, January, 
 1921. 
 
1 78 Rickets 
 
 Nor will the statement that the essential alterations in 
 the bones of the face and skull are associated with a simple 
 change of diet, interfering with the masticatory functions of 
 the jaws, and so retarding and altering their growth, suffice 
 as an explanation of these well-marked variations. These 
 notable alterations in the bones of the skull, and of the 
 upper and lower jaws, are due to a profound constitutional 
 modification taking place in the growing infant, a change 
 which is in once sense pathological, in that it is due to what 
 is considered a diseased state, but which, in a very real 
 sense, is purely physiological in that it is the natural response 
 produced by the adaptation of the growing organism to a 
 widespread and intense alteration in environment. 
 
 In other words, these changes are associated with the 
 origin and spread of rickets which has taken place in England 
 during the last three or four centuries. 
 
 For long after the Roman Period, right up to three and 
 a half centuries ago, about the end of the sixteenth and 
 the beginning of the seventeenth centuries, the same striking 
 characteristics are met with in English skuUs, viz., the wide 
 roomy flat palate, and the beautiful regular arch of teeth 
 meeting almost edge to edge, much ground down, but seldom 
 decayed or missing. Nor did this form of jaw disappear 
 suddenly. During the eighteenth century one gets a mixed 
 variety, with a tendency to the modern contracted jaw, whUe 
 others retain the more primitive form. But it is not till 
 the rise of the great cotton industry, in the end of the 
 eighteenth and the beginning of the nineteenth centuries, 
 with the growth of huge industrial centres and great towns, 
 that the jaws generally assume the type of to-day, where 
 the teeth are markedly irregular and prone to decay, the 
 upper set overlapping the lower, while the palate tends to 
 be arched and high and the maxilla as a whole is stunted 
 in growth. The superior maxilla is a membrane bone and 
 its ossification begins early, about the seventh week of 
 foetal life, and proceeds with great rapidity. The changes 
 which occur in the bone as the result of modern environ- 
 ment arise at an early period, although it is not, as a rule. 
 
Changes in the Bones of the Face 179 
 
 till from the third to the sixth year, and especially towards 
 the period of the second dentition, that the characteristic 
 signs of alteration appear and the deformation of the jaw 
 is found to be already accomplished, 
 
 Now, while the partial loss of the grinding function of 
 the jaws may have some effect on the growth of the bones 
 of the face, the main cause of the changes in the modern 
 skull lies much deeper. The high arched palate is more 
 common in the town than in the country, and it is more 
 frequent among the poor than among the well-to-do. It is 
 especially common and most severe in the slum dwellers 
 and those from the lowest grade of society. If well cooked, 
 easily masticated food were the chief cause it might be 
 expected that the condition would be more prevalent among 
 the rich. It is quite otherwise. The association of the 
 arched palate with crowded and defective teeth, though by 
 no means uncommon in the upper classes, is much more 
 frequent among the slum dwellers. 
 
 Again, it must be noted that the change is a very early 
 one. During the first two years of the child's life the 
 grinding action of the jaws, even among native races, is 
 brought but Uttle into play, and by this time the changes in 
 the superior maxilla and teeth have already made con- 
 siderable progress. A grave objection to the theory that the 
 changes in the jaws and teeth are dependent on loss of the 
 function of mastication will be noted in the following chapter. 
 By the end of the second year most of the gross defects of 
 development of the permanent teeth, which are commonly 
 associated with rickets, are fuUy developed, although the first 
 permanent molar does not erupt tiU the sixth year. That is, 
 the deviation from the normal occurs while the germ of the 
 tooth is still deep in the jaw, long before there is any possi- 
 bility of the function of mastication having any action. 
 Already, in the. second year, the growth of the permanent 
 teeth is stunted, and the gross enamel changes, which are 
 exposed when the teeth are erupted, are fully developed. 
 The formation of the permanent teeth is an important 
 factor in the normal growth of the jaws, and the fact that at 
 
i8o Rickets 
 
 this early period gross defects are already present in the 
 permanent teeth has an important influence on the develop- 
 ment of both maxillae. Softening of the bone of the superior 
 maxiUa, which occurs in rickets, is largely responsible for the 
 persistence of the arching of the palate, and the approxima- 
 tion of the alveolar margins, which are so commonly 
 associated with the presence of adenoids and with mouth 
 breathing. 
 
 The great thickening of the membrane bones of the 
 vault of the cranium, which tends to occur in rickets, has 
 already been dealt with, and it has been noted that this 
 thickening is often very persistent and may remain to late 
 adult hfe. The superior maxUla, to a much less marked 
 degree, also shows a tendency to thickening, but this is 
 much less marked than in the cranial bones. 
 
 In the adult, variation in the thickness of the waUs of 
 the antrum of Highmore, is one of the reasons why trans- 
 illumination of the antrum cannot, by itself, be considered a 
 reliable sign as to the presence or absence of pus in that 
 cavity. In a fair proportion of cases, where the crescentic 
 illumination below the orbit is missing, and the shadow 
 generally appears darker than normal, suggesting the 
 presence of pus, puncture and washing out of the antrum 
 reveal the fact that it is quite clear. This failure of the 
 illumination may be due to several causes. Deflection of 
 the septum of the nose may interfere with the illumination, 
 as also may gross enlargement of the turbinate bones, 
 but a fairly common cause is a general thickening of the 
 maxillary walls. When present, this is usually rachitic 
 in origin and may persist into late adult life. As a rule, 
 however, the walls of the antrum are thin, and there is much 
 less tendency to thickening of the maxillary waUs in rickets 
 than there is in the case of the frontal and parietal bones. 
 In this true rickets differs markedly from experimental 
 rickets, and from the so-called rachitic process which occurs 
 in fuU grown animals in confinement. In these conditions 
 enlargement of the bones of the face is very common, and 
 is often well marked, while the thickening tends chiefly to 
 
Changes in the Bones of the Face i8i 
 
 affect the superior maxilla. This is an exceedingly important 
 distinction between true rickets and these artificially pro- 
 duced states. 
 
 The deformations of the jaws may be considered in 
 relation to another function with which they are intimately 
 concerned, that of respiration, a function which affects the 
 growth of the bone at a much earlier age than that of 
 mastication. Two air-ways may be used in filling the 
 lungs, the one passing through the nose and the other 
 through the mouth. A simple experiment will illustrate the 
 effects of each. If the hps and teeth be lightly closed, and a 
 long breath be taken in through the nostrils, the lungs can 
 be fully inflated, especially in the region of the lower lobes 
 of the lungs and posteriorly. This act is done with a 
 conscious effort, and the muscles of inspiration can be felt 
 raising and everting the ribs and expanding the base of the 
 chest. If, now, the lower jaw be allowed to drop to its full 
 extent and a deep breath be taken through the mouth, it will 
 be found much less easy to satisfactorily fiU the chest. The 
 orifice and passage through which the air is taken in are 
 much larger and the upper part of the chest is inflated, but 
 the inspiratory muscles do not have the same point of 
 vantage as when the mouth is closed, and while the act of 
 shallow respiration is produced practically without effort 
 with the mouth open, the full inflation of the lungs is 
 rendered difficult. 
 
 In the healthy infant, when the environment is whole- 
 some, the respiration is very active, as nature intended it 
 should be, to cope with the rapid metaboUsm which is taking 
 place in the child's system. But with the debilitated rickety 
 child, living in a slum dwelling, healthy interchange between 
 the blood and fresh air is impossible, and nature adapts the 
 child to the altered environment by limiting the demands 
 for fresh and pure air which is not obtainable. The muscles 
 are thrown out of action and in.every way nature minimises 
 effort. As far as is compatible with growth, the metabolism 
 of the body is conserved and the flabby, soft, duU-com- 
 plexioned, apparently complacent and precocious child 
 
t82 Rickets 
 
 results. It sits quite still and does not learn to walk or to 
 speak till a comparatively late period ; it seldom cries. The 
 breathing is shallow and the air is inspired without effort by 
 the mouth, the apices and the bases and the anterior and 
 posterior borders of the lungs being but little used. But 
 such a child is adapted to its surroundings, and for the 
 safety of the tace the adaptation is necessary, where large 
 masses of the population are herded together in surroundings 
 wholly unfit for the rearing of infant life, or at least for the 
 production of healthy growth and development. 
 
 In these first few months of the child's life are sown, not 
 only many of the seeds of future diseases, such as decayed 
 and defective teeth, otitis media and deafness and nervous 
 diseases, but the whole physical and mental growth is 
 aborted, or at all events does not reach the level of attain- 
 ment which might otherwise be reasonably expected. 
 
 Among the Flemish painters of the fifteenth century, as 
 will be shown later in discussing the history of the disease, 
 the " front olympien " of an undoubted rickety variety had 
 come to be associated in the popular mind with ideas of 
 dignity and beauty ; similarly to-day, a type with short 
 upper lip, and slightly prominent upper teeth, and nez 
 retrousse, has been evolved and is held to be a somewhat 
 distinguished variation. Yet these individuals have suffered 
 from adenoids and from a mild form of rickets. Nor 
 are they by any means confined to the lower grades of 
 society. Such a type has probably suffered from a slighter 
 and more evanescent form of the disease than has the 
 heavy featured, sallow-complexioned and badly developed 
 individuals characteristic of the slums. There is a male 
 type of growth and a female type, and they may show a 
 varying response to the same factor. Sir Arthur Keith has 
 pointed out that the changes which occur in the cranium, 
 and especially in the bones of the face, as the result of 
 modern conditions, are much more common and more 
 marked in the female than in the male. 
 
 In rickets, the lower jaw frequently tends to drop 
 through muscular debility, apart from any post-nasal 
 
Changes in the Bones of the Face 183 
 
 obstruction, and once developed the habit of mouth 
 breathing is Ukely to persist. Though it may be controlled 
 during the day it is likely to reappear at night during sleep. 
 The breathing in the rachitic state is shallow and quick and 
 is carried on with a minimum of effort. When adenoids 
 develop at an early age, as they frequently do, they confirm 
 the tendency to mouth breathing. 
 
 Now the internal pressure of the air in the interior of the 
 nose is of great importance. It widens the nostril and 
 depresses the floor of the nose, thereby flattening out the 
 palate and keeping the alveolar arch well spread. The air 
 pressure tells on the lateral walls and increases the space on 
 either side of the septum. The constant passage of the 
 current of air has a tonic effect on the mucosa and actually 
 supports the lining of the nasal cavity. In the mouth 
 breather the nostrils are narrow and the nose is thin and 
 collapsed, and is obviously not used for breathing purposes. 
 The mucous membrane over the turbinates is liable to 
 become swollen and congested, and a negative pressure 
 tends to be established in the region of the naso-pharynx, 
 interfering with the proper ventilation of the ear through the 
 Eustachian tube.* In health the lower jaw is maintained 
 against the upper by muscular action, but as a result, of the 
 loss of muscle tone in rickets, the temporals, masseters, and 
 the internal pterygoids do not act satisfactorily, and the 
 jaw is allowed to drop. 
 
 Several factors thus contribute to the deformation of the 
 superior maxillae in rickets, viz. : (1) softening of the bone ; 
 (2) the falUng of the lower jaw, as the result of mouth- 
 breathing, producing a continuous drag on the soft tissues 
 of the cheeks, tending to approximate the alveolar borders 
 of both maxillae, and to perpetuate or increase the infantile 
 arching of the palate. The constant and ever varying 
 pressure of the tongue is an important factor, moulding the 
 formation of the palate. With the dropped jaw of the mouth 
 breather this pressure is rendered largely ineffective ; (3) the 
 
 * " studies in the Anatomy and Surgery of the Nose and Ear," by 
 Adam E. Smith, M.D. New York, 1918. 
 
184 Rickets 
 
 loss of the passage of the current of air through the nostrils, 
 which normally tends to flatten the floor of the nose and to 
 separate the lateral walls from the septum ; (4) the dwarfing 
 of the permanent teeth, which leads to irregularity in their 
 growth and eruption. 
 
 A further very characteristic and exceedingly common 
 defect associated with rickets and with modern environment 
 is deflection of the nasal septum. The septum of the^nose 
 is mainly composed of the vomer and the perpendicular 
 plate of the ethmoid bone. It is fixed between the base of the 
 skull above and the palatal plates of the superior maxillary 
 and palate bones on its lower border, and it forms one of 
 the supports of the bridge of the nose. This bony septum 
 is prolonged forwards by the middle cartilage of the nose. 
 
 Deviations of the septum may take place in : (1) the 
 cartilaginous portion of the septum ; (2) the bony portion 
 when it may involve — (a) the vomer ; (b) the perpendicular 
 plate of the ethmoid ; (c) more commonly both. 
 
 In considering the production of this deformity, it is to 
 be noted that there is no give in the base of the skull. 
 Normally, the palate of the infant has the shape of a Gothic 
 arch, which becomes flattened as the air-way through the 
 nose becomes developed and the naso-pharynx expands. 
 Anything which interferes with the growth of the bones of 
 the face, and especially with the descent of the hard palate, 
 naturally hinders the growth of the vomer and of the per- 
 pendicular plate of the ethmoid. When the palate retains 
 its infantile Gothic arch, and especially if this is increased, 
 the bony and cartilaginous septum cannot expand, owing to 
 the base of the skull being fixed, and a buckling of one or 
 other or of both of these parts' must occur. (See Plate V.) 
 Deviations of the septum are frequently spoken of as if they 
 were due to excessive growth of its bony and cartilaginous 
 constituents. Such a conception is wrong. They are due to 
 a failure of co-ordination in the development of the bones of 
 the face, including among these bones, the vomer, and the 
 perpendicular plate of the ethmoid, which really belong to 
 the face rather than to the skull. This failure in the great 
 
Plate V. 
 
 Coronal section through the skull behind the first molar, showing the normal 
 flattened condition of the palate. Dotted line indicates the vaulting 
 of the arch of the palate which occurs in rickets, and the consequent 
 buckling of the septum which takes place owing to the insufficient 
 room for its proper expansion and growth. 
 
 [To fa a- p. 1S4. 
 
Changes in the Bones of the Face 185 
 
 majority of cases is rachitic in origin. In this way are pro- 
 duced the varying degrees of one type of deflected septum. 
 Now all these changes depend on the fact that as a result of 
 the rachitic process the bone is unduly soft and is easily 
 moulded by outside forces. Indeed, if adenoids arise later 
 on, apart from rickets, as the result of some infection, 
 as they sometimes do, the adenoid facies does not develop. 
 
 As a result of my own experience in the examination of 
 school children in London, when this was first undertaken 
 by the London County Council, it was found that out of a 
 large number of children of all ages about one in six suffered 
 from enlarged tonsils or adenoids, or both, in a degree 
 sufficiently severe to call for surgical interference. In a few 
 years the effect of systematic treatment carried out on the 
 younger children made an appreciable difference in the in- 
 cidence of tonsils and adenoids among the upper school 
 classes, and the percentage of cases requiring to be dealt 
 with became, and has remained, very much smaller. Adenoid 
 growths are not necessarily due to rickets, but the great 
 majority of cases are undoubtedly associated with it, and 
 indeed these growths usually form but a part of the general 
 lymphatic hyperplasia which is commonly met with in this 
 disease. Adenoids are the most common cause of mouth 
 breathing, but it is important to remember that before the 
 growths develop the debilitated child may acquire the 
 habit. The infant and the young child have considerable 
 difficulty in clearing the naso-pharynx and the upper 
 respiratory passages from mucus. Young children do not 
 expectorate, and it is only by the act of vomiting or through 
 the action of the bowels that mucus can be removed. This 
 is a matter of importance, for these rickety children suffer 
 much from catarrhal conditions of the upper air passages, 
 especially in winter, and without the presence of adenoids 
 the naso-pharynx may be blocked. 
 
 In many cases the typical adenoid facies will develop in 
 mouth breathers who do not actually suffer from adenoids, 
 and in children who suffer from adenoids without rickets 
 the characteristic facies will probably not appear. 
 
1 86 Rickets 
 
 Like many rachitic changes, deviations of the septum are 
 exceedingly common among Europeans and are much less 
 common among non-Europeans. As TiUey remarks, if a 
 normal septum is one which is perfectly straight, and which 
 divides the nasal cavity into two symmetrical halves, very 
 few noses in Europeans would be free from defect. 
 
 In health, as already noted, the lower jaw is kept 
 opposed to the upper jaw by muscular action, but in rickets, 
 as a result of muscular debility, the temporals, masseters, 
 and the internal pterygoids, do not act satisfactorily, and by 
 their want of tone allow the jaw to drop. It wiU be noted 
 that these are strong and powerful muscles, generally used 
 in concert in keeping the lower jaw apposed. The opposite 
 movement of depressing the jaw is largely a question of 
 gravity and is therefore assisted by much smaller muscles, of 
 which the digastric is the chief. In the relaxed condition 
 of rickets the tendency is for the jaw to drop and the lower 
 lip to be pendulous, hanging away from the jaw, and pro- 
 ducing the vacant, stupid appearance often seen in these 
 debilitated children. This tendency is accentuated when 
 there is post-nasal obstruction, especially that associated 
 with adenoids. 
 
 Marfan, following Fleischmann, describes the lower jaw 
 as being flattened in front between the canines, while the 
 horizontal rami are approximated, and tend to join the 
 flattened front portion of the jaw almost at a right angle. 
 The lower border of the body of the jaw is described as 
 being in advance of the superior border, which is stated to be 
 directed inwards, producing the " menton de galoche," or 
 long pointed chin. Such a jaw is not typical of rickets. It 
 suggests an overgrowth rather than a failure of growth, which 
 is characteristic of the rachitic lower jaw, such a condition, 
 for instance, as is found in acromegaly when the strong 
 massive jaw with a pointed chin is a conspicuous feature. 
 The characteristic signs of rickets in the upper and lower 
 jaw are not present in all cases, and are most marked when 
 the child is a continuous mouth breather. 
 
 Normally, the vertical ramus of the lower jaw mounts 
 
Changes in the Bones of the Face 187 
 
 up from the posterior border of the body or horizontal 
 ramus of the jaw at nearly a right angle in adult age. Into 
 this vertical portion of the bone are inserted the powerful 
 muscles which close the jaw. In rickets the lower jaw, 
 hanging continually during growth, does not develop 
 properly, nor do the muscles attached to it attain their 
 proper size and strength. The whole mandible is small and 
 the chin is receding. The angle of the jaw tends to become 
 notably obtuse instead of approaching a right angle. The 
 horizontal rami of the two sides are approximated by the 
 pull of the soft tissues of the side of the face and neck. In 
 the normal skull the bite of the incisors is scissors-like, the 
 lower incisors biting just inside the upper teeth. This 
 adapts them the better for their nipping-off action and pre- 
 vents the tendency to trauma which would be present if the 
 sharp edges were accurately opposed. The labial surface of 
 the lower canine strikes against the lingual surface of the 
 upper eye tooth. The biting surfaces of the molars and 
 premolars are not in the same horizontal plane, that of the 
 lower teeth forming a slight curve with the concavity up- 
 wards, which receives the morsal surfaces of the premolars 
 and molars of the upper jaw which form a slight convexity. 
 In addition, the grinding teeth are so arranged that, when 
 the jaws are closed, the tooth in one jaw is opposed by two 
 in the other. In this way the teeth are excellently adapted 
 for the biting action of the incisors and the piercing and 
 holding action of the canines, and yet allow apposition 
 without interfering with the grinding action of the molars. 
 In the rachitic skull the scissors-like action of the incisor 
 teeth is greatly exaggerated, and indeed, in the modern skull 
 in Europe generally, the upper incisors markedly overlap the 
 lower. At the same time the teeth are irregular, due to over- 
 crowding, and the upper central incisors tend to b€ pro- 
 minent, and are often only partially covered by a short upper 
 lip, while the canines and lateral incisors of both jaws are 
 apt to be misplaced. 
 
 There can be but little doubt that this condition is 
 pathological, and is part of the penalty paid for the unnatural 
 
1 88 Rickets 
 
 overcrowding of modern populations, into great industrial 
 centres and huge cities. In the male, though a weak lower 
 jaw is a common rachitic deformation, it is less common 
 than in the female. Not infrequently the mandible of the 
 male is relatively well developed and is but little affected. 
 A fairly common variation is met with where the palatal 
 arch and the alveoli of the upper jaw are contracted and 
 badly developed, leading to overcrowding of the teeth, 
 while the lower jaw is strong and practically unaffected. 
 Seen from the front, it looks as if the thumb and forefinger 
 had been placed on the upper lip, one on each side of the 
 nose, and the face had been forced backwards, producing 
 flattening in this area. The result is that instead of the 
 upper teeth overlapping the lower teeth, as is most common 
 in the modern jaw, they may meet, or the lower teeth 
 may project beyond the upper, producing a form of false 
 prognathism. 
 
 The tendency to irregular arrangement and early decay 
 of the teeth, and to deformations of the jaws, are evils asso- 
 ciated with a vicious environment and are not due to any 
 inherent or unavoidable degeneration taking place in these 
 structures. If the changes in the jaw and teeth were due to 
 loss of function, owing to the diminished action required in 
 the mastication of modern food, the position would be 
 somewhat hopeless, for there is not much likelihood of 
 modern people returning to a primitive dietary. The grinding 
 down of the incisors and canines, as well as of the grinding 
 teeth proper, frequently almost to the sockets, which is so 
 common in skulls up to the sixteenth and seventeenth 
 centuries, shows that these early people used food, not from 
 choice but from necessity, for which their teeth were wholly 
 unadapted by nature. In all probability this was a potent 
 factdt shortening the duration of life. It is usually some- 
 what lightly inferred that the use of harsh foods and coarse 
 grains in primitive times made for healthy growth and 
 development, while the truth is, that it was neither whole- 
 some, nor well adapted to the economy of the individual. 
 
 With wholesome food to-day there is ample work for the 
 
Changes in the Bones of the Face 1 89 
 
 proper development of the jaws and teeth. The eating of 
 raw apples and other fruits, as is done by the children of 
 the poor from an early date, should be encouraged. It has 
 an excellent double effect in cleansing the teeth and in 
 giving the necessary exercise to the masticatory muscles, 
 which are otherwise not much used. But such a diet is 
 easily carried to excess, and it is not desirable to feed the 
 young child on raw vegetable salads, for which its digestion 
 is not adapted, and from which the growing organism finds 
 difficulty in withdrawing the pabulum required for its rapid 
 metabolism. The digestion of the young child is very 
 tolerant, and even in the rachitic child is but little affected, 
 but if meat be excluded from the dietary and large quantities 
 of vegetable foods containing much cellulose be substituted, 
 the best results will not be obtained either as regards, 
 physical or mental development. A generous diet, which is 
 varied and includes everything that is wholesome, is best 
 adapted for growth. 
 
 In discussing the changes occurring in the flat bones 
 of the vault of the cranium, it was shown that the tendency 
 was to produce a brachycephalic type of skull. The changes 
 in the bones of the face tend to produce elongation of the 
 face and the lantern-jawed type of individual. 
 
CHAPTER XV 
 
 The Teeth in Rickets 
 
 In many diseases there is a marked tendency for morbid 
 processes to exert a selective influence and to attack certain 
 tissues of the body. This is very notable in syphilis, and 
 Jonathan Hutchinson long ago pointed out the remarkable 
 tendency in certain cases for one set of tissues only to 
 suffer.* Thus, in syphilis the skin surface may be the seat 
 of multiple lesions to the exclusion of other structures. At 
 other times it is the mucous surfaces which suffer ; not in- 
 frequently it is the periosteal tissues or the central nervous 
 system which is alone or mainly affected. In no disease is 
 this tendency more marked than in rickets. Tissues which 
 are related to each other developmentally are frequently 
 subject to like degenerations. In rickets there are four 
 tissues, widely separated, which are often markedly affected, 
 viz., the teeth, the lens of the eye, the skin, and the central 
 nervous system. These various and dissimilar structures are 
 at once linked up when it is remembered that they are all 
 ectodermic in origin, and that they are all developed from 
 the outer germinal layer. In the teeth, the eye, and the skin, 
 these changes are easily demonstrated to the naked eye and 
 by the microscope. In the nervous system, the state of 
 present day knowledge of the intimate structure of the 
 neuron does not yet allow accurate dogmatic statements in 
 regard to histological changes in diseased conditions ; but 
 the profound and constant series of nervous symptoms which 
 supervene in rickets, warrant the inference that there is 
 probably an actual physical basis for these symptoms in 
 alteration of the nerve cells themselves. Our knowledge of 
 
 * " S3'philis," by Jonathan Hutchinson, F.R.S., LL.D., Lond., 1889. 
 Commentary CLX, p. 330. 
 
 190 
 
The Teeth in Rickets 191 
 
 the pathology of the nervous system, even in epilepsy, which 
 has been studied from the most ancient times, is no further 
 advanced than it was in the days of Hippocrates. One thing 
 seems clear, that heredity is not the all important factor in 
 its production. The causes of epilepsy are various, but they 
 act on a prepared soil not necessarily inherited ; as will be 
 shown, there is reason to believe that the pathological con- 
 dition of the nervous system which leads to the development 
 of epilepsy is probably, in very many cases, acquired in 
 early infancy, and is frequently associated with the rachitic 
 state. Certainly there can be no hesitation in connecting 
 up the convulsions of infancy with epilepsy, and the identity 
 of the two conditions in many of these cases is now 
 established. If these observations are accurate they are 
 capable of a very wide and important application. 
 
 The changes in these various structures will be studied 
 in sequence. 
 
 Defect in the calcium metabolism, especially in the 
 laying down of calcium salts throughout the skeleton, is the 
 most prominent feature in rickets, and is the one responsible 
 for most of the physical signs which mark the disease. 
 Nowhere is this factor more marked than in the teeth. In 
 rickets caries is exceedingly common, and hypoplasia, or 
 defective calcification of the enamel, is well marked. This 
 defective laying down of the enamel is not necessarily the 
 result of rickets. It may be the result of many general 
 disorders, and is occasionally seen in an isolated tooth as the 
 result of some local irritation, the defect in the enamel being 
 confined to that area of the tooth which was undergoing 
 calcification at the time of the general or local disorder. 
 
 A hypoplastic condition of the teeth * is characterised 
 not only by a defective formation of the enamel, but also 
 frequently by a stunted growth of the teeth. There may be 
 only a pitting, producing a honeycombed appearance of the 
 enamel, or the enamel covering is slight, and the cutting 
 
 * " The Teeth in Rickets," by J. Lawson Dick. " Proceedings of the 
 Royal Society of Medicine," 1916, Vol. IX (Section for the Study of 
 Disease in Children), pp. 83-89. 
 
192 Rickets 
 
 edge of the tooth presents sharp points, giving a character- 
 istic appearance to the tooth. The defect usually extends 
 from the cutting edge, and may, in severe cases, involve 
 the whole crown. As in syphilis, the condition is found 
 typically in the permanent dentition, but whereas the 
 notched incisors and the contracted first molars of syphilis 
 are but rarely met with in school children, the hypoplastic 
 teeth of rickets are common. In every-day life one con- 
 stantly sees these teeth and notes how well they often last. 
 Thus, frequently a smoker is seen whose teeth have been 
 worn down in depth, and only short stumpy teeth are left, 
 with a layer of enamel all around the cutting edge and the 
 dentine exposed in the centre of the biting edge. 
 
 Robert Bunon, an illustrious French dentist of the 
 earlier part of the eighteenth century, first accurately 
 described this condition. Bunon's work is of a very brilliant 
 and original nature, and in so far as it is the result of actual 
 and acute observation, it remains as accurate to-day as when 
 it was first written, and much of it has been rediscovered 
 without being amplified. It is interesting to note that 
 Bunon practised in the north of France, Antwerp, Brussels 
 and elsewhere, all localities where he would be likely to 
 come into contact with rachitic states. In contrast with 
 the frequent diseases of the teeth in these parts, he refers to 
 the common belief of the time that the peasant Savoyards 
 have very regular white teeth, free from disease. In 1743, 
 Bunon published his remarkable work on the teeth * 
 Rickets, Bunon shows, is one of the chief causes of many 
 defects of the teeth, such as lateness in eruption of the 
 primary teeth, and of malformation and irregularity, early 
 decay, overcrowding, the result of malformation of the jaws 
 in the second dentition, and well marked h5^oplasia, of which 
 he gives a very accurate and full description. Erosion, as 
 this h3^oplastic defect was termed by Bunon, sometimes 
 affects the milk teeth, but is much more frequent in the 
 
 • " Essay sur Les Maladies de Dents, Ton propose les moyens de leur 
 procurer une bonne conformation dfts la plus tendre Enfance, et d'en 
 assurer la conservation pendant tout le cours de la vie." Par M. Bunon, 
 Chirurgicn-Dentiste, k Paris, 1743. 
 
The Teeth in Rickets 193 
 
 permanent teeth. Those most often affected, he observes, 
 are the first molars, and in frequency follow the incisors, 
 canines, premolars ; the second and third molars are most 
 rarely affected. 
 
 Besides rickets, measles, small-pox, malignant fevers, 
 and notably scurvy, all produce hypoplasia of the teeth, the 
 area of the teeth affected in all these conditions depending on 
 the part of the tooth which was being calcified during the 
 period of the disease. A still greater observer followed 
 Bunon. John Hunter was at work on the teeth about the 
 middle of the eighteenth century, and published his work in 
 1771.* Hunter deals with hypoplasia under the heading of 
 " Decay by Denudation." It is hardly likely that he was 
 acquainted with Bunon's work, for if he had been cognisant 
 of it, it would have cleared up many points on which he was 
 somewhat vague. That Hunter was well acquainted with 
 the condition is apparent from the number of specimens 
 he collected. One such excellent specimen is figured in 
 Plate VI. 
 
 Besides the well marked examples in the Royeil CoUege 
 of Surgeons, London, there are several in the Hunterian 
 collection of Wm. Hunter, in the University of Glasgow, 
 which were almost certainly prepared by John Hunter while 
 assisting his brother. It is another example of the wide 
 range and the unvarying patience of Hunter's methods of 
 ir^vestigation. These teeth were laboriously prepared by 
 him and were set on one side, left, as it were, till further 
 observations would help him to complete the scheme. Sir 
 Frank Colyer f believes that in the chapter on " Decay by 
 Denudation " Hunter was referring to the state of the teeth 
 produced by abrasion, that is, the wearing away produced by 
 friction from tooth brushes, powders, etc., and that he did 
 not recognise the process as such. There can be littte 
 doubt that Hunter was referring to true hypoplasia and not 
 to the effects of abrasion, though he ascribes it to a form of 
 
 * " The Natural History of the Human Tooth, Structure, Use, Form- 
 ation, Growth and Diseases," illustrated with copper plates, to which is 
 added a " Practical Treatise on the Diseases of the Teeth," by John 
 Hunter. Third Edition, London, 1803. 
 
 t " John Hunter and Odontology " by J. F. Colyer, London, 1913. 
 
194 Rickets 
 
 decay of the enamel whereby more and more of the bone 
 becomes exposed, due to a denuding process. "I have seen 
 instances," says John Hunter, " when it appeared as if the 
 outer surface of the bony part, which is in contact with the 
 inner surface of the enamel, had first been lost, so that the 
 attraction of cohesion between the two had been destroyed, 
 and as if the enamel had been separated for want of support, 
 for it terminated all at once." In certain instances this 
 process of denudation does occur, and may be seen in the 
 imperfectly formed enamel on the crown of the first molar. 
 I have myself seen the process of denudation taking place, 
 on more than one occasion, on the flat surface of the crown 
 of the first permanent molar. It seemed as if the defect in 
 the enamel chiefly affected the layer in contact with the 
 dentine. As a result of slight trauma the enamel fractured 
 and peeled off in large flakes, leaving the exposed dentine 
 below. Occasionally I have been able to raise large flakes 
 of enamel with the wooden spatula, exposing the dentine 
 already blackened, consolidated, and insensitive, the process 
 of decay having become arrested.* But the ordinary form 
 of hypoplasia consists, not in a denuding process, but in a 
 defective laying down of the enamel, or, it may be, its com- 
 plete absence, leaving the dentine below either imperfectly 
 covered or entirely without covering. " From its attacking 
 certain teeth," says Hunter, " rather than others in the same 
 head, and a particular part of the tooth, I suspect it to be an 
 original disease of the tooth itself ; and not to depend on 
 accident, way of life, constitution, or any particular manage- 
 ment of the teeth." 
 
 The observation is accurate in so far as hypoplasia is an 
 arrest or a perversion of the development of the tooth itself, 
 due to some morbid condition affecting the system at the 
 period that calcium is being actively laid down in the enamel. 
 That John Hunter was not dealing with the state of the 
 tseth produced by abrasion, but with a condition of true 
 hypoplasia, is quite clear from a study of Plate VI. 
 
 * " Defective Housing and the Growth of Children," by J. Lawson 
 Dick, London, 1919, pp. 45, 46. 
 
Plate VI. 
 
 Left maxilla and left mandible of a child, age six years. The first 
 permanent molars are erupted. The other teeth of the second dentition 
 have been exposed by removal of the outer bony wall of the crypts. 
 Typical hypoplasia of the rachitic type is seen in the two incisors of the 
 lower jaw, and in the central incisor of the upper jaw, in the tip of the 
 lower canine (upper canine missing), and in the crowns of the first 
 molars. It is quite evident from this and other specimens prepared by 
 John Hunter that he was well aware that the defect in the teeth arose 
 as an original fault in the calcification of the enamel ; in this specimen 
 the incisors and canines have never been exposed to any form of 
 attrition. 
 
 [7"(i tacc f. !Q4. 
 
The Teeth in Rickets 19S 
 
 In this specimen, prepared by John Hunter himself, the 
 first molar is the only tooth of the permanent set which has 
 been erupted, and to expose the incisors, canines and pre- 
 molars the outer wall of the jaw has been removed. Ob- 
 viously, none of these teeth had been exposed to any form 
 of attrition. It is also quite evident that the hypoplasia 
 present is a defect in the actual laying down of the enamel. 
 This specimen, though it was not recognised as such by 
 John Hunter, is a typical example of hypoplasia due to rickets. 
 From the extent of the enamel affected it can be stated fairly 
 definitely that the child suffered from rickets during the first 
 year or eighteen months. After the eighteenth month the 
 calcification of the enamel proceeded normally. 
 
 Another point of interest is that the second upper 
 permanent incisor becomes calcified later than the central 
 incisor, and indeed, not infrequently escapes, as in this 
 specimen. Even when it does not escape the defect is 
 deeper in the upper central incisor than in the lateral. The 
 lower incisors, canines and first molars are always affected 
 when the upper teeth are imperfect. In the lower teeth the 
 process is usually not quite so extensive as in the upper teeth, 
 but the lateral incisor hardly ever escapes as the upper lateral 
 incisor does. Usually the lower central and lateral incisors 
 are fairly equally affected, as in John Hunter's specimen. 
 
 One century later another master mind was at work on 
 the same subject. In 1858, Jonathan Hutchinson first 
 pubUshed his observations on malformed teeth,* and this 
 work continued to occupy his attention for many years. 
 Hutchinson resembled John Hunter in many ways. He 
 was a great observer, who took the whole of medicine 
 within his purview, and such were the quahties of his mind 
 that he could approach most branches with a special know- 
 ledge, such as could only be acquired by most individuals 
 after a life-long devotion to that one study. He was an 
 indefatigable collector, and, hke Hunter, laid aside much 
 material which he could not at the time explain, often 
 throwing out tentative suggestions as possible explanations, 
 
 * " Syphilis," by Jonathan Hutchinson. Commentary CCXII. 
 
196 Rickets 
 
 but never failing to seize every opportunity of adding to his 
 knowledge, and a long life fortunately enabled him to bring 
 much of his work to maturity. Hutchinson established the 
 fact that a crescentic or semilunar defect in the laying down 
 of the calcium in the two upper permanent central incisors 
 was pathognomonic of inherited syphilis. Although he 
 agreed with the observations of Mr. Moon and others that 
 certain peculiarities in the other teeth, notably in the first 
 permanent molars, the dome-shaped teeth, were suggestive 
 of an inherited syphilitic taint, he always maintained that 
 the central upper incisors of the second set were the test 
 teeth. Hutchinson recognised clearly that there were many 
 varieties of hypoplasia. In the diagnosis of syphilis, he 
 correctly states, all transverse markings across several teeth 
 on the same level are to be disregarded, as also are defects 
 which lead to pits or honeycombing. Foliated or wart-like 
 projections on the teeth, with defective enamel and peg-like 
 teeth were, he taught, suspicious but untrustworthy signs of 
 syphilis. Hutchinson believed that all cases showing the 
 characteristic semilunar defect in the edge of the upper 
 central incisors were due to inherited syphilis, but he was 
 never able to give any satisfactory explanation of the far 
 more numerous forms of hypoplasia other than this which 
 he met with. The only explanation he could bring forward 
 was that these defects were due to the use of mercury in 
 early infancy. " I regard it as certain," he says, " that 
 mercury employed in infancy is attended by much danger to 
 the development of the child's permanent teeth." This was 
 for long a common beUef. " Tis fit," says Sir John HiU, in 
 his herbal, in 1771, " that the world should be reminded 
 that half the defective teeth in our young people are owing 
 to mercurials given to children." This was a natural con- 
 iusion when it is considered that it was customary to push 
 the use of mercury in syphilis till saUvation had been 
 produced. The loosening of the teeth, as the result of 
 ulcerative stomatitis, naturally led to the supposition that 
 nearly all defects ai the teeth had their origin in the 
 administration of this drug. 
 
The Teeth in Rickets 197 
 
 While any agent which produces severe and prolonged 
 stomatitis might reasonably be supposed to produce oc- 
 casional hypoplasia, it is practically certain that mercurial 
 stomatitis in early infancy is one of the rarest causes of this 
 condition. Hutchinson's teeth are comparatively rare, while 
 the other forms of hypoplasia are exceedingly common, and 
 probably affect some seven or eight per cent, of the whole 
 population. It is impossible to account for a condition of 
 such frequent occurrence by prolonged mercurial stomatitis 
 in infancy. 
 
 The term hypoplasia was first used by Dr. J,. E. Grevers, 
 of Amsterdam,* who emphasised the fact that all these 
 defects tend to follow the incremental lines of growth 
 in the enamel. Normal enamel consists of two portions : 
 (1) the rods, which are a product of the ameloblast cell, 
 are built up of Httle blocks of coalesced granules, and- 
 are arranged like piles of bricks ; they show a cross- 
 marking where they meet one another, which is the cause of. 
 the minute cross-striations of the enamel prisms ; (2) the 
 cement substance between the rods which, according to 
 Leon Williams, t is calcified independently of the rods, 
 cementing them, together and forming a compact tissue, 
 which in normal enamel is completely calcified and contains 
 no trace of organic matter. Enamel in human teeth, 
 according to Mummery, is seldom if ever a perfect tissue. 
 Imperfections, especially at the dentine margin, and minute 
 channels from the dentine are so common as scarcely to be 
 looked upon as abnormalities. J 
 
 The organic matter, in which the lime salts are either 
 mechanically deposited or are secreted, as, it were, by a vital 
 process of the ameloblasts, loses its original structure and 
 tends to become clear, uniform and structureless, constituting 
 the densest and hardest of animal tissues. According to 
 
 • " Hypoplastic Teeth." " Transactions Odont. Soc. of Gt. Britain," 
 Vol. XXVII, 1895. 
 
 ■f " A Contribution to the Study of Pathology of Enamel," by J'. Leon 
 Williams. " Dental Cosmos," Vol. XXXIX, 1897. 
 
 J " The Microscopic Anatomy of the Teeth," by J. Howard Mummery, 
 London, 1919. 
 
198 Rickets 
 
 Colyer,* the commonest malformation is a failure of the 
 cementing substance between the enamel rods in the outer 
 one-fourth to one-third of the surface of the enamel, and 
 frequently a colouring matter is formed in place of the 
 cementing substance. Two theories may be stated as to the 
 origin of caries : (1) that it is due in its inception to the 
 solvent action of acids which have been generated by 
 fermentation in the mouth, due to the action of micro- 
 organisms ; (2) that it is due to the vulnerability of the 
 enamel, owing to defects in its minute structure rendering 
 the teeth more feadUy liable to the action of organisms, and 
 also to injury, which still further exposes the deeper layers 
 to their activity. As already noted, fracture of the enamel 
 in the case of the first molar is quite common. It seems 
 reasonable to suppose that the best defence of the teeth lies 
 in the laying down of perfect enamel, and the probabiHty 
 is that micro-organisms do not materially interfere with 
 the teeth provided that the tooth is of healthy normal 
 structure. It is well to inculcate cleanliness of the mouth, 
 especially in communities where the teeth are liable to 
 premature decay, but no amount of attention to oral 
 hygiene will be entirely effective when the first and best 
 defence of the tooth has been imperfectly laid down, as 
 occurs in the slum populations of our large industrial cities. 
 The occurrence of rickets in early infancy is the most potent 
 factor in the production of defective teeth. 
 
 The calcification of the teeth begins about the fifth 
 month of intra-uterine life, and the following diagrams give 
 the rate of progress of calcification at various periods for 
 both the temporary and permanent teeth. 
 
 The only teeth of the permanent set which show any 
 signs of calcification at birth are the cusps of the first 
 molars. Fig. 8, p. 199, shows the portion of the enamel 
 which has undergone calcification at the end of the first two 
 years of life, and the parts affected by the commonest 
 form of hypoplasia. 
 
 * " Dental Surgery and Pathology," by J. F. Colyer, F.R.C.S., L.D.S.. 
 London, 19 19. 
 
The Teeth in Rickets 
 
 199 
 
 7«4 "v.". 
 
 -Jim 
 .jOne 
 
 L\-£vvHi 
 
 4X^ 
 
 Fig. 6. — Showing calcification of temporary teeth at various periods. 
 
 Kv /■^W 
 
 years 
 
 LSioc 
 '-Mime, 
 
 Fig. 7.— Showing calcification of permanent teeth at various periods. 
 
 OOBQQf 
 
 Fig 8 --Permanent teeth, showing the parts calcified in the first two years. 
 Beiow to show the parts affected by commonest form of hypoplasia. 
 
200 Rickets 
 
 In the typical form of hypoplasia commonly met with, 
 the teeth affected are the central and lateral incisors, the tips 
 of the canines, and the crown of the first molars. The 
 condition is symmetrical, affecting both jaws. The biting 
 edges of the incisors are almost always affected, and the 
 deficiency of enamel extends for some distance on the labial 
 and buccal surfaces of the teeth towards the gum. As a 
 rule, only the very tips of the canines, and the biting 
 surfaces, with one quarter to one third of the crowns of the 
 first molars are affected. These teeth will again be referred 
 to in some detail in speaking of the association of rickets 
 with lamellar cataract. Usually the depth of the defect is 
 greater in the enamel of the central incisors than in that of the 
 lateral incisors, and it will be noted that the enamel affected 
 is identical with that laid down during the first two years. 
 This condition is pathognomonic of rickets. Rickets is the 
 only condition which interferes with the deposition of 
 calcium over this prolonged period. As already noted, the 
 upper lateral incisors are occasionally passed over. The 
 dentine is either thinly coated with badly laid down enamel, 
 which tends to be brown and discoloured by the collection 
 of sordes in the irregularities, or the dentine may be entirely 
 exposed and irregular, and jagged dentine, which rapidly 
 becomes blackened and consoMdated, is exposed at the 
 biting edge of these teeth. This tends to become worn 
 down in adult life, so that the condition may be completely 
 masked, owing to the fact that the exposed dentine has been 
 completely ground away (see Plate VII, Fig, 1). 
 
 In cases of acute illness, especially fevers, the finger 
 nails are apt to show grooves marking the state of depressed 
 growth of the cells of the bed of the nail during the progress 
 of the disease. In the case of the teeth, a groove more or 
 less broad, or even a succession of grooves with healthy 
 enamel in between, may mark attacks of grave illness in the 
 child. Frequently, without a history, a shrewd guess can be 
 made at the period of occurrence of some serious illness by 
 the part of the enamel of the teeth which is affected. But 
 it is usually a grave and prolonged illness which thus leaves 
 
Plate \ll. 
 
 _„'f''''^'-^'m»m„^/:f^''"'>^'^. 
 
 Fig 
 
 I. 
 
 Appearance of Ihe teeth in a di<;charf;ed soldier of 21 years of age 
 suffering from double lamellar cataract. Tlie teeth are small and 
 stunted. The upper central incisors, the lateral incisors and the 
 canines all show typical hypoplasia, although the exposed dentine 
 has been a good deal ground down in the upper jaw. The lower jaw 
 has^ also exhibited hypoplasia, but the exposed dentine has been 
 entirely ground down. 
 
 Fig. 2. 
 
 Hypoplasia in the form of a deep groove running across the central 
 and lateral incisors and the canine. This form of hypoplasia is not 
 usually due to rickets but is characteristic of the condition produced 
 by a severe and prolonged debilitating illness such as measles, 
 especially when accompanied by whooping cough. From the part of 
 the teeth affected it can be definitely stated that the disease producing 
 this condition occurred about the age of eighteen months. 
 
 \To face f. :oo. 
 
The Teeth in Rickets 201 
 
 its mark, more especially measles, followed by whooping 
 cough. Scarlet fever is less hkely to have this effect. 
 
 This form of hypoplasia (see Plate VII, Fig. 2) is not 
 typical of rickets, but is more commonly due to an attack of 
 some severe or depressing illness. In my experience, the 
 commonest of the children's diseases to give rise to this 
 groove is measles, more especially when this is accompanied 
 by whooping cough. Both upper and lower teeth of the 
 permanent set are affected in a similar way. From the part 
 of the enamel affected in Plate VII, Fig. 2, it can be fairly 
 definitely stated that the illness occurred at the age of from 
 eighteen months to two years. 
 
 At birth calcification has involved the crowns of the 
 deciduous incisors, the cusps of the deciduous canines and 
 deciduous molars, and the tips of the cusps of the first 
 permanent molars. The portions of the enamel not yet 
 calcified at birth in the temporary set frequently suffer from 
 hypoplasia. While a considerable portion of the crown 
 of the tooth is already laid down in the new-born infant, 
 the enamel round the necks of the teeth have not yet been 
 formed. It is suggestive, that in the decay which is so 
 common in the temporary set in rachitic children, that the 
 necks of the teeth frequently show advanced caries, in- 
 dicating that there has been some failure in the defence of 
 the enamel at this part. 
 
 Any disturbance in the function of the ameloblasts, the 
 cells which, according to Tomes, either secrete the enamel 
 or in which the calcium salts are deposited, will lead to the 
 enamel being thin in parts and to the lime salts being im- 
 perfectly laid down, so that the compact enamel is more 
 easily disintegrated. In other words, the agents which 
 determine the tendency to decay are those which affect the 
 soft enamel organ in the earliest history of the tooth, and 
 not those which affect the enamel after the tooth has been 
 erupted. 
 
 Seafaring communities are said to have good teeth, and 
 this is generally attributed to the action of ozone and pure 
 air. But more hkely causes are the favourable conditions 
 
202 Rickets 
 
 under which the children of such communities are brought 
 up in early life, as regards fresh air, sunlight and ventilation. 
 Sydney Spokes found that hypoplastic teeth were more 
 commonly met with in the lower classes than among the 
 well-to-do. He gives the following figures as the result of 
 an examination of a number of public school boys and of 
 Poor Law school children. 
 
 Percentage rate of 
 Class of School. incidence of hypoplasia. 
 
 Public School (258 boys) 4-6 per cent. 
 
 Poor Law School (1,463 boys and girls) 7 „ 
 
 Some observations on the state of the teeth amongst rickety 
 children in London County Council schools in the East 
 end of London. 
 
 In judging of the presence of hypoplasia, it was found 
 practically impossible to make accurate observations on the 
 temporary teeth of infants of school age. Caries was so 
 universal and extensive that it completely masked the hypo- 
 plasia. It was evident that a hypoplastic condition of the 
 teeth was common in the temporary set, and was, in all 
 probabihty, the chief factor in bringing about premature 
 decay. For the purposes of statistics only the records of 
 the permanent dentition have been taken, and in marking a 
 case as one of hj^poplasia only the severer forms are ad- 
 mitted, and cases of slight pitting, chalky-looking patches in 
 the enamel, and so on, have been excluded, although micro- 
 scopically such teeth would be found markedly defective and 
 liable to disintegration. Of the 586 rickety cases in which 
 a record of the permanent teeth could be taken, 42 per cent, 
 had normal teeth, and 58 per cent had defective or decayed 
 teeth ; 20 per cent, of these showed hypoplasia frequently 
 combined with decay, and 38 per cent, had decayed teeth. 
 This is not equivalent to saying that 42 per cent of school 
 children have normal teeth. As already pointed out, all 
 infants with a record only of temporary teeth have been 
 excluded, because these teeth were so universally decayed as 
 to make accurate observations on the structure impossible. 
 Again, most of the children with records of the permanent 
 
The Teeth in Rickets 203 
 
 teeth were about the ages of twelve or thirteen years, when 
 all the permanent teeth have been erupted except the third 
 molars, and caries has had least time to make its appearance. 
 It is a somewhat quaint commentary on the general state of 
 the teeth of the community to be compelled to explain why 
 only 58 per cent, are given as having defective teeth. 
 
 Of the cases with carious teeth, the lower first molar 
 was decayed in 80 per cent., the upper first molar was 
 decayed in 30 per cent., one or more lower premolars in 
 30 per cent., and one or more upper premolars in 12-5 per 
 cent. The incisors, canines and second molars were seldom 
 decayed. The shape of the incisors and canines must 
 protect them from many of the causes of decay to which 
 the flattened grinding molars are subjected. The lower 
 first molars decay out of all proportion to the others, and 
 their earUer eruption is not a sufficient explanation of this. 
 It is to be attributed rather to the main part of the enamel 
 of the crown having been laid down in the first t\yo years of 
 life, when rickety conditions are operative. Naturally the 
 lower teeth, which lie in the well of the mouth, will suffer 
 more seriously from deleterious influences which surround 
 the teeth. 
 
 Even though no macroscopic change indicative of 
 hypoplasia is to be found in these teeth, in all probability 
 their microscopic character is distinctly affected. One 
 practical point may be noted. Frequently, on looking into 
 a child's mouth, the two milk molars or the first permanent 
 molar will be seen with blackened exposed dentine and the 
 enamel on the surface of the crown removed. Closer 
 examination will show that these are still effective teeth and 
 that there is no pyorrhoea or gum irritation around them. 
 The surface of the tooth can be freely touched with the 
 spatula. The dentine of the tooth seems to have become 
 consolidated, and usually, though the teeth do not look 
 well, they can be safely left, the process of decay having 
 become arrested. 
 
 Many of the conditions conducive to rickets are present 
 in the parents of these children, and a priori it might be 
 
204 Rickets 
 
 expected that this would frequently be a congenital defect. 
 In such a case, in a certain proportion of children, the milk 
 incisors should show hypoplastic changes. The enamel of 
 the crown of the milk incisors begins to be laid down about, 
 the seventeenth week, halfway through intra-uterine life, 
 and has progressed to a considerable extent at the time of 
 birth. At birth, half the crowns of the incisors, the tips of 
 the canines and the cusps of the molars are calcified in the 
 temporary set, and by about six months after birth the cal- 
 cification of the crowns is completed. Careful search for a 
 hypoplastic condition of the biting edge of the milk incisors 
 during a long period, both in school children and in the 
 babies who have attended infant welfare centres, has. failed 
 to detect a case. It is strong presumptive evidence that 
 rickets is not a congenital condition, and is another instance 
 of the care that nature takes, that whatever else suffers the 
 germ at least is protected during intra-uterine life. 
 
 A later form of hypoplasia is every now and then seen, 
 in which the two premolars and the second molars are 
 affected, while the incisors, canines and. first molars are not 
 affected. This later form of hypoplasia must be diie to in- 
 fluences acting on the child from the second to the sixth year. 
 
 If one hundred better-class children, living under good 
 social conditions, are compared with one hundred poorly 
 fed children, living under slum conditions, even a casual 
 inspection wiU show that the teeth of the poorly fed and 
 badly housed children are much more defective than those 
 of the children living under better conditions. 
 
 Another inquiry was made as to the teeth conditions in 
 403 children taken from the ordinary London County 
 Council schools.* All these children were eleven years of 
 age and over, and of the 403 children, 281 were taken from 
 schools where the general conditions as regards feeding and 
 housing were distinctly below the average, whilst in 122 these 
 conditions were relatively good. No. attempt, was. made to 
 select children of poor nutrition, beyond that they belonged 
 
 * " Abnormal Conditions of the Enamel in Cases of Malnutrition." 
 Lancet, Oct. 5, 1918, p. 456. 
 
The Teeth in Rickets 
 
 205 
 
 to a poor school and lived under slum conditions in poor 
 and overcrowded neighbourhoods, such as Bethnal Green 
 and Shoreditch. As a contrast, 122 children were tak^n 
 from goadTclass schools in North Londoii, where the social 
 conditions were fairly good, and where the general state of 
 nutrition was good. The following results were obtained : — 
 (a) 403 children, (b) 281 where nutrition and environ- 
 ment were decidedly poor, (c) 122 children living under 
 good social conditions. 
 
 Enamel normal 
 Enamel defective 
 
 (A) 
 
 Per 
 Cases, cent. 
 273 = 67-5 
 130 = 32-5 
 
 (B) 
 
 Per 
 
 Cases, cent. 
 167 = 60 
 114 = 40 
 
 (c) 
 
 Per 
 Cases, cent. 
 106 = 87 
 16 = 13 
 
 Carious conditions have not been dealt with in these 
 figures. The conditions of the enamel met with in these 
 cases may be summarised as follows : — 
 
 1. Typical rickety hypoplasia. — This has already been 
 dealt with. 
 
 2. Honeycombed teeth. — This condition is much the 
 same as the first, except that the deficiency in the enamel 
 leads to the formation of small depressed pits scattered 
 over the surface of the teeth, giving a very characteristic 
 appearance. 
 
 3. Horizontal hands of thickened enamel and transverse 
 grooves in the enamel, indicating acute illnesses of a more 
 or less prolonged nature. Short acute illnesses seem less 
 likely to produce this condition than prolonged debilitating 
 conditions, such as measles, especially when followed by 
 whooping cough. 
 
 4. Chalky appearance of the enamel, varying from white 
 patches or transverse bands on the surface of the enamel to 
 a general opacity affecting its whole surface. This is a very 
 well-marked defect, and the contrast which this condition 
 gives with the clear semi-transparency of healthy enamel, 
 is one of the chief things which strike the observer in the 
 teeth of these badly housed and poorly nourished children. 
 
 5. Brown lines of Retzius, or brown Staining of 'the 
 
206 
 
 Rickets 
 
 enamel, is a common and well-marked defect found in the 
 poorer class of children. This defect may be found as a 
 brown line, running as a rule across the incisors, and, it may 
 be, the canines. It may be a brown patch of varying size 
 and intensity of colouring, though it is usually a rusty 
 brown. Very commonly it is associated with marked 
 opacity of the enamel, and it seems to indicate a somewhat 
 severe degree of disturbance of the nutrition. 
 
 Placing the frequency of occurrence in the poor-class 
 and the better-class children side by side, the following is 
 the result given in percentages : — - _. _ - 
 
 In 122 good-class 
 children. 
 
 Opaque chalky enamel 
 Brown line of Retzius 
 Hypoplasia ... 
 Honeycombed teeth... 
 
 As already shown, out of 281 poor children, 114, or 40 
 per cent., had defective enamel, as compared with 13 per 
 cent, amongst the better-class children. Taking the 114' 
 cases with defective enamel amongst the poorer-class children 
 there was found : — 
 
 Per cent. 
 
 Chalky enamel 80 = 70 
 
 Brown lines of Retzius 38 = 33 
 
 Typical hypoplasia 24 = 21 
 
 Honeycombed teeth 7=6 
 
 It is of great importance to note the teeth most 
 commonly affected. In the children where the enamel 
 was opaque and chalky the teeth were affected in the 
 following order of frequency : — 
 
 Per cent. Per cent. 
 
 Central incisors ... 78 Premolars 20 
 
 Lateral incisors ... 55 First molars ... 10 
 
 Canines 30 Second molars ... 5 
 
 These figures are accurate, except in the case of the first 
 and second molars. The first molars were frequently badly 
 
The Teeth in Rickets 207 
 
 decayed or the tooth had been extracted. The second 
 molars in many of these cases had not yet been erupted. 
 
 In thirty-eight cases, where the teeth showed the brown 
 hnes of Retzius : — 
 
 Per cent. 
 
 Central incisors affected in 36 = 95 
 
 Lateral incisors affected in 11 = 29 
 
 Canines affected in 5 = 13 
 
 First molar lease. 
 
 It is important to note that in hypoplasia, and in cases 
 where the chalky patches and the brown lines of Retzius 
 were found, the teeth which suffered chiefly were : first, 
 the central incisors ; secondly, the lateral incisors ; and, 
 thirdly, the canines, in this order of frequency. Reference 
 to the diagram will show that the calcification of the enamel 
 of the crowns of these teeth goes on during the first two 
 years of the child's life. So that these defects are due to 
 errors of metabolism affecting the child at this early period, 
 when the rate of growth, and notably that of the brain, is 
 relatively enormous. 
 
CHAPTER XVI 
 
 Skin Affections in Rickets. Lamellar Cataract and some 
 other Conditions of the Eye associated with the 
 Rachitic State 
 
 Skin Affections in Rickets. 
 
 Rickets is often brought forward as a common cause 
 of eczema, on the ground that gastro-intestinal catarrh is 
 erroneously held to be a constant factor associated with 
 the disease. In so far as rickets is a constitutional con- 
 dition, which depresses the health of the child and alters its 
 metabolism at a very early period of its growth, it probably 
 has an influence on the incidence of eczematous conditions, 
 but these cannot be described as part of the disease or as 
 being in any way directly due to it. Probably more than 
 one-third and rather less than one-half of all cases of eczema 
 in children begin within the first year of life, and, as is well 
 known, they tend to be very persistent. Eczema at this 
 tender age tends to assume the pustular form, and a certain 
 intractable variety attacking the head, face, and neck, is very 
 common. Often these children are very fat and appear in 
 excellent health, and digest their food well without any 
 tendency to sickness or diarrhoea. Naturally, excess of food 
 suggests itself, bringing the condition into line with the 
 gouty eczema of later adult life, but as a rule regulation of 
 the diet has but little effect. The fact that it is most common 
 during the time of eruption of the temporary teeth seems to 
 suggest a connection with teething and irritation of the fifth 
 nerve. Certainly many of these cases get well spontaneously, 
 at the end of the second year after the milk teeth are erupted. 
 Infantile eczema, then, is inost common during the 
 period when rickets is most active and an indirect con- 
 
 208 
 
Skin Affections, Lamellar Cataract, etc. 209 
 
 nection between the constitutional condition and the skin 
 manifestation is almost certain in many of these cases. 
 
 The possibility of a scorbutic factor in these inveterate 
 forms of moist eczema about the head, face, and neck, 
 should always be kept in mind. In scurvy there is a well- 
 marked tendency to exudative conditions of the skin and 
 mucous surfaces, and every now and then the condition 
 yields readily to an anti-scorbutic. While it is tempting to 
 believe that a constitutional cause or some source of reflex 
 irritation is present in all these cases, and it is important to 
 keep this possibihty in mind, my own experience has been 
 that they yield more readily to local treatment diUgently 
 applied. 
 
 In the young infant, one of the early signs of rickets, 
 as has been seen, is a thin shiny appearance of the skin, 
 especially over the forehead, so that the subcutaneous veins 
 show through very markedly, and this is associated with 
 greatly increased activity of the sweat glands of the forehead, 
 neck, and shoulders, so that when the child sleeps the pillow 
 is frequently quite damp where the impress of the head lies. 
 Such a condition, however, is hardly an ailment of the skin, 
 and is in all probabiUty associated with defective oxygenation 
 of the blood and the accumulation of an excess of carbonic 
 acid, which is a marked feature of rickets. By the act of 
 sweating itself much carbonic acid is removed from the 
 system. As a result of the excessive sweating, miliaria or 
 sudamina are exceedingly liable to develop, and may assume 
 a vesicular form due to obstruction of the sweat ducts ; or 
 the eruption may be papular, as occurs in Uchen strophulus 
 or " red gum," where crops of red papules appear which cause 
 much irritation and restlessness. Later, the skin of the 
 rachitic child becomes coarse and the complexion pale and 
 pasty. 
 
 But a very common and distinctive skin disease directly 
 due to rickets is a form of xerodermia, or " dry skin." This 
 condition is, I believe, characteristic of rickets, and is 
 frequently found in well nourished children where there is 
 no suspicion of scurvy and the supply of the anti-scorbutic 
 
2IO Rickets 
 
 factor is adequate, but where rickets is markedly present. 
 This is often classified as a congenital condition, but if 
 careful enquiry is made, it is found that the infant was bom 
 with a healthy skin which, after the lapse of a few weeks or 
 a few months, became dry and harsh. The ailment is a 
 distinctive one, and is most commonly met with during the 
 routine examination of the chest in school children, for it is 
 comparatively seldom that it is severe enough for the mother 
 to seek medical advice. Though not uncommon, it is much 
 less frequently met with amongst the infants at welfare 
 centres. It is a very persistent sign and may last through 
 the hfe of the individual. As the hand is placed on the 
 back of the shoulders one is struck with the rough, nutmeg- 
 grater like feel of the skin. It is most common on the back 
 of the upper arm and forearm, frequently extending on to 
 the back of the shoulders. The extensor aspect of the leg is 
 also not infrequently affected, but not so often nor to the 
 same extent as the extensor surface of the arm. When well 
 marked it involves the face and front part of the chest. 
 Pathologically, there is an increase in the homy layer of 
 the skin, wilJi a tendency to atrophy of the deeper spiny 
 layer of cells. The state of nutrition of the skin is markedly 
 impaired, and there is a less succulent condition of the spiny 
 cells, which change more rapidly than normal into the cells 
 of the homy layer. It is usually associated with diminished 
 activity of the sweat glands and scanty and coarse hair. 
 The bends of the elbows, flexures of the knees, and the 
 anterior surface of the abdomen, usually remain free. The 
 skin is rough, dry, and dirty looking, and the natural hues 
 of the skin are more marked than usual from the thickening 
 of the epidermis. The scalp is often covered with fine, 
 branny scales. This form of xerodermia is often greatly 
 benefited by the administration of th5n:oid extract, and warm 
 alkaline baths and oily inunctions are also useful. The hair 
 in rickets tends to be thin, coarse and scanty. During the 
 active stage of the disease the sweat glands over the head, 
 face, and neck are often extremely active, while the skin of 
 the rest of the body remains hot' and dry. Later on, the 
 
Skin Affections, Lamellar Cataract, etc. 211 
 
 sweat glands show diminished action and the skin, as has 
 been seen, tends to be harsh, dry, and scaly. 
 
 Diseases of the eye in rickets. 
 
 The condition of the lens and the rachitic state seem 
 subjects very remote from each other, but a study of the 
 disease known as lamellar or zonular or infantile cataract, 
 also frequently but erroneously called congenital cataract, 
 shows that the connection is a very direct one. 
 
 As far back as 1865, Prof. Johann Friedrich Homer, 
 of Zurich (1831, 1886), first called attention to the con- 
 nection between the occurrence of zonular cataract and 
 certain dental deformities which he attributed to rickets. 
 Homer was a busy practitioner, who did not court pubHcity 
 and found but little time to write, but he was ever generous 
 in giving his material to his students for the purposes of 
 publication. In 1865, Dr. Davidson,* then a student at 
 Zurich, embodied the views of Prof. Homer in an in- 
 augural thesis, and showed definitely a clear relationship 
 between lamellar cataract and certain rickety changes, 
 notably in the skull and long bones, and in the defective 
 lasdng down of the enamel of certain teeth. In 1883, M. v. 
 Arx, another student attending his clinic, again expressed 
 his teacher's views in an inaugural thesis, published at 
 Zurich, " Zur Pathologie des Schichtstaares," and gave 
 the results of his extended observations. 
 
 Prior to 1865, Prof. Arlt, of Vienna, had noted that 
 individuals with lamellar cataracts generally had a history of 
 infantile convulsions. The observation was an accurate 
 one, and the connection was explained when Homer pro- 
 posed the view that both conditions are rachitic in origin. 
 Homer's views were widely accepted on the Continent, but 
 have only of late years been generally adopted in this 
 country. This delay was largely due to the influence of 
 Jonathan Hutchinson. The constant association between 
 zonular cataract and a hypoplastic condition of the enamel 
 did not escape his acute observation, and though he 
 
 * " Zur Lehre von Schichstaar," Inaug. Dissert., Zurich, 1865. 
 
212 Rickets 
 
 recognised that the changes in the enamel associated with 
 zonular cataract were entirely different from the hypoplastic 
 changes met with in congenital syphihs, he was unable to 
 accept Homer's view that they were due to rickets. He 
 beUeved that the administration of mercurial powders for 
 the treatment of convulsions in early infancy produced a 
 stomatitis which affected the permanent teeth at the time 
 when calcification was actively proceeding in the enamel.* 
 
 Hutchinson placed himself in communication with 
 Homer, who forwarded him the results of his observations 
 in an extended number of cases, and stated that the adminis- 
 tration of mercury in infancy would not, in Zurich, explain 
 the constant association of these two conditions. 
 
 Several other important papers have been written on 
 the subject since that time.f Treacher Collins published 
 some interesting observations on the distribution of rickets 
 and lamellar cataract in Australia and Persia. J In Adelaide 
 he finds, as the result of inquiry, that rickets is a rare 
 disease and lamellar cataract is very infrequent ; in 
 Melbourne until lately, that is prior to 1895, rickets was rare 
 but is more common now, though the severity is much less 
 than in England, and lamellar cataract and hypoplasia of the 
 teeth are both uncommon ; in Sydney rickets is common, 
 but lamellar cataract is less frequent than in England. In 
 Persia, he notes, as the result of personal observations, that 
 both rickets and lamellar cataract are rare. 
 
 Norman G. Bennett, in an important paper read before 
 the Ophthahnological Society, in 1901, approaches the 
 subject from the point of view of the dentist.§ He gives 
 the result of the examination of twenty-six cases of lamellar 
 cataract, examined with a view to obtaining an accurate 
 
 * " Imperfect Teeth and Zonular Cataract," by Jonathan Hutchinson, 
 British Medical Journal, March 6th, 1875. 
 
 t " Zonular Cataract and Dental Deformities," by John B. Story, 
 Ophthalmic Review, Vol. V, 1886, p. 277. 
 
 t " Lamellar Cataract and Bickets," by E. Treacher Collins. " Trans- 
 actions of the Ophthalmological Society," Vol. XV, 1895 ; also " Trans 
 of 8th Session Australian Medical Congress," Oct., 1908 ; also " Trans. 
 Ophthal. Soc," Vol. XL, 1920. 
 
 § " .etiology of Lamellar Cataract," by Normal S. Bennett, " Trans. 
 Ophth. Soc," Vol. XXI, 1901. 
 
Skin Affections, Lamellar Cataract, etc. ai3 
 
 record of the teeth affected. In four cases he notes there 
 was no abnormahty of dental tissue, while twenty-two 
 showed a hypoplastic condition of the teeth, varying in 
 extent but constant as regards the teeth affected. 
 
 Bennett remarks that possibly this may be an undue pro- 
 portion, in view of the fact that being a dentist, ophthalmic 
 surgeons would be more likely to send him cases which were 
 of interest from the point of view of the dental defect. As 
 will be seen later, however, in a series of thirty-five con- 
 secutive cases of lamellar cataract, which I have myself 
 examined during the past year without any special reference 
 to the teeth, or any other organ, I have found the proportion 
 of cEises of hypoplasia somewhat greater than that found in 
 Bennett's observations. 
 
 A few well known points in the growth of the lens may 
 be usefuUy recapitulated. The lens is developed as an in- 
 vagination of the superficial epiblast, so that the nucleus 
 corresponds to the epithelial surface. Unlike most epithe- 
 lium, the surface cells cannot be cast off, so that the centre of 
 the lens contains the oldest cells, a factor of importance in 
 considering the pathological changes which the lens is likely 
 to undergo. Just as the epithelium of the skin continues to 
 grow throughout life, so the development of new lens fibres 
 continues, though less rapidly, as time goes on. There 
 being no blood vessels and no mesoblastic tissue, inflamma- 
 tion cannot occur, and all lens changes are essentially 
 degenerative in their nature.* 
 
 Treacher CoUins examined seven cases of lamellar 
 cataract microscopically, and found three kinds of changes, 
 of which he gave a resume in a lecture at the Royal College 
 of Surgeons,. London, in 1894. The pathological changes 
 correspond with three varieties of changes in the lens which 
 can be observed clinically. 
 
 Firstly, there are fissures between the lens fibres, which 
 may or may not contain a granular substance. It must be 
 remembered that while the lens fibres are arranged concen- 
 
 * " The Pathology of the Eye," by J. Herbert Parsons. Lond., 1905. 
 Vol. II. " Histology," Part II. 
 
214 Rickets 
 
 trically round the nucleus, they are also arranged like the 
 segments of an orange. These fissures extend between these 
 segments and are seen, on dilating the pupil, in the periphery 
 of the lens, radiating from the centre like the spokes of a 
 wheel, and are commonly spoken of as " riders." Slight 
 conditions of this nature are quite common, much more so 
 than is generally supposed, and as they produce no disabihty 
 when very slight, they hardly excite any comment in the 
 mind of the examining surgeon. 
 
 The second variety of change is produced as the result 
 of small vacuoles, mostly round or oval, but in places elon- 
 gated and beaded. Some of these spaces, whose average 
 size is five micromillimetres, contain a hyaline substance 
 which stains deeply with haematoxylin. This change cor- 
 responds with a uniform haze clinically. 
 
 Thirdly, there are larger vacuoles, measuring on an average 
 twenty micromillimetres, mostly circular, with very irregular 
 margins. They contain a granular substance which stains 
 deeply with hsematoxylin. Clinically these correspond to 
 denser dots in the substance of the lens. 
 
 Examined by oblique illumination with the pupil dilated, 
 the first appearance which strikes one is a tolerably uniform 
 greyish opacity, which does not extend so far as the equator 
 of the lens. This opacity is distinctly denser at the margin 
 and the outer edge is usually well defined. It is situated in 
 the layers surrounding the central core or nucleus of the 
 lens. The superficial cortex is quite clear and the nucleus 
 is usually but little affected. This grey discoid opacity is 
 surrounded by a perfectly transparent marginal area. With 
 the ophthalmoscope the disc appears black and sharply 
 defined at the outer edge, diminishing in density towards the 
 centre. The peripheral area shows a normal red reflex. 
 Along the outer edge spokes of opacity, resembling the 
 handles of a steering wheel, often extend slightly into the 
 clear area. These are the so-called riders. A convenient 
 method of examining these various conditions is to focus 
 the ophthalmoscope on the opacity. This is most strikingly 
 done with an electric ophthalmoscope, using a -|- 10 or -h 12 
 
Skin Affections, Lamellar Cataract, etc. 215 
 
 lens before the sight hole, and working at a distance of from 
 three to four inches. By this means fine early changes may 
 often be seen which would otherwise be missed. 
 
 In lamellar cataract both eyes are almost always affected, 
 though the changes may be more marked in one lens than 
 in the other. Once formed, the condition, as a rule, is 
 stationary, but in certain cases the opacity gradually increases 
 in density. The formation of the cataract occurs at such an 
 early period in the child's life that it is frequently spoken of 
 as congenital, though the probability is that it is always post- 
 natal in origin. This is borne out by the fact that the 
 hypoplasia of the teeth, which is so constant a concomitant, 
 is certainly post-natal in its origin, frequently beginning 
 within a few weeks after birth. That lamellar cataract 
 develops after birth has been seen by actual observation* 
 Thus, Knapp records the case of a child who, at the age of 
 two years and two months, had clear lenses, and who four 
 years later had developed a large lamella^ cataract in 
 each eye.* 
 
 True congenital cataract is a rare condition, but many 
 instances have been recorded. Thus, there may be a con- 
 genital cataract involving the nucleus of the lens while the 
 periphery is healthy. Or the cataract may be total, involving 
 the whole lens, which may be shrunken and degenerated, a 
 condition often associated with congenital defects in the 
 fundus. Not infrequently a circular spot may be seen on 
 the back part of the lens, due to a persistent hyaloid artery, 
 giving rise to a condition often inaccurately termed posterior 
 polar cataract. These true congenital conditions have no 
 association with defective laying down of the calcium of 
 the enamel, and have no connection with rickets. 
 
 The main difficulty which has been raised in regarding 
 
 lamellar cataract as a post-natal condition, is the fact that the 
 
 diameter of the lens at birth may be considerably greater 
 
 than that of the perinuclear zone in which the opacity occurs. 
 
 Bernard Dub f argues in this way in favour of the con- 
 
 • Knapp: Archiv. of Ophthal., Vol. XXXV, 1906, p. 141, 
 t Archiv. fiir Ophthalmohgie, Band XXVII, p. 36. 
 
2i6 Rickets 
 
 genital origin of lamellar cataract, and bases his calculations 
 on measurements of the opaque zone of ten lenses obtained 
 ophthalmoscopically during life, and a comparison of these 
 measurements with foetal, infantile, and adult lens measure- 
 ments. 
 
 Mr. Treacher Collins gives the result of direct measure- 
 ments of the opaque zone in ten cases collected from various 
 sources. Both observers come to the conclusion that the 
 diameter of the opaque zone is hardly ever larger than that 
 of the lens at birth. This impHes that if the opacity is due 
 to conditions of post-natal origin, either : (1) the condition 
 after birth which gives rise to the opacity is capable of 
 injuring fibres already laid down in the lens, as well as those 
 in the course of formation ; or (2) that contraction of the 
 iens nucleus is sufficient to account for the difference. 
 Too much has been made of this difficulty, for although the 
 chief growth of the lens has already been accompHshed at 
 birth, its condition is very different from that of the adult. 
 No special provision in the adult is made for the nutrition of 
 the lens, but in the embryo a more active growth necessitates 
 a special mechanism for nutrition. This is provided by the 
 vascular tunic of the lens, which invests the whole surface of 
 the capsule on all sides. This vascular tunic is suppUed by 
 the hyaloid artery, which runs through the centre of the 
 vitreous from the central artery of the retina. The tunica 
 vasculosa reaches its maximum development in the seventh 
 month of intra-uterine life, after which it begins to 
 degenerate, and has, as a rule, entirely disappeared before 
 birth. Occasionally, however, parts of this mechanism 
 persist. 
 
 In the infantile lens no nucleus proper has been 
 developed, though these fibres which are to form the 
 nucleus are already deposited and can never be either cast 
 off or replaced. The fibres are altogether more succulent 
 and softer than in the adult lens, and changes continue to 
 occur in them after the birth of the child, fitting them for 
 their special optical function. It is, therefore, quite 
 feasible that while the fibres now laid down show marked 
 
Skin Affections, Lamellar Cataract, etc. 217 
 
 vacuolation either in or between their fibres, the subjacent 
 fibres which have been recently laid down may also suffer 
 from the disordered nutrition before they have become 
 properly consolidated. An actual contraction of the lens 
 nucleus is also likely to occur, for, as already remarked, the 
 fibres in this nucleus are soft and have not yet become 
 sclerosed into the fibres of the adult nucleus. These fibres 
 are the first laid down, and are the furthest removed from 
 the nutrient supply, and contraction as the result of the 
 failure of this supply can be readily understood. Mr. 
 Treacher Collins agrees with this, and believes that as the 
 result of rickets the part of the lens furthest removed from 
 the nutrient supply shrinks, and in consequence of this 
 shrinkage an opaque zone forms between the nucleus and 
 the cortex from which it has retracted. This is also borne 
 out by the fact that while the peripheral portion of the lens 
 outside the definite line of the opacity is usually quite clear, 
 the nucleus is only relatively clear, and generally shows 
 some signs of degeneration. The degenerative changes in 
 the lens fibres differ from those which occur in the enamel 
 cells. In the teeth calcium is being actively laid down, 
 either by or in the ameloblasts, and the part of the enamel 
 affected is definitely marked out by a failure, either partial 
 or complete, in the process of calcification proceeding at 
 the actual time at which the rachitic state is operative. 
 From the teeth one can definitely map out the time at 
 which the morbid process begins to operate and the time 
 when it has ceased to act. 
 
 Lamellar cataract, then, is held to be a characteristic sign 
 of rickets ; in consonance with the changes in the teeth, 
 these alterations in the lens fibres occur after birth. The 
 point is of considerable importance in considering the 
 question as to the existence of foetal rickets. 
 
 During the year 1920, through the courtesy of the 
 ophthalmologists attending the ophthalmic boards attached 
 to the headquarters of the Ministry of Pensions, London 
 region, I have had the opportunity of examining thirty-five 
 consecutive cases of lamellar cataract, which came up for re- 
 
2i8 Rickets 
 
 survey in the ordinary routine examination of pensioners. 
 There was no possibihty of selection of cases, every 
 pensioner with lamellar cataract being examined from the 
 point of view of associated defect in the enamel of the teeth. 
 In thirty of these cases definite h3rpoplasia of the enamel 
 was present, that is in 857 per cent. In five cases the teeth 
 were negative. It wiU be noted that these figures ap- 
 proximate very closely the results found by Mr. Norman G. 
 Bennett in his series of twenty-six cases. This very constant 
 association of hypoplasia with lamellar cataract clearly 
 proves that both are produced by the same condition. 
 
 Very striking is the constancy of the nature of the 
 change which occurs in the teeth. It has been already 
 noted that there are several varieties of hypoplasia. The 
 form associated with lamellar cataract is the very definite 
 rachitic form of hypoplasia already described, and involves 
 only the following teeth, viz., the central and lateral in- 
 cisors, the tips of the canines, and part of the crown of 
 the first molars, in both the upper and the lower jaws. The 
 biting edges of the upper and lower incisors are almost 
 always affected. Depending on the severity and the dura- 
 tion of the disease, the deficiency of the enamel extends to 
 a varying extent upwards on the labial and buccal surfaces 
 of the tooth towards the gum margin. As a rule, it is 
 somewhat more extensive on the central incisors than in 
 the lateral incisors. Generally, only the tip of the canine is 
 involved. In the first molar tooth, Bennett states that he 
 has usually found the deficiency of the enamel involving 
 the whole tooth almost up to the gum margin. This has 
 not been my experience, the part affected being usually the 
 biting surface and not more than the third of the buccal 
 and labial surfaces of the crown of this tooth. Though 
 always involving both jaws, the condition is usually some- 
 what less extensive in the teeth of the lower jaw than in 
 those of the upper jaw. As has been shown, this is the typical 
 form of hypoplasia which has already been described as 
 characteristic of rickets. 
 
 It must be carefully noted that this condition is frequently 
 
Skin Affections, Lamellar Cataract, etc. 219 
 
 masked by grinding down of the teeth. If the enamel is 
 entirely absent and jagged dentine projects on the biting 
 edge of the tooth, this is likely to be worn down, so that 
 the biting edges become flattened, due to the wearing down 
 of the exposed dentine, and a layer of blackened dentine is 
 seen on the flat surface surrounded by a layer of enamel. 
 (See Plate VII). 
 
 Hypoplasia, as has been seen, is a common form of defect 
 involving, if aU the varieties are included, some seven or eight 
 per cent, of the population. The great majority of these 
 defects are of the purely rachitic form. Lamellar cataract, 
 on the other hand, is a comparatively uncommon condition, 
 but the probability is that it occurs much more frequently 
 than is generally supposed. If the lenses of one hundred 
 cases showing definite hypoplasia were examined with the 
 pupils dilated, the probabiUty is that in a very fair proportion 
 sUghter forms of lamellar cataract, where the condition was 
 only marked by a few " riders " in the periphery of the lens, 
 having no effect on the vision, would be fairly commonly 
 found. When these riders alone are present, they are not 
 visible if the pupil is not dilated. It may be stated that the 
 thirty-five cases examined among the discharged soldiers 
 were all definite well-marked double lamellar cataracts, and 
 were not of this very slight nature. 
 
 It is difficult to estimate the frequency of occurrence of 
 lamellar cataract in the general population. Some recent 
 figures, pubhshed by Dr. J. Kirk,* giving the result of the 
 examination of 16,000 recruits, suggest that lamellar cataract 
 of a degree sufficient to interfere with vision to the extent of 
 6/12 and over in each eye, occurs in about one in five 
 hundred of the general population. 
 
 The question arises as to why hypoplasia and lamellar 
 cataract should occur in certain cases and not in others. 
 Their incidence is partly related to the severity of the 
 disease. As already noted, though common to all classes of 
 society, hypoplasia is more prevalent amongst the poorer 
 
 • " Sight Efficiency in the General Population," J. Kirk, British Medical 
 Journal, July 8th, 192 1. 
 
220 Rickets 
 
 classes of the community. In Australia, where rickets of 
 a modified type is now fairly widely spread, hypoplastic 
 conditions of the enamel seem to be almost unknown 
 among the Australian bom. Where hypoplasia is rare, Mr. 
 Treacher Collins' observations tend to show that lamellar 
 cataract is also very rare, so that apparently where the type 
 of rickets is slight neither of these conditions is likely to 
 arise. 
 
 Nyctalopia in rickets. 
 
 Certain other defects of the eye associated with rickets, 
 though not perhaps in the very definite way that lamellar 
 cataract is, may be conveniently noted. Nyctalopia, or night- 
 blindness, unassociated with ophthalmoscopic changes, is 
 now and then met with in out-patient departments among 
 rachitic subjects. It is not apparently specially indicative 
 of rickets, but is met with in many exhausting and nutritional 
 diseases. The mother complains that the child stumbles 
 over things as darkness comes on, and generally, if these 
 children are taken into hospital, the condition improves 
 rapidly under general hygienic treatment and good feeding. 
 It is a prominent symptom in scurvy and in Barlow's 
 disease. In 1880 Snell * reported on several cases in 
 which this symptom was associated with a well-marked 
 form of xerosis of the conjimctiva in children, and since 
 then these observations have been confirmed ; but this 
 condition of xerosis does not seem to have any specific 
 connection with the rachitic state. In view of the claim 
 recently put forward that rickets is a deficiency disease, it 
 is interesting to note that a severe and destructive form of 
 xerophthalmia has been produced experimentally in rats, 
 and has been ascribed to absence of a fat soluble factor, f 
 In children, a similar and extremely rare condition was first 
 described by von Graefe J as occurring occasionally in 
 
 * " Transactions Ophth. Soc," Vol. I, 1880-81. 
 
 t " Report on the Present State of Knowledge concerning Food 
 Factors (Vitamines)," 1919. 
 
 } A. V. Graefe, Archiv. f. Ophthal., XII, Part 2, p. 250. 
 
Skin Affections, Lamellar Cataract, etc. 221 
 
 wretchedly delicate and marasmic children early in the first 
 year of life. The condition tends to proceed to ulceration 
 of the cornea and panophthalmitis. Both eyes are affected 
 and the condition is usually fatal. The disease is known 
 as keratomalacia and is very rare in this country, but, as 
 Fuchs points out, it is fairly common in Russia at certain 
 seasons. It is a form of necrosis and is not preceded or 
 accompanied by acute inflammation. It is usually associated 
 with diarrhoea, vomiting, marasmus, and extreme debility 
 induced by chronic starvation. It seems to have no 
 connection whatever with rickets. 
 
 The nyctalopia associated with rickets is usually a mUd 
 condition, and like many other rickety symptoms shows a 
 marked tendency towards spontaneous recovery. Besides 
 being common in scurvy and rickets, it prevails in some 
 countries every year during Lent when no meat is eaten.* 
 
 Nystagmus in rickets. 
 
 Spasmus nutans, or nodding spasm, is a well known 
 condition frequently associated with nystagmus and is 
 commonly due to rickets. It is a rare condition and is 
 characterised by irregular movements of the head, which 
 may be from side to side or of the nodding variety. The 
 movements may be continuous while the child is sitting up, 
 but disappear when lying down and during sleep. Some- 
 times gesticulations with the arms follow the head move- 
 ments. The symptoms usually begin suddenly, almost 
 always in mid-winter, and usually last from three to six 
 months, when they end in complete recovery. The con- 
 dition was described by Henoch | and also by Steiner.J 
 Generally it begins between the ages of four and twelve 
 months. 
 
 It has been met with not infrequently in America, where 
 
 * " Diseases of the Eye," by Edmund Nettleship, London, 1887, p. 240. 
 
 t " I-ectures on the Diseases of Children," by Edward Henoch ; first 
 published in 1876 ; 4th edition translated by John Thomson. 
 
 J " Compendium der Kinderkrankheiten," by Johann Steiner, Leipzig, 
 1878. 
 
222 Rickets 
 
 it is seen in bottle-fed and breast-fed babies, and in black 
 and in white children.* 
 
 As this condition almost invariably ends in recovery, 
 it is important to differentiate the nystagmus which occurs 
 in nodding spasm from the more serious forms of nystagmus 
 due to congenital cataract, tumours of the brain, hydro- 
 cephalus and hereditary ataxia. John Thomson f has 
 pointed out several peculiarities present in this slighter form 
 of the disease. Thus, it is often unilateral instead of being 
 nearly always bilateral. Often the movement is vertical or 
 rotatory instead of being nearly always horizontal, and the 
 direction of the movement may be different in the two eyes. 
 In the rotatory form the excursion of the centre of the 
 cornea is much greater than usual in rotatory nystagmus. 
 
 In ordinary horizontal nystagmus, the anterior-posterior 
 axes of the two eyes remain parallel to one another, that is, 
 it is conjugate in its character, whereas in the variety 
 associated with nodding spasm the eyes incline towards 
 and away from one another, that is, it is a convergent 
 nystagmus. The chief causes of this condition, Thomson 
 believes, are insufficient light and rickets. 
 
 Myopia and. Rickets. 
 
 An association between these two diseases is suggested 
 by the fact that the one follows the other, and that both 
 seem to be connected with the same conditions. 
 
 The ordinary explanation of the origin of myopia is, that 
 during convergence on near work the extra-ocular muscles, 
 notably the internal rectus and the superior oblique 
 (StilUng), exercise undue pressure on the eyeball, thereby 
 increasing the tension outside the eye and causing a 
 lengthening of its antero-posterior axis. This explanation 
 is felt to be very inadequate, and does not explain many 
 
 • Miller : " Three Cases of Head-Nodding," " Trans. Amer. Fed. 
 Soc," New York, igoo, XII, 72-80. August A. Eshner : " Nodding and 
 Rotatory Spasm of the Head with Nystagmus in Rachitic Chil<fi:en," 
 Archiv. of Pediatrics, Vol. XVIII, 1901, p. 598. 
 
 t " Guide to the Clinical Examination and Treatment of Sick Children," 
 by John Thomson, M.D Edinburgh and London, 1908. 
 
Skin Affections, Lamellar Cataract, etc. 223 
 
 marked cases occurring in young persons who develop high 
 degrees of myopia before they have begun to use the eyes 
 for near work ; nor does it explain the fact, that although 
 all children are educated in much the same way myopia 
 only develops in a few. Sir Arnold Lawson found myopia 
 in five per cent, of all children under fourteen years of age, 
 as a result of the examination of 2,000 London school 
 children.* 
 
 High myopia is common among peasants as well as 
 among the educated classes, and the probabihty is, that 
 while near work may be harmful in myopia, it is seldom 
 if ever, by itself, a cause of the disease. 
 
 The shape of the eyeball depends chiefly on its firm, 
 resistant outer coat, which is formed by the strong, opaque, 
 fibrous structure, the sclera, with the transparent forepart, 
 the cornea. Around the posterior two-thirds of the eyeball 
 there is another supporting tunic — the capsule of Tenon. 
 The cornea and the front part of the sclerotic are com- 
 paratively unsupported from the outside, and would tend 
 to bulge forwards if they were not efficiently supported by 
 the lens with its capsule and ligament, which help the 
 cornea to resist forward pressure. 
 
 Now many facts show that myopia is essentially 
 associated with debilitated states of the individual. It is a 
 disease of modern civilisation. It is seldom congenital, 
 but develops during the period of active growth of the body, 
 manifesting itself between the ages of from four to sixteen 
 years, most commonly about the period of adolescence. 
 It is more prevalent in towns than in the country. Unlike 
 highly civilised nations, savage communities are but little 
 prone to the disease. During wasting illnesses it is apt 
 to increase, and it diminishes as health and vigour return. 
 The generally accepted explanation maintains that vigorous 
 muscular action required in the act of convergence is the 
 cause of the increase in length in the myopic eye, whereas 
 all the conditions showed a marked tendency to debility 
 rather than to continuous and excessive muscular action. 
 
 * " Diseases and Injuries of the Eye," Arnold Lawson, London, 1903. 
 
224 Rickets 
 
 In health, the fundus and the sides of the eyeball are 
 well braced up by the extra-ocular muscles, and the fundus 
 is supported by the fat and loose areolar tissue which lies 
 between it and the orbit. All the muscles together combine 
 to maintain this uniform healthy tension. In enucleation 
 of the eyeball, when the long muscles of the eye are divided, 
 the globe starts forwards owing to the sudden release of the 
 backward pressure against the elastic pad lying between the 
 fundus of the eyeball and the back of the orbit. Much 
 the same condition arises in cases of extreme muscular 
 debility. Rickets plays a formidable part in the production 
 of these debilitated states, and like scoUosis, fiat-foot, and 
 knock-knee, myopia may arise as the sequel of the per- 
 sistence of a debilitated muscular state long after the active 
 stage of the disease has passed. 
 
 But yet another factor has to be reckoned with. Nor- 
 mally, the sclerotic coat is thinner in the young child than in 
 the adult, and in rickets, and other debilitating states, 
 notably after measles and whooping cough, it tends to be 
 softened and is rendered still more attenuated as a result 
 of malnutrition. In the convergence on near work, the 
 pull of the ciliary muscle on the choroid, and through this 
 coat on the sclerotic, may have some slight action in the 
 production of myopia, but it is only likely to do so when 
 the supporting extra-ocular muscles have lost their tone, and 
 when the sclerotic coat is thinned and weakened as the 
 result of debilitating disease. 
 
 As has already been shown, alterations occur in the bony 
 orbit as a consequence of the rachitic state, and the question 
 arises if such changes have an influence on the shape of the 
 contained globe. 
 
 Stilling * advanced the theory that lengthening of the 
 eyeball is due to pressure of the superior oblique muscle, 
 and that the action of this muscle varied with the configura- 
 tion of the orbit, and the position of the trochlea, the pulley 
 through which the round tendon of this muscle plays. If 
 
 * " Ueber Schadelbau und Refraction," Herr Stilling (Strassburg), yth 
 Intemat. Ophth. Cong., 1888, p. 97. 
 
Skin Affections, Lamellar Cataract, etc. 225 
 
 the trochlea were below the normal level, he held that the 
 muscle exerted much pressure on the eyeball, and in support 
 of his view, he maintained that in myopia the orbit is broad 
 and low, whereas in hypermetropia and emmetropia the 
 orbit is relatively high. This, however, is not an explana- 
 tion capable of general appUcation. Among many broad- 
 faced peoples myopia is rare. 
 
 Others have maintained that as a result of the softening 
 of the bones which occurs in rickets the weight of the 
 anterior lobes of the brain acts on the orbital plate of the 
 frontal bone, producing depression of that plate and com- 
 pression and flattening of the globe of the eye.* In this 
 way, it is argued, an elongation of the long axis of the 
 eye may be produced by an excess of curvature of the 
 cornea and of the lens, and an increase in the depth of 
 the anterior chamber, or by a distension of the posterior 
 part of the sclerotic. Such theories lose sight of the fact 
 that the globe of the eye is a comparatively small structure 
 contained in a large cavity, which could accomiiiodate with 
 ease a globe of much larger circumference. In some extreme 
 cases of advanced hydrocephalus there is evidence' of such 
 compression of the eyeball, and there may be a certain 
 degree of proptosis of the eye, with the characteristic ex- 
 posure of the sclerotic between the iris and the lids. But 
 even in hydrocephalus myopia is not a common feature, 
 and severe degrees of hydrocephalus are not usually a result 
 of the rachitic state. The tendency of rickets is, as has been 
 seen, to elongate the orbit from above downwards rather 
 than to produce flattening. 
 
 In this way myopia is linked up with a large class of 
 morbid conditions produced by the rachitic state, viz., 
 scoliosis, pes planus, and genu valgum, defects which are 
 dependent on loss of muscular tone, and softening and re- 
 laxation of fibrous and ligamentous structures. The muscular 
 debility and general loss of tone continue long after the 
 active stage of rickets is passed, and the disease has under- 
 
 * " Myopia and Astigmatism in Rickets," M. Hauchcorne, La Semaine 
 Medicale, 1901, p. 159. 
 
226 Rickets 
 
 gone partial cure. In inducing myopia these conditions act 
 in two ways : (1) by loss of tone of aU the extra-ocular 
 muscles which act on the eyebaU ; (2) by interference with 
 the integrity of the great supporting tunic of the eye, the 
 sclerotic coat, owing to thinning and softening. As already 
 noted, these conditions may be induced by attacks of pro- 
 longed and debihtating disease, but among ova large town 
 populations rickets is by far the most widespread influence 
 producing profound debihty in the infant and the growing 
 child. I have myself known definite and permanent in- 
 crease of myopia to occur as a result of the depressing 
 influence of typhoid fever. 
 
 Another condition of the eye may be shortly mentioned 
 in association with rickets, though the connection is in- 
 diirect. Corneal ulcer in the young child is rare, but the 
 condition known as phlyctenular, or formerly strumous 
 ophthalmia, is common at the age of three or four years. It 
 is a conjunctival condition primarily attacking Bowman's 
 membrane, and may, if neglected, lead to opacity seriously 
 interfering with vision. It may follow measles and scarla- 
 tina, and is often the result of direct infection through the 
 nasal duct from unhealthy conditions of the naso-pharynx, 
 so frequently associated with mouth breathing and the 
 rachitic state. 
 
CHAPTER XVII 
 The Nervous System in Rickets 
 
 It has long been recognised that certain states of the nervous 
 system are very definitely associated with rickets. It is of 
 considerable interest and importance to consider the rachitic 
 state as it affects various definite structures, apparently quite 
 remote from each other and dissociated in function, which 
 are yet clearly linked up embryologically, in that they are 
 developed from the same embryonic layer. No structures 
 would seem at first glance to be more imlike than the enamel 
 of the teeth, the skin with its appendages, and the lens of 
 the eye ; and yet it has been shown that changes along 
 definite lines occur in each of these . structures, which are 
 frequently definitely associated with each other, and all of, 
 which are due to one common cause — crickets. 
 
 The consideration of the diseases of the central nervous 
 system associated with rickets presents more difficulty. 
 There are no gross changes in this system exhibiting them- 
 selves readily to the naked eye, as in the cases of the enamel 
 of the teeth and the lens. But the signs and symptoms 
 produced by abnormal action of the central nervous system 
 in rickets are so definite, and so well defined, that it may 
 reasonably be inferred that actual structural changes occur 
 in the very nerve elements themselves. It has been usual to 
 speak vaguely of an increase in the connective tissue element 
 of the brain in this disease,, but the,probabihty is that the 
 essential alteration is much more subtle and affects the actual 
 neurons. The fact, that the characteristic nervous diseases 
 which result from,rickets are frequently accompanied by 
 definite naked eye alterations in other structures derived 
 from the same embryonic layer lends corroboration to this 
 view. Thus, lamellar cataract is nearly always accompanied 
 
 227 
 
228 Rickets 
 
 by convulsions in infancy ; when the second teeth are 
 erupted, 85-7 per cent, of these cataract cases show a 
 definite form of hypoplasia affecting the enamel laid down 
 during the first two years of the child's Hfe. 
 
 In tetany, another very characteristic defect of the nervous 
 system usually due to rickets, Fleischman noted the constant 
 presence of hypoplasia affecting the permanent teeth.* 
 
 The outer or ectodermic layer of the blastoderm gives 
 rise to the following. structures : (1) the enamel organ which 
 grows as a ridge from, the epithelium of the oral cavity into 
 the cellular embiyonic connective tissue ; (2) the epidermis 
 and its appendages, including the: hair and* nails ;. (3) the 
 most important functional pants i of the sensory organsj.such 
 as the lens, and the optic, auditory and olfactory nerves ; 
 (4) the whole of the central nervous system, including not 
 only the centred organs (brain andi spinal cord),, but also> the 
 peripheral nerves and S5nTipathetic. In rickets changes may, 
 and frequently do, occur in aU these structures, and the 
 factor responsible for their production is the aberrant action 
 of the glands of the endocrine system;, induced in response 
 to the conditions of altered environm^it which arexesponsible 
 for the disease. 
 
 The gross rickety changes which occur, such.as-hypoplasia. 
 of the enameliiharsh and dry skin with, coarse and scanty 
 hair, and:) lamellar cataract;, are easily recognised by the 
 naked- eye. The pathology of the nervous system is more 
 elusive, dependent as it is on the intimate structure ofrthe 
 neuron; but when; it is found that there is a: constant 
 association^ of certaiui nervous symptoms, such, as epilepsy, 
 tetany; spasmus nutans', andi laryngismus stridulusj with 
 rickets, and: especially- whea certain of ^ these symptoms are 
 definitely related to visible and well-marked changes in the 
 other-epithelial structures, it seems reasonable to conclude 
 that these nervous diseases are due to struGtural alt^ations 
 in the nerve elements themselves and; are produced! byJ the 
 same cause. 
 
 * Fleischman-: " Beziehungem'zwischeir'derTetameund'derEntwicke- 
 lung von Defekt-bildungen des Zahnschmelzes." Mitt, d, Geselhch. /. inn 
 Med, u, Kinderh, in Wien, 1908, yil, i82'i84. 
 
The Nervous System in Rickets 229 
 
 Convulsions in infancy and their relation to epilepsy. 
 
 In the new bom child, as is well known, the lowest 
 level centres of the nervous system, that is, those of the 
 spinal cord, medulla and pons, are relatively more fully 
 developed than the higher brain centres, which as yet possess 
 very little of that controlling influence which they speedily 
 acquire as the child grows. Thus certain simple reflexes 
 occur with great ease in the young infcint. The association 
 between sensations of hunger and the seventh cranial nerve 
 are easily understood, estabhshing a ready reflex to allow of 
 the action of the buccinators and the other strong sucking 
 muscles. In the young infant a few weeks old slight 
 attacks of flatulence after a meal frequently produce rippling 
 spasms passing over the face, especially during sleep, 
 -elevating the angles of the mouth into the appearance of 
 a smile or drawing the face to one side. This occurs under 
 perfectly normal circumstances with a healthy infant. If 
 prolonged or somewhat more severe, the third cranial nerve 
 may be thrown into action and the eyes of the child may 
 be turned up, exposing the whites, or the eyebrows may be 
 elevated and the eyelids frequently twitch. Mendel, sup- 
 ported by Tooth and Turner, has. shown that there is a 
 eonnectiom between the nuclei of the oculomotor and the 
 facial nerves, and the probability is that these movements 
 are the result of simple reflexes which do not reach further 
 than the nuclei, and which have no tendency to become 
 generahsed into convuisions. Flatulent attacks produce 
 these reflex actions in, the seventh and third cranial nerves 
 in perfectly Jiealthy infants, but when the child is a few 
 months old they are less easily, produced. 
 
 This reflex excitability is recognised to be perfectly 
 natural inith? Jbealthy .infant, and its .absence may in itself 
 be a sign of disease. Thus, in children reduced to a 
 jcacbectic state by : malnutrition consequent on insufiicient 
 or unwholesome diet, apart altogether from the rachitic 
 state, this excitability may be greatly reduced. 
 
 Eustace Smith emphasises two facts in these debiUtated 
 
230 Rickets 
 
 children : (1) that reflex convulsions are rare, owing to the 
 insensibility of the nervous system concerned in the pro- 
 duction of reflex movements so characteristic of the healthy 
 child ; (2) acute diseases in these children have a character 
 all their own. They are more insidious and have a slower 
 course, and give rise to fewer symptoms ; often they end 
 suddenly and unexpectedly in death.* 
 
 Very different is the state of affairs found in rachitic 
 children. They may be wasted and debilitated, but on the 
 other hand they may be fat, plump, and well nourished. In 
 either case the child is likely to exhibit a false appearance 
 of placidity, whereas the reflex excitability is extreme and 
 laryngismus stridulus and convulsions are very common. 
 Healthy infants do not easily become convulsed unless the 
 stimulus is strong, and in the large majority of children 
 who suffer from convulsions up to the age of three years 
 the signs of rickets are present. Convulsions chiefly occur 
 during the first six months, and four-fifths of all cases occur 
 before the end of the second year. Normally the gastro- 
 intestinal tract of the infant easily rids itself of excess, either 
 by the act of vomiting or by increased intestinal peristalsis. 
 It is not so easy as is often stated, to overload the system 
 of the young infant. Provided other conditions are healthy, 
 nature fortunately, allows for a large margin of error in 
 feeding. But in the rickety child, a solid curd in the stomach 
 or bowels may excite a stimulus over a wide area, and many 
 nerve centres may be thrown into activity. The facial 
 muscles twitch and the eyes roll upwards. Frequently 
 there is spasm of the glottis and of the respiratory muscles. 
 The hands may be clenched and the legs drawn up, to be 
 followed by a clonic spasm of all the muscles of the 
 extremities. 
 
 Dentition may be an exciting cause of convulsions. The 
 eruption of the teeth is usually spoken of as a perfectly 
 natural process, devoid of symptoms in a healthy infant. 
 This is far from being the case. The healthy breast-fed 
 
 * " The Wasting Diseases of Children," by Eustace Smith,. London, 
 1878. 
 
The Nervous System in Rickets 231 
 
 infant frequently shows the gums swollen, hot and dry, as 
 the result of the rapid descent of the teeth, and no one who 
 has watched the gum slowly receding over the advancing 
 tooth can doubt that it causes considerable constitutional 
 disturbance. In health the irritation of the trigeminal 
 nerve induces the child to bite at every object it can raise 
 to its mouth, but in the rachitic child the reflex act may 
 spread much more widely, and often ends in general con- 
 vulsions. Not all cases of convulsions are rickety ; scarla- 
 tina is very liable to be ushered in by fits, as also are diseases 
 which cause high temperature, such as pneumonia. The 
 onset of meningitis and the acute stage of infantile paralysis 
 may also be marked by convulsions. But in the great 
 majority of infants and young children who suffer from 
 spasmodic and convulsive states, rickets is the essential 
 cause which renders the nervous system hable to give an 
 excessive response to what is often a comparatively small 
 stimulus. Out of fifty cases of laryngismus stridulus, Dr. 
 Gee found that forty-eight were rickety, and of these nine- 
 teen had general convulsions. In 102 children in whom 
 general convulsions occurred, forty-six were rickety — that is 
 about half ; * the probability is that the number of rachitic 
 cases among these last children is considerably under- 
 estimated. 
 
 The relationship of infantile convulsions to the onset of 
 epilepsy is a matter of the greatest importance. The 
 majority of convulsive seizures in infants are single, but in 
 certain cases they are repeated and may recur over a long 
 period. While it is probably true that the greater number 
 of children who suffer from convulsions in infancy lose the 
 tendency to these seizures as they grow older, it is un- 
 doubtedly true that in a large percentage the fits continue, 
 or recur after a certain interval, and pass into the disease 
 known as true epilepsy. The two conditions in these cases 
 are identical. 
 
 Jenner held this view, and Gowers found that in 12 '5 per 
 cent, of cases of chronic epilepsy, there was a history of the 
 * " St. Bartholoniew's Hospital Reports," Vol. Ill, 1867. 
 
232 Rickets 
 
 fits commencing during the first three years of hfe, while in 
 5"5 per cent, they occurred during the first year. 
 
 Osier, in 460 cases of epilepsy in children, noted the 
 time of onset in 428, as follows : — 
 
 Ito 5 years 229 
 
 5 to 10 „ 104 
 
 10 to 15 „ 95 
 
 These figures illustrate in a striking manner the early onset 
 of the disease in a large proportion of the cases. 
 
 Much weight is often laid on the exciting causes of fits 
 in children, such as gastro-intestinal irritation and teething, 
 but their importance is apt to be much exaggerated. Fits 
 would not occur in healthy children under such circum- 
 stances. The important point to remember is that the 
 exciting cause acts on a prepared territory, and once 
 established, as in most cases of chronic epilepsy, no such 
 cause for the actual convulsion can be discovered. The 
 nerve cells have become highly unstable, and there is 
 apparently an actual degenerative change in the neurons 
 themselves responsible for the disease. It is now generally 
 beheved that these fits may have their origin at three levels : — 
 
 1. The lowest level situated in the spinal cord, medulla and 
 
 pons. Laryngismus stridulus is usually supposed to be 
 produced at this level. 
 
 2. The middle level, consisting of the motor centres in the 
 
 Rolandic area. In this, the Jacksonian form of epilepsy, 
 the convulsion begins in certain muscles and may only 
 involve a certain group without becoming generalised. 
 Some of these cases are due to gross lesions in the brain, 
 but in many no such cause is to be found. 
 
 3. The highest level, situated in the frontal and occipital regions 
 
 of the cortex. Such cases are apt to be exceedingly 
 complex, and the fit is usually preceded by an aura 
 followed by a widespread generalised convulsion. 
 
 What the nature of the changes in the brain cells which 
 follow on the rachitic state is, it is at present impossible 
 to say, just as it is in most of the so-called idiopathic forms 
 of epilepsy. In rickets, error in the calcium metabolism is 
 a prominent feature of the disease, and the association of 
 myetetic and nervous irritabihty in such cases is now well 
 
The Nervous System in Rickets 233 
 
 known. There may be no want of calcium in the system, 
 indeed, it may be excreted in excess in the urine, but there 
 is a want of capacity on the part of the tissues to make use of 
 the calcium which is present. It can readily be understood 
 that the continued deprivation over a prolonged period of 
 any one element necessary for the proper nutrition of the 
 nerve ceU may easily produce permanent and serious 
 damage in its structure. The importance of the relation- 
 ship between epilepsy and rickets lies in the fact that, if the 
 connection is proved, it brings a large number of these grave 
 conditions within the class of preventible diseases, for 
 rickets is pre-eminently one of the maladies capable of 
 mitigation and cure, and with reasonable care its incidence 
 might be wholly prevented. 
 
 The hereditary factor in epilepsy is one on which 
 opinion varies greatly, and of late years the tendency has 
 been to discount its influence. Thus, Osier * notes that the 
 French physicians, notably Marie, take strong grounds 
 against heredity as an important factor. In a series of 126 
 cases. Osier himself found that in thirty-two, there was a 
 famUy history of nervous derangement of some sort, but that 
 there were only two, in which the mother had had epilepsy, 
 and not one in which the father had been affected. 
 
 The probability is that the proportion of rachitic and 
 therefore preventible cases of this very grave malady may 
 ultimately prove to be very large. It would be of much 
 interest to compare the rate of incidence of epilepsy in 
 countries such as New Zealand and Australia, where rickets 
 is either rare or present only in a mild form, with that which 
 occurs in Europe, where rickets is prevalent. 
 
 Laryngismus stridulus in rickets. 
 Laryngismus stridulus, on account of its frequency and 
 its alarming nature, is one of the most important of the 
 convulsive attacks of infancy. It tends to occur early, and 
 is not so likely to appear after the age of three years, though 
 it may do so up to the age of seven. This condition is 
 
 * Ibid., p. 1094. 
 
234 Rickets 
 
 characterised by paroxysms of dif&cult breathing, which 
 come on suddenly and may be so severe that they end in 
 suffocation, though usually they end in recovery marked by 
 a deep crowing inspiration. Frequently the face is pale, 
 but may become dark, swollen and congested. The first 
 attack generally comes on at night, the child waking 
 suddenly from sleep and making as if it were about to cry. 
 But instead of inflating the lungs, repeated spasmodic 
 attempts are made to fill the chest, between each of which 
 a squeaking sound is made. In a few seconds the attack 
 passes off and the child cries itself to sleep. The attacks 
 may not recur for some considerable time, but if the rickety 
 state is continued and severe, they tend to come on by day 
 as well as by night, and are brought on by the most trivial 
 circumstances, such as surprise or fright. The attacks, 
 which at first were quite short, are prolonged, and may last 
 for a quarter of an hour or longer. Usually the infant is 
 obviously in poor health, but in fat rickets it may look quite 
 healthy and may seem perfectly well in the intervals. 
 
 When the attacks are severe, carpo-pedal contractions 
 are apt to occur, the thumbs being bent into the palms of 
 the hands, while the feet and toes are bent in the position of 
 equino-varus. Later, general convulsions may supervene, 
 and in these cases death is not infrequent following an attack. 
 Cranio-tabes, first described by Elsasser, was, as has already 
 been noted, held to be responsible for most of the convulsive 
 seizures of infancy. This received the support of Kassowitz ; 
 Jacobi found this condition of the skull in an extraordinary 
 number of cases of children suffering from laryngismus 
 stridulus, noting softened areas of such smaU extent that 
 they would not be appreciable to most observers. As 
 a general Tule, pressure on these softened areas is well 
 borne, and there is probably no direct association be- 
 tween the convulsive attacks of infancy and cranio-tabes. 
 Larjmgismus stridulus is probably due to malnutrition of 
 the nerve cells which subserve the function of respiration in 
 the lower level centres of the brain, and, as was suggested 
 in speaking of epilepsy, the likelihood is that there is an 
 
The Nervous System in Rickets 235 
 
 actual structural alteration in the neurons themselves. Post- 
 mortem examinations in fatal cases are usually negative, for 
 the distended state of the meningeal veins and the presence 
 of serous effusion under the arachnoid and within the 
 ventricles of the brain are lesions produced by the mode of 
 death. Enlargement of the thymus has been cited as 
 a cause of laryngismus stridulus, and though it is not a 
 common cause it may be present, and the possibility of the 
 existence of the associated condition of status lymphaticus 
 should be borne in mind. This is the condition described 
 by the older wiiters as thymic asthma. 
 
 Tetany in Rickets. 
 
 Tetany is a well known disease of the nervous system, 
 which is commonly associated with rickets in the young 
 child. Fischl found that sixty-three per cent, of his 
 cases were rachitic. It is characterised by marked hyper- 
 excitabihty of the neuro-muscular system, and is associated 
 with bilateral spasms of the extremities, which may be 
 continuous or intermittent. In laryngismus stridulus, as 
 has already been seen, a form of carpo-pedal spasm is a 
 frequent accompaniment, and is usually an early manifesta- 
 tion of this disease. As a rule it occurs early, and is much 
 more common before three years than after. Griffith found 
 that sixty-eight per cent, of cases occurred before the end of 
 the second year. It is interesting to note that tetany may 
 occur in the adult, when it is usually connected with the re- 
 productive functions. Thus, it may occur in a mild form in 
 girls about the age of puberty ; or it may supervene during 
 pregnancy, but it is most likely to begin during the period 
 of lactation, especially if prolonged, a condition named by 
 Trousseau " nurses' contracture." It may follow successive 
 pregnancies. 
 
 Tetany also occurs in epidemic form, particularly in 
 spring and in the winter. It may follow infections such as 
 typhoid fever and measles. Dilatation of the stomach is a 
 condition which has been noted fairly frequently in tetany, 
 and is usually associated with a more severe form of the 
 
236 Rickets 
 
 disease and a higher mortality. The prognosis, as a rule, 
 is very good in ordinary rachitic cases. 
 
 ;It is now well known that tetany may follow operations 
 on the thyroid. Since the discovery of the parathyroid 
 glands by Sandstrom, in 1880,. the nature of this artificially 
 produced condition has been made much clearer. 
 
 The term " tetania struniipriva " is applied to the f orjn 
 of tetany following operations on the thyro-parathwoid 
 apparatus. It is now fairly well established that this 
 condition follows removal of the parathyroids, and is not 
 likely to occur when the thyroid is removed and the para- 
 thjnroids are left intact. In animals, partial removal of the 
 parathyroids may lead to nutritional changes, such as 
 emaciation, apathy, and roughening of the coats. Complete 
 removal leads to trophic and nervous changes, ending in 
 death in from three to five days, though this may be delayed. 
 There is great excitability of the nervous system, leading to 
 muscular twitchings over the whole body. Fibrillary 
 twitching of the muscle fibres of the tongue is apt to be 
 present, and tonic contractions of the facial muscles and of 
 the laryngeal muscles producing stridor may supervene. 
 Acute tetanic spasms are hkely to follow, ending in death. 
 This disease has been checked by transplantation of para- 
 thyroid tissue. MacCallum's experimental observations 
 would seem to show that some change takes place in the 
 blood. The exact nature of the chemical change which 
 occurs has not been established, but it may be of two kinds : 
 (1) there may be an active poison in the blood ; Noel Paton 
 has suggested an intoxication produced by guanin com- 
 pounds ; (2) something is withdrawn from the blood 
 which normally exerts a moderating and quieting influence 
 on the nerve cells, leaving them unbalanced and hyper- 
 excitable. 
 
 MacCallum * has suggested as a plausible working hypo- 
 
 * " On the Relation of the Parathyroid to Calcium Metabolism and 
 the Nature of Tetany," by W. G. MacCallum and C. Voetglin. The 
 Johns Hopkins Hospital Bulletin, Vol. XIX, Baltimore, 1908. " Xhe Func- 
 tion of the Parathyroid Glands," W. G. MacCallum. The Journal of Amer. 
 Med. Assoc, August 3rd, 1912. 
 
The Nervous System in Rickets 237 
 
 thesis that withdrawal of calcium salts from the cells occurs 
 in this disease, leaving them hypersensitive. There is a 
 good deal of experimental evidence to support his hypo- 
 thesis, and the clinical study of rickets in connection with 
 changes produced as the result of inactivity of the thyroid 
 and parathyroid apparatus, lends plausibihty to a view, 
 which, if true, is capable of wide application. 
 
 It is a weU known observation that withdrawal of 
 calcium from a cell, leaving a greater proportion of sodium 
 and potassium, renders the cell hyperexcitable. MacCaUum 
 beUeves that there is a striking reduction in the calcium of 
 the blood in tetany, and his statement has been confirmed 
 by other observers. The injection of calcium salts into the 
 blood has an immediate soothing effect on the experi- 
 mentally produced condition, and in children suffering from 
 the disease, the administration of calcium lactate in five to 
 fifteen grain doses has proved very efficacious. The concep- 
 tion that rickets is due to deficiency of calcium in the food 
 is a very old one, whichj however, does not agree with the- 
 fact that in the urine there is frequently an excess of calcium 
 in this diseeise. Neither is the addition of calcium to the 
 diet a certain method of ameliorating the condition. 
 MacCallum's observations suggest that there is an incapacity 
 of the tissues to utilise the calcium which is present, due 
 to the loss of some internal secretion which is normally 
 passed into the blood. As more is learnt about the action 
 of the glands of internal secretion, the more is one diffident 
 in ascribing a definite disease to any one gland. But it would 
 seem justifiable to say that the thyroid apparatus, in- 
 cluding under that term the parathyroid glands, exerts a 
 controUing influence on calcium metaboHsm. It is obvious, 
 from what is known of the action- of the thyroid in 
 myxoedema and: cretinism, that it tends to hasten tissue 
 metabolism. Hutchison* points out that its secretion 
 hastens the fife history of the cell. Cell division occurs 
 more rapidly and the ceU reaches maturity more rapidly; 
 
 * "The Pharmacological Action of the Thyroid Gland," by Robert 
 Hutchison, Brit. Med. Jownal, July i6thj 1898, 
 
238 Rickets 
 
 In myxoedema, on the other hand, many of the cells never 
 reach a mature stage and the subcutaneous tissue becomes 
 filled with cells in an embryonic stage, and when the old 
 hairs fall, out, the cell division, which should lead to the, 
 formation of new hair, does not take place. The thyroid 
 exerts its beneficial influence by hastening the life history of 
 the cell. This explains its action in backwardness of growth 
 in school children, and the good effect it often produces 
 in such conditions as psoriasis and in dry skin and in 
 ichthyosis. 
 
 Removal of the thyroid or impairment of its action, 
 tends to produce reduction of temperature, and decreased 
 intake of oxygen, and diminished output of carbonic acid. 
 Associated with this change, there is a lymphatic hyperplasia 
 in rickets, such as is commonly found where there is a 
 conservation of metabolism. Naturally, this diminished; 
 metabolism, leads to partial, or more or less complete, 
 arrest of. the processes of nutrition and growth. These are 
 points of the first importance in considering the origin of 
 rickets and the adaptation of the infant to the inimical, 
 environment which surrounds it in slum dwellings in. large, 
 industrial centres. 
 
 Tetany seems to be more common in Europe than in, 
 England, and is not common in the United States, though 
 the condition has been, carefully studied in America, 
 a,nd many cases have been described. In larjmgismus 
 stridulus, convulsions, and epilepsy, there seems to be 
 instability and a tendency to irregular discharges in the actual 
 nerve cells themselves situated in the various brain centres. 
 In tetany there is also a marked irritability in the peripheral . 
 nerves. The, symptoms of tetany are characterised by. 
 spasmodic contractions or cramps in the legs and arms, 
 which are the parts most commonly affected. The child, 
 does not lose consciousness and the cramps are associated 
 with a good deal, of pain. The arms are pressed against 
 the thorax, the elbows are flexed, the thumbs are bent into . 
 the palms, and the fingers are tightly flexed over the thumb. 
 The fingers are approximated and are in the position pro-. 
 
The Nervous System in Rickets 239 
 
 duced by contraction of the interossei, that is, they are 
 flexed at the metacarpo-phalangeal joints, while the inter- 
 phalangeal joints are extended, producing the so-called 
 obstetric position of the hand. The lower limbs may be 
 adducted with the thighs flexed on the abdomen and the 
 legs on the thighs. Usually the feet are in the position of 
 equino- varus, that is, the ankle joint is extended, and the 
 soles of the feet are turned inwards with the toes bent. 
 After the contraction has lasted some time there is often 
 oedema over the dorsum of the foot. (Kophk.) 
 
 The irritability of the peripheral nerves is responsible 
 for the production of two well known signs in tetany, viz., 
 Chovstek's sign, in which tapping over the distribution of 
 the facial nerves produces well-marked spasm of the muscles 
 supplied by the nerve, and Trousseau's sign, in which pressing 
 over the main nerve trunk of the limb produces an attack of 
 the spasmodic contractions characteristic of the disease. 
 There is also increased electrical excitability of the nerves. 
 Erdheim's observations are of interest in connecting up 
 tetany with failure of the calcium metabolism. He found 
 that in rats with chronic tetany the incisor teeth become 
 son" and break off, because no calcium is deposited in the 
 dentine, and fractured bones fail to unite because no callus 
 is formed. 
 
 Grouping these several conditions — convulsions, laryn- 
 gismus stridulus and tetany — ^under one heading, the 
 various theories as to their causation may be summarised 
 as follows : — 
 
 1. Elsasser's view that it is due to pressure on the brain 
 
 through softened areas in the cranial bones, due to 
 cranio-tabes, is not now considered a factor of much 
 importance. 
 
 2. Kassowitz believed that in tetany rickets first produced an 
 
 irritable condition of the nervous system associated with 
 congestion, and that toxic products from the polluted 
 atmosphere of smaU, overcrowded, and badly ventilated 
 rooms inhaled through the lungs, excited the already 
 over-sensitive nerve cells to irregular discharges. 
 
 3. Intestinal toxaemia has been held by many to be the 
 
 essential agent in producing these states. As already 
 
240 Rickets 
 
 noted, the association of gastric-dilatation and a certain 
 severe form of tetany lends colour to such a view, but in 
 a large proportion of cases there is no evidence of any 
 irritation in the gastro-intestinal canal, and in many cases, 
 where there is marked gastro-intestinal disturbance, 
 tetany does not supervene. Escherich has observed that 
 tetany is especially apt to occur in very fat children who 
 are constipated and show but little evidence of bony 
 change — a very definite and well recognised type of 
 slight rickets. 
 
 4. Disturbance of the calcium metaboUsm has been blamed for 
 the production of the spasmodic diathesis, and two 
 diametrically opposed views have been put forward. 
 Stoeltzner maintains that there is a condition of calcium 
 intoxication due to an excess of calcium salts in the 
 system. Supporting his view, several German investi- 
 gators have maintained that the use of cow's milk, 
 owing to the excess of calcium contained, may be a 
 factor in producing this disease. The gastro-intestinal 
 mucosa is one of the chief emunctories dealing with the 
 excretion of calcium, and it has been suggested that the 
 excess of calcium may be due to retention owing to some 
 defective state, possibly inherited, of the mucosa. 
 Stoeltzner holds that there are two varieties of tetany, 
 the one — ^infantile tetany — ^being due to excess of calcium, 
 while the other is due to injury or disease, or removal of 
 the parathyroids — tetania strumipriva. The most recent 
 view is that based on the work of MacCaUum and 
 Voetglin, already referred to, that the spasmodic state 
 is due to thyroid and parathyroid insufficiency. The 
 fault does not lie in any deficiency in the intake of 
 calcium, which is usually ample, but in an insufficiency 
 or deprivation of some internal secretion, which renders 
 the tissues incapable of utilising the calcium which is 
 available. This last view is the one which fits in best 
 with the experimental evidence, and accords with the 
 metabolism of the rachitic state which is found clinically. 
 
 Some aspects of the general development in rickets may 
 be here touched upon. 
 
 The delay in walking and in speech has already been 
 referred to, and not infrequently the prolonged inability to 
 walk, or the backwardness in speaking, first induces the 
 mother to seek advice. 
 
 During the active stage of the disease, the child, instead 
 
The Nervous System in Rickets 241 
 
 of rejoicing in activity, is unduly placid. But this placidity, 
 as has been shown, is only apparent. 
 
 Mental development in rickets. 
 
 Incontinence is a symptom that is of frequent occurrence 
 in rickets, and it is of interest to note that thyroid treatment 
 is frequently successfiil in these cases. The mental progress 
 of the child is slow, and this is especially shown in speech, 
 as already noted. Defective forms of speech are frequent ; 
 lalling is common, and stammering and stuttering are apt 
 to develop later. The child has difficulty in picking up 
 new words. 
 
 Mental state at time of entry into school. 
 
 At school age the rickety child is distinctly backward 
 when compared with the normal child. The backwardness 
 naay last for some years, and then somewhat suddenly the 
 child often makes a rapid advance, noticeable to both parents 
 and teachers. There is, as it were, a sudden intellectual 
 awakening. This is characteristic of the mentality of rickets. 
 Typically, the child at school age is dull, and its powers of 
 attention are poor, rendering it the despair of its teacher. 
 By the fourth or fifth year of life the child is beginning to 
 improve physically and to become more active ; but the 
 mental improvement does not begin till somewhat later. 
 The mother frequently makes the statement that all her 
 children begin to pick up wonderfully about the age of 
 seven, an observation which is quite consistent with the 
 facts in the great majority of cases. 
 
 Mental condition in later school life. 
 
 In the slighter forms of rickets, and especially when the 
 natural surroundings become more favourable, the child's 
 mental condition may return to the normal, and no perma- 
 nent damage seems to be done. But in a large number of 
 cases the sudden progress which the child makes only 
 carries it to a certain limit still below the normal, so that 
 its capacity is only equal to that of a child two or three 
 
242 Rickets 
 
 years . younger. The child's powers of attention and con- 
 centration remain poor, the mental response is much delayed, 
 and frequently a question will have to be repeated several 
 times before the child grasps what has been said. In the 
 ordinary work of the class the child remains a distinct drag. 
 A judicious selection of such children, and the placing of 
 them together in a class where they can be put to modelUng 
 in the round, drawing with coloured chalks, and, in the 
 case of girls, housework, is often followed with the happiest 
 results. For the first time the child does work which it 
 can really do well; a few weeks at such work, where the 
 hand assists the brain, wiU often convert a duU, Mstless 
 child into one that is bright and alert. Its self-respect is 
 increased as it finds that at certain kinds of work it can hold 
 its own. The training of the mind through the muscular 
 sense is peculiaxly well adapted to this type of child. When 
 the mental condition remains below the normal, the child 
 in severer cases is apt to be moody, and is not infrequently 
 vicious and spiteful, and uncertain in temper. Such cases 
 are especially troublesome, as they are often associated with 
 children of younger . age than themselves owing to their 
 slow progress through the standards. In many cases the 
 early struggle against adverse circumstances leads to a 
 certain infirmity of purpose which persists through adult 
 life, and probably accounts for a good many half failures in 
 adult hfe. 
 
 Dividing the eight hundred rickety children out of one 
 thousand examined in the East end of London into three 
 classes — ^bright, average, and backward, it was found that : — 
 
 11 per cent, could be considered bright. 
 64 „ „ „ average. 
 
 25 „ „ „ backward. 
 
 The very universality of the condition probably makes 
 one content with not only a much lower general standard 
 of mental development, but also with a lower standard of 
 growth than might legitimately be expected if the environ- 
 ment of the child were such as to allow of its full mental 
 and physical development. It must be remembered that this 
 
The Nervous System in Rickets 243 
 
 arrest of development is permanent ; if a systematic examin- 
 ation were made of the mental development of the adults 
 in our crowded cities and slum areas, a large proportion 
 would be found who had never attained a mental develop- 
 ment beyond that of a child of twelve years. 
 
CHAPTER XVIII 
 
 Affections of the Blood and of the Lymphatic System 
 
 in Rickets 
 
 Changes in the blood in rickets. 
 
 There are several fallacies to be guarded against in an 
 examination of the blood in infancy. The ordinary standards 
 for blood counts do not apply where many of the features 
 of pre-natal blood formation still persist. Thus, nucleated 
 red blood corpuscles are not uncommon normally in the 
 young infant. Megaloblasts, if present in the adult in any 
 appreciable number, are usually indicative of pernicious 
 anaemia, but in infancy their presence seems to be of 
 comparatively little importance. Pernicious anaemia is 
 excessively rare in children under the age of ten, if it exists 
 at all. Leucocytosis is common in infancy, and 20,000 to 
 60,000 leucocytes per cubic miUimetre are frequently met 
 with and the presence of myelocytes is common. Another 
 possible source of error lies in the fact that rickets is an 
 exceedingly common disease, so common indeed that in 
 the hospital and dispensary class of patient it is probably 
 difficult to obtain a normal standard as a control. It may 
 well be that the tendency to leucocytosis in infancy is a 
 widespread reaction against a vicious environment and has 
 a definite protective influence, though Cannata * states 
 that the phagocytic action of the leucocytes in rickets is 
 low. 
 
 CUnically, there is little doubt that slighter forms of 
 anaemia are fairly common in uncomplicated rickets. On 
 the other hand, it is equally certain that fairly severe rickets 
 may be present without any evident signs of anaemia ; there 
 
 * S. Cannata. " II potere fagocitario del Sangue nel Rachitismo 
 Rivista di clinica pediatrica," August, 1909, p. 652 
 
 244 
 
Affections of the Blood and Lymphatic System 245 
 
 is no relationship between the severity of the rickets and the 
 degree of anaemia. 
 
 In the type of child suffering from " f at " rickets a fairly 
 marked degree of anaemia is quite common clinically, 
 associated with definite leucocytosis. 
 
 Lovett Morse * from the examination of twenty cases of 
 imcomphcated rickets, found that the number of red blood 
 corpuscles was either normal or nearly normal, but that the 
 percentage of haemoglobin was both absolutely and relatively 
 diminished. Leucocytosis might or might not be present, 
 and when present was due to an increase of all the varieties 
 of white ceUs. Marfan f agrees with these results, but points 
 out that in many cases where leucocytosis is present, it is 
 due to a secondary infection, such as broncho-pneumonia, 
 diarrhoea or syphilis, and is not an essential part of the 
 rachitic process itself. 
 
 Findlay J as the result of an examination of the blood 
 in active and uncomplicated rickets, in thirty cases between 
 the ages of twelve and forty-two months, came to the 
 following conclusions, which have not yet been con- 
 firmed : (1) in active and uncomplicated rickets anaemia is 
 not the rule, but is to be regarded as exceptional. On the 
 contrary, in rickets the number of blood cells and the 
 amount of haemoglobin are notably in advance of the 
 normal average. This may be due to a reaction against the 
 confinement and lack of exercise which plays such an im- 
 portant part in the production of rickets, and may be a 
 compensatory charge. In consequence of the deficient 
 amount of oxygen and the defective inspiration, this poly- 
 cythaemia may help the economy in limiting the evil 
 influence of those deficiencies ; (2) the red blood corpuscles 
 in rickets vary more in size than in normal individuals of 
 similar ages ; (3) nucleated red blood corpuscles, poly- 
 chromatophilia, and myelocytes are of rare occurrence ; 
 (4) leucocytes may be normal, or shghtly increased, or even 
 
 * " The Blood in Rickets," by J. Lovett Morse, Archiv. of Ped., Vol. 
 XVI, 1889, p. 619. 
 
 t Marfan : loc. cit., p. 346. 
 
 j Findlay : " The Blood in Rickets." The Lancet, April 24th, 1909. 
 
246 Rickets 
 
 slightly diminished. The mononuclears, more commonly 
 than the polymorphs, show an absolute increase. 
 
 These results do not conform with the conclusions 
 drawn by other observers, and are somewhat difficult to 
 reconcile with chnical experience, where definite ansemia 
 is frequently met with in the rachitic state. 
 
 It may be stated that while in rickets there is no dis- 
 tinctive variety of anaemia characteristic of the disease, 
 there is frequently a diminution of the red blood cells and 
 of the hsemoglobin, both relative and absolute. Shght 
 forms of leucocytosis are fairly common and may be well 
 marked in the incipient and active stages of the disease; 
 if the leucocytosis is severe and prolonged, it may be due 
 to intercurrent attacks of broncho-pneumonia, diarrhoea, 
 syphilis, or some other infection. 
 
 Affections of the lymphatic system in rickets. 
 
 In rickets there is a marked tendency towards lym- 
 phatism. The hyperplasia which has been shown to occur in 
 the bone marrow also affects the thymus, spleen, lymph 
 glands, and the outlying patches of lymphoid tissue. It is 
 owing to this state that the child assumes the fat, pale, stohd, 
 type so characteristic of the rachitic state. The enlargement 
 of the lymphatic glands has already been spoken of. The 
 condition is one of true hyperplasia, and there is not the 
 tendency to matting and massing of the glands together, such 
 as occurs in true adenitis. Usually the glands are discrete 
 and shotty, and can be rolled freely under the skin. They 
 can be felt in such situations as the neck, armpit, or groin. 
 
 Frohlich * found that in eighty per cent, of cases this 
 enlargement was present, and that if ansemia was at all 
 marked the enlargement was constant. The condition is a 
 matter of some importance in the defence of the organism 
 against infections, notably against the tubercular infection, 
 and the better adapts the infant to its surroundings when it 
 is compelled to hve in an unwholesome environment. 
 
 * Frohlich : " Lymphdriisenschvellung bei Rachitis ; Jahrbuch fur 
 Kinderheilkunde," XLV, 1897, p. 282. 
 
Affections of the Blood and Lymphatic System 247 
 
 A certain antagonism between rickets and tubercle has 
 long been believed in by the older writers, and this is pro- 
 bably true of rickets in its early stages. When a failure of 
 the defences against the tubercle bacillus does occur, the 
 glands are most commonly affected. Even so, the failure 
 is not usually complete, and the tuberculous infection is 
 often limited to the glands, more often those of the neck 
 than of other parts, and the disease is capable of being treated 
 by several methods, or surgically, with a fair prospect of 
 success. This is the commonest form of tubercle in children 
 under the age of ten years. It is interesting to note that, 
 in the child where the tuberculous diathesis, as described 
 by Sir Wm. Jenner, is well marked, rickets rarely develops. 
 The failure to successfully combat tubercle in these sus- 
 ceptible subjects may in part be due to the inability of the 
 child to afford an effective resistance to an unhealthy 
 environment, such as the rachitic infant is able to make. 
 
 The recurring acute catarrhal affections to which the 
 rachitic child is liable, tend to lead to a secondary enlarge- 
 ment of the lymphatic glands; but it is important to 
 remember that before the development of these infections 
 the glands undergo a primary enlargement or hyperplasia. 
 The lymphatic glands may be enlarged in two ways, viz. : 
 
 (1) from hyperplasia as part of the rachitic process itself ; 
 
 (2) as a result of secondary infections, especially of the 
 mucous membranes, to which children suffering from this 
 disease are peculiarly Uable. 
 
 The spleen in rickets. 
 From the time of Ghsson this organ has been accurately 
 described by all observers as somewhat enlarged. The 
 increase in size is part of the general lymphatic hyperplasia 
 which occurs in rickets. At first, in both the lymph glands 
 and in the spleen, there is an increase of the cellular 
 elements which form the parenchyma or true glandular 
 substance. Later there is a tendency to increase of the 
 capsule and trabecular connective tissue which surrounds 
 the pulp. These changes are comparable to those occurring 
 
248 Rickets 
 
 in the bone marrow, where it has been shown there is first 
 of all an increase of the marrow cells, while later the 
 marrow tends to become firmer and more fibrous, owing to 
 an increase of the connective tissue element. 
 
 In the later stages the spleen presents the usual appear- 
 ance of chronic induration. On section it is firmer than 
 natural, the capsule and the trabeculae which extend from it 
 being somewhat thickened. The Malpighian bodies are 
 often enlarged but may be more difficult to distinguish from 
 the surrounding firm tissue than in the normal spleen. 
 Only a httle pale blood can be squeezed fromithecut surface, 
 the walls of the blood vessels being frequently thickened 
 and their lumen narrowed. It is not usual, however, in 
 uncomplicated rickets to find the spleen notaibly enlarged. 
 Fairly commonly it can be palpated just below the maargin 
 of the ribs, owing to the enlargement and induration which 
 occurs, together with the deformation of the chest which 
 tends to thrust the abdominal organs downwards, and to 
 render them more easily palpable. When notably enlarged, 
 and especially if this is associated with marked anaemia, 
 congenital syphilis is almost always present. 
 
 The thymus in rickets. 
 
 The thymus is a lymphoid structure, which is usually 
 notably affected in rickets. Indeed, enlargement of this 
 structure, with definite delay in its normal involution, is so 
 commonly seen that it must be considered an essential part 
 of the rachitic process. 
 
 GHsson himself observed, as the result of many autopsies, 
 that while in young children the thymus was a larger 
 structure than in the adult, in rickets the gland was distinctly 
 larger than in normal children. Its enlargement is important, 
 in view of the fact that it forms part of the affection of the 
 ductless glands, which probably in rickets plays an important 
 part in the production of the disease. 
 
 The liver in rickets. 
 In the embryonic stage and up to the time of birth, 
 nucleated red blood corpuscles are formed in the liver as well 
 
Affections of the Blood and Lymphatic System 249 
 
 as in the lymphatic glands, spleen, and thymus, and in 
 rickets a slight increase in the size of the liver is fairly 
 commonly observed. As a result of the constriction of the 
 chest wall, the liver is thrust downwards, and is rendered 
 more easily palpable. The organ is seldom much enlarged, 
 but its edges are harder and sharper than in health. It is 
 somewhat dark, hard, and elastic to the touch, but on section 
 it is pale and contains but little blood. The fibroid tissue 
 throughout the liver is somewhat increased. Within the 
 acini the cells are more closely packed than in health and 
 the cells are not rich in oil globules.* 
 
 Enlargement of the tonsils and adenoid vegetations in rickets. 
 
 In no part is the hyperplasia which occurs in the 
 lymphatic system more marked or of greater importance than 
 in the enlargement of the tonsils and the production of 
 adenoid vegetations. It has been shown that out of 1,000 
 children in the East end of London, 800 showed definite 
 signs of rickets. Of these 800 rachitic children, twenty- 
 one per cent, suffered either from enlargement of the tonsils, 
 or from adenoid vegetations, or, most commonly, from 
 both.f The chief interest attaches to the adenoid vege- 
 tations, though their evil influence is markedly increased by 
 the presence of large tonsils. 
 
 Normally, the posterior wall of the naso-pharynx is 
 thickened, and is thrown into a number of folds which 
 run chiefly in a vertical direction. In this thickened and 
 rugose mucosa large masses of lymphoid tissue are present 
 in the young child in health. These lymphoid masses, to- 
 gether constituting what is called the pharyngeal tonsil, 
 stretch across the back of the pharynx between the orifices 
 of the Eustachian tubes, extending into the lateral recess or 
 fossa of Rosenmiiller on each side. When hypertrophied 
 these masses are exceedingly apt to block up the Eustachian 
 
 * " The Wasting Diseases of Children," by Eustace Smith, London, 
 1878, p. 146. 
 
 t " Defective Housing and the Grovrth of Children," by J. Lawson Dick, 
 London, 1919, PP- 28, 29. 
 
250 Rickets 
 
 orifices and even the posterior nares. Catarrhal and infective 
 conditions are very Hkely to pass along the Eustachian tubes, 
 which not only contain numerous mucous glands on the 
 inner surface of the cartilaginous portion of the tube, but 
 which also, in the young child, contain a considerable 
 amount of lymphoid tissue situated near their pharyngeal 
 ends. When it is considered that, in the adult, the 
 transverse diameter between the Eustachian cushions only 
 measures three-fifths of an inch, and the antero-posterior 
 diameter from the lower part of the posterior edge of the 
 nasal septum to the posterior wall of the pharynx the same, 
 it can readily be understood that the smaller space in the 
 young child will be easily blocked by lymphoid overgrowth 
 and the catarrhal conditions likely to ensue. 
 
 Now, while it is true that adenoids may arise apart 
 from rickets, as the result of acute infections such as measles, 
 scarlatina, and diphtheria, the great majority of cases 
 originates in the rachitic state. In other words, adenoid 
 vegetations, as is the case with all lymphoid overgrowths, 
 form part of the ordinary rachitic process apart from in- 
 fections. Nay more, it has been shown that in the debihtated 
 infant, mouth-breathing is likely to develop from dropping 
 of the lower jaw through muscular relaxation and the 
 inability to maintain the muscular effort required to sustain 
 nasal breathing. In such a child a negative pressure is 
 likely to be produced in the naso-pharynx, which increases 
 the tendency to congestion of the mucous surface and to 
 the retention of secretions. These conditions naturally lead 
 to further increase of the lymphoid tissue. 
 
 As has akeady been shown, the bones of the face are 
 soft as the result of rickets, and the lateral pressure of the 
 soft parts of the face tends to approximate the alveolar 
 margins still further ; there is no column of air passing 
 backwards and forwards through the nose during respiration 
 which would tend to depress the floor of the nose, and with 
 it the hard palate, and at the same time, to separate the 
 lateral walls of the nose from the septum. The result is the 
 nose remains thin and soft, the palate is high and arched^ 
 
Affections of the Blood and Lymphatic System 251 
 
 and the septum tends to become buckled on account of the 
 want of space for its proper expansion. 
 
 As a result of continued mouth breathing many dis- 
 abilities are likely to arise, notably : (1) frequently recurring 
 colds and bronchial attacks ; (2) certain chest deformities 
 which have already been dealt with ; (3) imperfect aeration 
 of the blood associated with anaemia and generally impaired 
 health ; (4) defective growth ; (5) deafness and affections 
 of the ear. 
 
 Adenoid vegetations may require attention at any period 
 from early infancy onwards, though usually they only reach 
 a condition demanding operation after the fourth or fifth 
 year. 
 
 In infancy snuffling, which is usually due to S3rphilis, 
 may be caused by adenoids. Difficulty in suckling, owing 
 to the infant being unable to maintain continuous nasal 
 respiration, is met with and laryngeal stridor is common. 
 Snoring is not a usual s5miptom of adenoids at this early 
 age. When the adenoid state is present in older children 
 the other signs of rickets are present. The teeth of the 
 second dentition are overcrowded and irregular, and the 
 bridge of the nose is often widened, owing to congestion of 
 the soft parts, whUe the alae nasi are collapsed. The child 
 sleeps with the mouth open, and granulations may appear 
 on the posterior wall of the phar5nix, continuing below the 
 soft palate. This may be accompanied by enlargement of 
 the lymphatic glands along the posterior border of the 
 sterno-mastoid. Deafness is apt to supervene, and the child 
 is backward mentally and physically. In the adult, chronic 
 post-nasal catarrh, deafness, and muffling of the voice point 
 to a diagnosis of adenoids. 
 
 Aprosexia and rickets. 
 Deafness dependent on the rachitic state may be due to 
 three causes, viz. : (1) a blocking up of the pharyngeal end 
 of the Eustachian tube by an overgrowth of the pharyngeal 
 tonsil ; (2) a chronic catarrh extending by continuity from 
 the pharyngeal mucosa to the middle ear — chronic catarrhal 
 
252 Rickets 
 
 otitis media. One of the first signs that the tubes are 
 becoming infected in this way is an indrawing of the mem- 
 brana tympani ; (3) an actual infection of the middle ear 
 by a process of extension ending in suppurative otitis media 
 and perforation of the drum. 
 
 Infection of the middle ear is usually considered to arise 
 as the result of acute z37motic diseases, notably scarlatina 
 and measles. In many cases, however, no such direct con- 
 nection can be made out. 
 
 The relationship of these diseases to the rachitic state is 
 of interest. 
 
 Scarlet fever is a disease which has a distribution not 
 unlike that of rickets. It is most common in temperate and 
 humid climates, especially in northern and western Europe 
 and in North America, but has failed to estabhsh itself in 
 Africa or in any part of Asia except Asia Minor.* It is 
 more prevalent in urban than in rural districts, and in 
 mining districts and manufacturing towns it attains its 
 maximum in frequency and intensity. Children under one 
 are comparatively rarely attacked, but the incidence rapidly 
 increases and reaches its maximum in the fifth year of hfe. 
 Thus the disease occurs chiefly in those areas where rickets 
 is most prevalent, and in the production of the secondary 
 infection of the ear there can be but little doubt that rickets, 
 by producing overgrowth of lymphoid tissue and catarrhal 
 conditions of the mucosa of the naso-pharynx, strongly pre- 
 disposes to the extension of the disease to the middle ear. 
 Many children escape scarlet fever, while but few seem to 
 escape measles. If the relative frequency of the two diseases 
 be considered, the probabihty is that scarlet fever tends 
 to yield a higher percentage of cases of acute suppurative 
 otitis media than any of the other acute infectious diseases. 
 This is due to two causes : (1) the very acute nature of the 
 throat infection ; (2) the Very common association of the 
 disease with rickets and pre-existing morbid states of the 
 naso-pharjmx. 
 
 * " Hygiene and PubHc Health," by B. Arthur Whitelegge, London, 
 iSgo, p. 275. 
 
Affections of the Blood and Lymphatic System 253 
 
 Measles, unlike scarlet fever, seems to be but little depen- 
 dent either on climate or locality, and no race is exempt 
 from its invasion. As already noted, many children of 
 school age escape scarlet fever, while comparatively few 
 escape measles. 
 
 It is exceedingly common in crowded populations, but 
 it is also very common and produces a high mortedity even 
 in such situations as the high uplands of the Karroo, in 
 South Africa, where the population is sparse and the climate 
 is ideal. In South Africa, among native children, both 
 Kaf&r and Hottentot, epidemics of measles are much more 
 destructive of life than they are in England. 
 
 Measles, from its tendency to attack the upper respira- 
 tory tract, is very likely to cause a spreading infection along 
 the Eustachian tube, affecting the middle ear. Rickets 
 undoubtedly frequently prepares the soil for this invasion. 
 I have seen repeated severe epidemics of measles affecting 
 native children in the high uplands of South Africa. The 
 mortality from broncho-pneumonia is very large, but com- 
 pUcations such as catarrhal suppurative otitis media in the 
 children who recover are quite infrequent. At home the 
 death rate is less high, but the proportion of cases of infec- 
 tion of the middle ear amongst those who survive is very 
 high. Whooping cough is a common concomitant of 
 measles, but tends to be more prevalent and more severe in 
 Europe and in temperate climates generally than in hot 
 countries. Both measles and whooping cough, unUke 
 scarlet fever, are common in the young infant, and when 
 combined form the most formidable depressing agent that 
 can attack the young child. Rickets is a most serious com- 
 plication, and if these two diseases attack a rachitic child 
 during the first year of Hfe the chances of recovery are 
 exceedingly small. 
 
 Whether associated with acute zymotic diseases or no, 
 chronic suppurative otitis media and chronic catarrhal non- 
 suppurative otitis media are exceedingly common conditions 
 affecting the general population. So common are they that 
 but little heed is paid to them in their initial stages, and the 
 
254 Rickets 
 
 great difficulty in treating these cases is to persuade the 
 mother of the child, and later, the patient himself, that these 
 conditions are sufficiently serious to necessitate prolonged 
 and careful attention. 
 
 At the present time there are 34,000 pensioners dis- 
 charged from the army and navy with ear disabiUties which 
 are held to be due to, or aggravated by, the conditions of 
 military service, and which are therefore pensionable. This 
 large number by no means represents the amount of aural 
 disease which existed in the army, but simply includes those 
 men from Great Britain and Ireland who were discharged 
 from the army as permanently unfit for further service on 
 account of deafness, or who claimed, at a date subsequent to 
 discharge, that they were suffering from an aural disabihty 
 due to service. The very great majority suffer from catarrhal 
 suppurative or catarrhal non-suppurative otitis media. 
 
 From a large experience of those men, I have little 
 hesitation in saying that by far the greater number have 
 suffered from these conditions from very early years. Large 
 numbers exhibit signs which can be definitely attributed 
 to rickets in infancy. This is seen in the condition of the 
 jaws and teeth. Thickening and consolidation of the bones 
 of the cranial vault, the permanent result of the reconstruc- 
 tive process which has taken place at an early date, is quite 
 common. Deflection of the septum is the rule rather than 
 the exception. It has previously been noted that, contrary 
 to what is generally supposed, the osseous changes in rickets, 
 when at all well marked, are remarkably constant, and are 
 quite commonly seen in men of thirty or forty years of age. 
 In the majority of cases the pathological state of the ears 
 points to an old standing disease which has continued from 
 early childhood. Scarlet fever, or measles, or influenza, 
 may have been the actual exciting cause of an acute sup- 
 purative condition in many, but the essence of the condition 
 was the development of adenoids and mouth breathing, 
 and unhealthy conditions of the naso-pharynx following 
 the rachitic state in childhood. The infection took place 
 on a prepared soil. 
 
Affections of the Blood and Lymphatic System 255 
 
 Large numbers of these are men of poor physique and of 
 a low grade of intelligence, and they constitute a difficult 
 problem from the labour point of view. These men look 
 degenerate, but they are merely the product of unhealthy 
 environment opeiating from birth onwards. 
 
 It is an observation that has frequently been made, that, 
 with the onset of deafness, children become duller mentally, 
 and retrograde in their class work to an extent out of all 
 proportion to the amount of their disability. Such cases 
 are well known to the teacher in the ordinary primary 
 schools. 
 
 In 1887, Prof. Guye,* of Amsterdam, drew attention to 
 this class of patient and revived the use of the term aprosexia, 
 a word borrowed from the Greek lexicographer Hesychius, 
 of the fourth century, meaning heedlessness. 
 
 Aprosexia embraces the class of child which suffers from 
 adenoids and imperfect nasal development associated with 
 some chronic inflammatory condition affecting the ears, 
 tending to produce deafness. These children are notably 
 dull and their faculties of attention and observation are 
 markedly defective. They are the despair of their teacher — 
 they have no power of concentration, and they make no 
 progress even with the most careful handling. 
 
 This condition is peculiarly a sequel of rickets. In these 
 cases operative treatment of the adenoid vegetations often 
 produces most favourable results. A child from being dull 
 and listless and apathetic, with a pale and pasty complexion, 
 may become alert and active, with a better colour and im- 
 proved general health, in the space of a few days. Such 
 favoiarable results are a matter of common experience after 
 this comparatively simple operation, and the improvement 
 is maintained and progressive. Prof. Guye held that this 
 improvement was due to the relief of a condition of con- 
 gestion of the intra-cranial circulation. He maintained, 
 what is anatomically correct, that the intra-cranial veins have 
 communications with the veins of the frontal, ethmoidal, 
 
 * " On Aprosexia," and etc. British Medical Journal, 1889, Vol. II, 
 p. 709. "Ueber Aprosexia." Deutsche med, Wochensfhrift, Leipz. u. 
 Berl., 1887, xiii. 
 
256 Rickets 
 
 and sphenoidal sinuses, and through these with the vessels 
 of the nose and naso-pharynx. 
 
 Retzius showed that intra-cranial lymphatics are in con- 
 nection with lymphatics lying in the cranial nerve sheaths, 
 and that these Ijonphatics, passing from the frontal region 
 of the brain through the cricriform plate of the ethmoid in 
 the sheaths of the branches of the olfactory nerves, are in 
 direct communication with the nasal and naso-pharyngeal 
 lymphatics, which in their turn pass to the lymphoid tissue 
 and glands of the naso-pharynx. Thence the efferent 
 lymphatics proceed to the lymphatic plexus on the pterygoid 
 muscles and from thence to the anterior cervical glands.* 
 Such an anatomical continuity is of great interest and im- 
 portance as a possible line of infection, but it is unhkely that 
 it is commonly so. If it were a common path of infection it 
 might reasonably be expected that every now and then 
 accidents would occur after these operations, which are 
 often performed under conditions far from favourable. As 
 a matter of practice accidents are exceedingly rare, and a 
 more real source of danger arises from the fact that most of 
 these cases are. associated with lymphatism ; actual status 
 lymphaticus with the tendency to sudden death under an 
 anaesthetic is a danger to be guarded against in these cases. 
 
 The establishment of a free passage way for the current 
 of air through the nose, and the better aeration of the blood, 
 with the relief of local congestion and improved sleep, seem 
 quite adequate to explain the beneficial results which foUow 
 the operation. 
 
 Shaw examined 693 school children for signs of apro- 
 sexia. One hundred and nine of these children were pointed 
 out as below the average mentally, and in twenty-five of 
 these evidence of adenoids was definitely present. That 
 is, 3-5 per cent, of all the children attending the school 
 suffered from this condition. 
 
 This syndrome is so definite, and the promise of benefit 
 from active treatment at an early stage is so great, that the 
 
 * " Aprosexia in Children," by Ernest A. Shaw. The Practitioner, Vol. 
 XLV, July,- 1890. 
 
Affections of the Blood and Lymphatic System 257 
 
 term aprosexia might, with advantage, be more freely used 
 than it is, and the condition recognised as a true entity. 
 
 If left untreated these children are likely to result in 
 failure in later adult life, and to drift into the class who 
 swell the casual labour market or who belong to the 
 unemployed. 
 
PART II 
 
 THE NATURAL HISTORY OF RICKETS 
 
 THE ETIOLOGY OF THE DISEASE AND ITS 
 TREATMENT 
 
CHAPTER XIX 
 
 THE LITERATURE OF RICKETS 
 
 Glisson and His Times 
 
 The history of rickets properiy begins with the publication 
 of Ghsson's book " Da Rachitide " in 1650. It was pub- 
 lished in Latin under the title " De Rachitide sive Morbo 
 Peurili qui vulgo The Rickets dicitur, Tractatus." * In 
 1651 it was republished, translated into English by Phil. 
 Armin.f The work impressed itself at once on the medical 
 thought of the time not only in England, but throughout 
 Europe, and several editions were published in this country 
 and abroad between 1650 and 1682. 
 
 Francis Glisson was born in 1597 at Rampisham, in 
 Dorsetshire, and he died in London in 1677. He entered 
 Caius College, Cambridge, in 1617, graduating B.A. in 1621 
 and M.A. in 1624, and was elected a Fellow of the Royal 
 College of Physicians, London, in 1635. On October 25th, 
 1627, he was incorporated M.A. Oxford. In 1636 he was 
 appointed Regius Professor of Physic at Cambridge, an 
 office which he held till his death. At the Royal College of 
 Physicians, London, Glisson lectured on anatomy, which at 
 that time included pathological and comparative anatomy 
 
 * " De Rachitide sive Morbo Puerili qui vulgo The Rickets dicitur, 
 Tractatus ; Opera primo ac potissimum Francisci Glissonii Doctoris, et 
 publici Professoris Medicinae in alma CautabrigiEe Academia et Socii 
 CoUegii Medicorum Londinensum, conscriptus : Adscitis in operis societatem 
 Georgio Bate et Ahasuero Regemortero Medicinse quoque Doctoribus, et 
 pariter Sociis Collegii Medicorum, Londinensum, Little Britain, 1650." 
 
 t " A Treatise of the Rickets, being a Disease common to Children, 
 wherein {among many other things) is shewed (i) The Essence ; (2) The 
 Causes ; (3) The Signs ; (4) The Remedies of the Disease. Published in 
 Latin by Francis Glisson, George Bate and Ahasuerus Regemorter, Doctors 
 in Physick and Fellows of the CoUedg of Physitians at London. Trans- 
 lated into English by Phil. Armin, London. Printed by Peter Cole at the 
 sign of the Printing Press in Cornhill, near the Royal Exchange, 1651." 
 
 261 
 
262 Rickets 
 
 besides normal anatomy,* and he published a book on the 
 anatomy of the liver, " Anatomia Hepatis," in 1654, in which 
 the capsule, or fibrous sheath, of the liver is so accurately and 
 fully described that the name of Glisson's capsule, familiar 
 to every student of medicine, is now given to it. 
 
 In the Sloane MSS. at the British Museum are preserved 
 several interesting relics of Glisson. That he was a prolific 
 writer is shown by ten large volumes containing the manu- 
 script of his lectures at the Royal College of Physicians alone. 
 There are several letters from patients requesting advice and 
 thanking him for previous help. One dated June 26th, 1671, 
 written from Thorpe, thanks him for his care of a rickety 
 child. " There hath since been but little appearance of them 
 [the rickets] more than by a greater weakness in him than in 
 other children of his own age and a crookedness of his leggs; 
 He is now about 4 years and 4 months, and hath been affected 
 with a quartan ague ever since the last day of August last." 
 In a quaint, very elaborate and laborious journal of the 
 weather for the years 1675-1676 to 1678-1679 kept by J. 
 Conyers there is a note of the death of Glisson : " Now in 
 September, 1677, my very good friend and unckle (Dr. 
 Francis GUsson, aged about 83) about September 4th began 
 to be very sick, . . . until September 19th, when at night he 
 was taken up dead in his chamber when he was going into 
 bedd by reason of some vertigo." | 
 
 GHsson's chief claim to fame is his great work on rickets. 
 This work places him in the front ranlc of illustrious men in 
 the history of medicine. He was a product of an age of great 
 advance in scientific thought. Harvey published his dis- 
 covery of the circulation of the blood in 1628, when Glisson 
 was thirty-one years of age. In France 'the mechanical 
 philosophy of Descartes and the progress of physics pro- 
 foundly affected medicine throughout Europe, and led to the 
 application of mechanical ideas to physiological processes. 
 
 * Article by Sir Norman Moore on Glisson, " Dictionary of National 
 Biography." 
 
 t " Register of the Weather from 1675-6 to 1678-9 inclusive," by 
 J, Conyers, Sloane MSS. 816, fo. 219. 
 
Glisson and His Times 263 
 
 Thus the movements of bones and muscles were referred to 
 the theory of levers, digestion was held to be essentially a 
 process of trituration, and metabolism and secretion were 
 stated to be dependent upon the tension of the bloodvessels. 
 Harvey's discovery, combined with these Cartesian principles, 
 stirred many active minds to work out a new system of 
 scientific medicine. Glisson was twenty-nine years of age 
 when Bacon died, and the completed " Novum Organon," 
 which is specifically mentioned in " De Rachitide," was 
 pubhshed when he was twenty-three. 
 
 Two other great names are associated with that of 
 Glisson. Newton was bom when Ghsson was forty-five 
 years old, and must in later years have known Glisson well 
 both at Cambridge and in London. In 1669 Newton was 
 appointed Lucasian Professor of Mathematics at Cambridge, 
 while Glisson still held his chair. Glisson was one of the 
 original Fellows of the Royal Society, and Newton was 
 elected a Fellow in 1672. Sir Thomas Browne must also 
 have known Glisson, probably intimately. Browne settled 
 in Norwich in 1637, and rapidly acquired a reputation for 
 skill as a medical practitioner. At this time Ghsson still 
 resided chiefly at Cambridge, but in 1640 he moved to 
 Colchester, and soon obtained much practice there. Both 
 were men widely known for their professional skill, and the 
 advice of both was much sought by the wealthier families 
 over a wide area. It may well be that Glisson, the senior of 
 the two both in years and in the practice of his profession, 
 consulted with Browne over difficult cases. For eleven 
 years (1637-1648) they practised in neighbouring counties, 
 Browne being at Norwich and Glisson part of the time at 
 Cambridge and the rest of the period at Colchester. Both 
 Browne and Glisson were Royahst in their sympathy during 
 the Civil War, and Glisson not only sympathised with, but took 
 an active part on, the Royalist side. He was in Colchester 
 during the two months' siege, and on August 21st, 1648, six 
 days before the town capitulated owing to starvation, 
 Ghsson was sent by the Royalists to Lord Fairfax to ask for 
 better terms, but failed to obtain any concession. His 
 
264 Rickets 
 
 activity on the Royalist side, however, does not seem to have 
 unduly prejudiced his position with Cromwell. In the British 
 Museum is preserved the original order of the Protector and 
 Council, dated April 7th, 1654, to the Receiver-General of 
 Revenue, ordering the payment of the salary of his pro- 
 fessorship to 1654. Glisson was appointed a censor of the 
 College of Physicians 1656, and was President of the College 
 during the years 1667, 1668, 1669. In 1664 Browne was 
 elected a Fellow of the College of Physicians, and he fre- 
 quently contributed papers to the Royal Society, of which, 
 however, probably much to his regret, he never became a 
 FeUow. 
 
 After the siege of Colchester the town was much im- 
 poverished, and Glisson went to London and settled in the 
 parish of St. Bride, where he remained till his death. There 
 is a certain similarity in the writings of Browne and those of 
 Ghsson. Both are dignified, and show a love of scholastic 
 forms, which was largely due to the fact that both wrote in 
 Latin. Several passages in " A Letter to a Friend," perhaps 
 the most charming of all Browne's writings, show that he 
 was familiar with " De Rachitide," though he does not 
 mention Glisson by name. But while Browne was quaint 
 and discursive and cast his net widely over all subjects of 
 human interest, Glisson, as became a follower of Bacon's 
 inductive philosophy, was incisive and held himself to his 
 subject, even in the long disquisition on the philosophical 
 side of medicine which occupies so much of his work. 
 
 It is worthy of note that, while Glisson adopted the experi- 
 mental method expounded by Bacon, he made no attempt to 
 separate himself from the humoral pathology of Galen which 
 had dominated medical thought throughout Europe for many 
 centuries. Galen considered that all diseases had their origin 
 in the fluids of the body, and that the normal condition of 
 the body depended upon a proper mixture of four elements : 
 heat, cold, wetness and dryness. From faulty mixtures or 
 proportions of these so-called elements distempers arose 
 which, while not diseases in themselves, were yet the causes 
 of all diseases. Into the theories of disease as elaborated at 
 
Glisson and His Times 265 
 
 great length by Glisson it will not be necessary to enter. The 
 subject is treated in a philosophical manner with great dignity 
 of diction, and is chiefly of interest from the historical point 
 of view, as giving the prevaihng ideas of the time on the 
 origin of disease. In language unfamiliar to present-day 
 readers Glisson holds : (1) that rickets is a cold distemper ; 
 (2) that it is moist ; (3) that it consisteth in penury or 
 paucity of the spirits; (4) that it consisteth in the stupe- 
 faction of the spirits. The minuteness with which the origin 
 of all diseased conditions could be argued out on these lines 
 appealed to the philosophic side of the most advanced minds, 
 and Glisson warmly attacks the problem on the old lines. 
 
 Itwasnot till the seventeenth and eighteenth centuries that 
 this system of humoral pathology was slowly undermined. 
 CuUen, who was appointed Professor of Medicine in Glasgow in 
 1751, and who removed to the chair at Edinburgh in 1756, 
 delivered his famous lectures there and built up the system of 
 pathology known as solidism. He denied that the liquids of 
 the body had anything to do with disease, and held that all 
 diseases arose in the solids of the body. These solids were 
 either simple, their functions being the same in animate as in 
 many inanimate bodies, or vital, whose properties appeared 
 only in living bodies. Simple solids, he taught, having fewer 
 functions, had fewer diseases to which they were liable, and 
 these were easily classified. But according to Cullen the 
 real diii&culty was with the vital solids, because on their 
 peculiarities the whole condition of the nervous system 
 depended, and nearly all diseases were due to them. Cullen 
 therefore made the nervous system the basis of his pathology. 
 As Buckle * points out, Cullen's system erred on the other 
 side, but it was a mistake of a salutary kind, for it led to a 
 gradual cessation of the constant and indiscriminate vene- 
 section which had prevailed whilst the blood and the fluids 
 of the body were believed to be the seat of disease. Glisson 
 beheved that rickets was a diseased condition of the blood, 
 and chiefly of the liquid parts of the blood, though the solids 
 also contributed. 
 
 * " Civilisation in England," Buckle, London, 1904, Vol. III., p. 415. 
 
266 Rickets 
 
 The ease with which Galen's philosophy lent itself to 
 explain every problem connected with disease, and the 
 appearance of finality with which it could be applied to any 
 theory, hampered the progress of medicine for many cen- 
 turies, and Glisson, with his love of logic and philosophical 
 discussion, never threw off its fetters. Theory is requisite to 
 connect ascertained facts and to guide us in their application. 
 It is useful to point out the way to future workers, but all 
 theories must be elastic and adaptable so as to conform to 
 each addition to our knowledge, and must not be held in 
 themselves to be final and definite. It is in the application 
 of the inductive method of Bacon to the study of this new 
 disease that Glisson shows his greatness. When he argues 
 from his own observations his work is marvellously clear and 
 brilliant. 
 
 " De Rachitide " is the first monograph of importance on a 
 disease in this country. John Caius, the learned co-founder of 
 GonviUe and Caius College, Cambridge, it is true, published a 
 book in 1552 on the " sweating sickness," * but this is a 
 small volume of thirty-nine pages written for popular 
 instruction, and lays no claim to important original research. 
 The academical physicians of the Tudor period hardly ever 
 wrote. The men who wrote on medicine were men like Sir 
 Thomas Elyot (1490-1546), or irregular practitioners anxious 
 to advertise themselves, or booksellers' hacks. Up to 
 Glisson's time medical works were not addressed, as they now 
 are, to the medical profession, but were meant to be read by 
 all who were interested in polite learning. This custom lasted 
 long after Ghsson's time. Naturally writing in Latin 
 limited the audience in certain directions, but it widened the 
 area of the appeal, in that the work could be read all over 
 Europe in learned circles. Not only did medical men write 
 for the information of the general public, but it was not 
 uncommon for amateurs interested in experimental science 
 to write on philosophical and medical subjects. Robert 
 
 * John Caius, 1510-1573 (AnglicS Kees, Keys, etc.), " A Boke or 
 Counseill against the Disease commonly called the Sweate, or Sweating 
 Sicknesse," London, 1552, in Latin, " De Ephemera Britannica," Louvain, 
 1556, reprinted London, 1721. 
 
Glisson and His Times 267 
 
 Boyle (1627-1691), the great natural philosopher and chemist, 
 spent his life in the experimental study of various branches 
 of natural science, and was one of the founders and after- 
 wards President of the Royal Society. He also, however, 
 meditated and wrote on theological subjects, and he learned 
 Hebrew and Greek so that he might read the Bible in the 
 original. So much was he devoted to the study of theology 
 that Lord Clarendon strongly urged him to enter the Church. 
 
 Stephen Hales (1677-1761), the great physiologist, chemist 
 and inventor, graduated M.A. at Cambridge in 1703 and 
 proceeded to take Holy Orders. In 1708-1709 he was pre- 
 sented to the perpetual curacy of Teddington, in Middlesex, 
 where he remained all his life, notwithstanding that he was 
 subsequently appointed rector of Porlock, in Somerset, and 
 later of Faringdon, in Hampshire. In 1717 Hales was 
 elected a Fellow of the Royal Society, and in 1727 was 
 published his great work on " Vegetable Staticks," and in 
 1733 his work on " Hsemo-Staticks," where he dealt with 
 his experimental results on blood pressure. 
 
 Glisson's book was a new departure in the history of 
 medical literature, and, like many other fresh ventures, the 
 work produced belongs to the first rank and has never since 
 been surpassed or superseded. Once and for all Glisson 
 defined rickets as a separate entity, and so successful was he 
 in delimiting the disease that, so far as the naked eye anatomy 
 goes, not a great deal has been added to our knowledge of 
 the condition up to the present day. 
 
 The name of rickets was in common use throughout Eng- 
 land in 1650, when Ghsson published his work. The general 
 behef of the time was that it was comparatively a new dis- 
 ease. It is first described as a cause of death in the table of 
 casualties in the Bills of Mortality for London in the' year 
 1634.* The word "rickets" is probably derived from the 
 Middle English word wrikken, to twist. It is connected with 
 the word "rick," as in "ricked ankle" and "ricked back," 
 
 * " Reflections in the Weekly Bills of Mortality from the Cities of 
 London and Westminster and the Places adjacent," Captain John Graunt, 
 London, 1665. 
 
268 Rickets 
 
 which is a variant speUing of "wrick." Cognate words are 
 "wring," "wry" and "wrong." Ghsson in his book sug- 
 gested the word "rachitis," from the Greek paxts, the spine, 
 as being a suitable scientific name, which had not only the 
 advantage of resembhng the popular name for the disease in 
 sound, but also denoted the part which was first affected. 
 
 The origin of " De Rachitide " is interesting. It reprcr 
 sented work extending over a period of five years. Glisson 
 communicated his observations to other Fellows of the 
 Royal College of Physicians, and apparently at informal 
 meetings seven Fellows added further notes and observa- 
 tions. Three of these FeUows were appointed to prepare a 
 treatise on the subject, but, as the work progressed, it 
 became evident that Glisson's observations were so volu- 
 minous, and so complete, that the other two courteously 
 withdrew, and asked him to undertake the whole work lest 
 they should destroy its unity and harmony. Glisson under- 
 took the task, but, with equal courtesy, he insisted that the 
 other physicians should lend him the aid of their suggestions 
 and criticisms, and the names of George Bate and Ahasuerus 
 Regemorter are associated on the title-page with his name as 
 joint authors. Thus the work was freely discussed in 
 medical circles in London for some years before it was 
 published. Not only was the subject talked of amongst 
 physicians, but it was a topic of interest in lay circles in 
 London and elsewhere. 
 
 It is to be noted that two editions of the English transla- 
 tion were published in 1651 ; at least there are two copies, 
 each precisely the same in the body of the book, but in one 
 copy there is an addition on the title-page which reads as 
 follows : " Enlarged, corrected and very much amended 
 throughout the whole book by Nich. Culpeper, Gent., Student 
 in Physick and Astrology, living in Spittlefields, neer London." 
 In both copies it is stated on the title-page that they are 
 " Printed by Peter Cole in Leaden-Hall, and are to be sold 
 at his shop at the sign of the Printing-press in Cornhil, neer 
 the Royal Exchange, 1651." Nicholas Culpeper (1616- 
 1654) was an active figure in London during his short life. 
 
Glisson and His Times 269 
 
 He was on the Parliamentary side in the Civil War, and was 
 said to have fought and to have been seriously wounded in 
 the chest. Culpeper was a herbalist who combined astro- 
 logy with the practice of medicine in Red Lion Street, Spital- 
 fields, and was at variance with the College of Physicians, to 
 whom he had given much offence. He first roused the 
 indignation of the College by publishing an unauthorised 
 translation of the College of Physicians' Pharmacopoeia.* 
 
 He was closely associated with Peter Cole, the printer, 
 and evidently acted as his medical pubUsher. But Cul- 
 peper was himself a prolific writer on medical subjects, and 
 his books sold remarkably well. In September, 1653, he 
 again trespassed on the monopoly claimed by the recognised 
 medical writers by publishing, with Peter Cole, a book 
 entitled " The English Physician." f This book had an 
 enormous sale. 
 
 Culpeper, notwithstanding the statement " enlarged, 
 corrected and very much amended " on the title-page of the 
 English translation of "De Rachitide," does not seem to 
 have interfered with the matter of the work, though he may 
 have amended the translation, for he was an excellent Latin 
 and Greek scholar. There could be no sympathy between 
 Glisson and Culpeper, and the part the latter played as medical 
 agent for Peter Cole was probably wholly unauthorised, and 
 the addition of his name to the title-page strongly objected 
 to. Doubtless it would greatly aid the sale of the work, but 
 there is evidence that his efforts were not appreciated by 
 the authors of " De Rachitide," for two years later he rails 
 against the whole College of Physicians, and against Glisson 
 in particular, for some statements in the work which he 
 himself had apparently failed to amend. J 
 
 As already stated, the history of rickets begins with the 
 publication of Glisson's book, but it was not actually the 
 
 * "A Physical Directory or Translation of the London Dispensatory," 
 pubUshed for Peter Cole, London, 1649. 
 
 I " The English Physician, enlarged, with 369 medicines made of 
 English Herbs that were not in any impression until this. The Epistle 
 will inform you how to know this impression from any other." 
 
 t Galen's " Art of Physick, by Nich. Culpeper, Gent., Modern, etc.," 
 printed by Peter Cole, London, 1652. 
 
2/0 Rickets 
 
 first book published on the subject. Daniel Whistler — 1619 
 to 1684 — ^was bom at Walthamstow, in Essex, and entered 
 Merton College, Oxford, in 1639, graduating B.A. in 1642 
 and M.A. in 1644. He took his degree of M.D. at Leyden 
 in 1645, and on October 18th, 1645, he read as his inaugural 
 address a short treatise on rickets. This was published in 
 Leyden in the same year, that is five years before the pubU- 
 cation of Glisson's work, under the title " Disputatio Medica 
 inauguralis de morbo puerili Anglorum quem patrio idio- 
 mate indigenae vocant the rickets." It was republished in 
 London in 1684. Whistler, a notable man in his day, was 
 elected President of the Royal College of Physicians in 1683, 
 and is mentioned in the diaries of both Samuel Pepys and 
 John Evelyn. But Glisson owed nothing to his work. Sir 
 Norman Moore points out * that Whistler's book does not 
 bear the impress of original work ; he speaks of rickets as 
 having been discussed by learned men, and he alludes several 
 times to a very learned man, probably meaning GHsson, but 
 nowhere does he mention the names of his authorities. As 
 Sir Norman Moore somewhat caustically remarks, while 
 Whistler does not claim originaUty for his work on rickets, 
 he does claim to be the originator of the name " paedo- 
 splanchnosteocaces " for this disease, and he was the sole user 
 as well as the sole inventor of the word. 
 
 It has been suggested that Whistler pirated his informa- 
 tion and made use of it without acknowledgment. In 1645 
 Whistler, at the age of twenty-six, had just graduated, 
 while Glisson was forty-eight years of age, well estabUshed 
 as one of the most learned men of his time, and had already 
 been Regius Professor of Physic at Cambridge for eleven 
 years. Probably Whistler was quite open about the fact 
 of having used Glisson's work for his inaugural thesis; 
 indeed, it would have been impossible for him to conceal it, 
 for Glisson at this time was actively engaged in making the 
 research and observations necessary for his great work, and 
 was already holding informal and open meetings with other 
 
 * " The History of the First Treatise in Rickets," St. Bartholomew's 
 Hospital Reports, Vol. XX., 1884. 
 
Glisson and His Times 271 
 
 Fellows of the College of Physicians to elaborate the 
 subject. Glisson would think nothing of a keen young pupil 
 having made use of his work in a comparatively unimportant 
 graduation thesis pubhshed in Leyden, especially when the 
 subtle flattery of " vir consummatissimus " was used in 
 referring to him, even if it were only by implication and not 
 by name. Jonathan Goddard, M.D., F.R.S., is one of the 
 seven names mentioned at the end of Glisson's preface as 
 having collaborated with him in his work. It is interesting 
 to note that Pepys in his diary makes the following entry 
 on February 15th, 1664 : — 
 
 " After this being done, they to the Crown Tavern 
 behind the Change, and there my Lord (Brouncker) 
 and most of the company to a club supper : Sir P. 
 Neale, Sir R. Murray, Dr. Clerke, Dr. Whistler, Dr. 
 Goddard, and others, of the most eminent worth." 
 
 There was apparently no animosity felt by Goddard against 
 Whistler on account of his publication, even though the only 
 observations of value it contained were borrowed from 
 Glisson and his collaborators. If further evidence that no 
 slight was meant or felt is required, it might be found in a 
 list lying in the Sloane MSS. in the British Museum headed 
 " Subscription towards building of a CoUedge, 28th April, 
 1669 : those who have subscribed and paid." Dr. Glisson, 
 President, heads the list with £100 ; next to him comes the 
 ever-generous Dr. Hamey with £100, followed by Dr. Goddard 
 £40, Dr. Whistler £50, Dr. Wharton £40, and several others. 
 A second and more notable publication than Whistler's 
 appeared in 1649, one year before Glisson produced his 
 work. Arnold de Boot, also known as Arnold Boate or, in 
 the latinised form, as Amoldus Bootius, was a Frisian who 
 practised in Ireland for some time. In 1649 he pubhshed 
 a treatise, "De Afectibus Omissis," one chapter of 
 which deals with the subject of rickets.* He states 
 that, while up to recent years rickets was exceedingly rare, 
 
 * " Observationis Medicae de Affectibus Omissis, Authorje Amoldo 
 Bootio, Lond., 1649. Caput duodecim, De Tabe Pectorea." 
 
272 Rickets 
 
 the disease is now (referring to the date of his publication) 
 common both in England and Ireland, and accounts for 
 several thousands of deaths amongst infants each year. He 
 himself, he affirms, has had frequent opportunities of making 
 autopsies on these cases. With great accuracy he describes 
 the signs of the disease, noting carefully and in detail the 
 alteration in the formation of the chest, the enlargement of 
 the wrists and ankles, the tendency to spinal curvature, and 
 the relative enlargement of the skull. He is of opinion that 
 the disease may be acquired at the time of conception, and 
 may be due to .the defective constitution of one or other of 
 the parents, or that it may arise during the period of gesta- 
 tion owing to a faulty regimen on the part of the mother, or 
 that it may appear soon after birth from the persistence of 
 these errors affecting the child through the breast milk. It 
 is very probable that he was acquainted with Whistler's 
 short treatise, and he may have obtained much of his know- 
 ledge from GUsson himself. But his work gives the impres- 
 sion of information obtained at first hand, and he seems to 
 have had a considerable experience of the disease in his own 
 practice. He makes the interesting statement "Not only 
 does this disease exist in England and Ireland, but in other 
 regions it is probably also present, and so far as Gaul is con- 
 cerned, to my knowledge, it most certainly exists. Indeed, 
 in the space of three and a half years since these things were 
 written I have seen various children here at Paris labouring 
 with the disease, and by these methods familiar to me and 
 by the principles indicated I have happily been able to 
 effect a cure." * 
 
 As early as 1609 Guillemeau, a French surgeon, published 
 an excellent treatise on the nursing of children,! and though 
 he, of course, does not speak of rickets by name or define 
 
 * " Morbum istum non in Anglia duntaxat et Hibernia, sed et in Aliis 
 quoque Regionibus grassari verisimile est, et de Gallia quidem mihi cer- 
 tissimo constat. Quippe illo trium annorum et dimidi spatio, quod 
 efluxit, ex quo ista scripserim, diversos hie parisiis infantes vidi eo 
 laborantes eosque methodo mihi usitata atque isto capite indicata foeliciter 
 persanavi" (loc. cit.). 
 
 t " De la nourriture et gouvernement des enfans dfis le commencement 
 de leur naissance," etc., Paris, 1609, 8. 
 
Glisson and His Times 273 
 
 the condition, it is difficult to believe that he is not dealing 
 with this disease. " We must have an eye," he says, " that 
 the nurse or she that mothers him and dresseth him doe not 
 make him worse, and of a well-fashioned child, in all the 
 parts of his body, do not malce him deformed or misshapen, 
 and so spoile him. For in swathing the child most com- 
 monly they bind him and crush him so hard that they make 
 him grow crooked. . . . This crushing makes his breast 
 and the ribs which are fastened to the back bone to stand 
 out, so that they are bended and draw the vertebrse to 
 them, which makes the back bone to bend and give either 
 inwardly or outwardly or else on the one side, and that 
 causeth the child to be either crump-shouldered or crooked- 
 brested, or else to have one of his shoulders stand further 
 out than the other. Some also bind the hips so hard that they 
 become very small, and that hinders them from growing and 
 waxing big. Galen has observed," he continues, " that the 
 too straight and hard binding or crushing of the hams and 
 legges of little children when they are swathed doth make 
 them grow crooked-legged, and they will remaine, as the 
 Latines call it, Van or Valgi, growing either inward or out- 
 ward with their knees." * 
 
 Of course tight binding of the limbs might easily produce 
 bending of the bones apart from any rachitic change, but 
 the description given by Guillemeau of the chest deformi- 
 ties, the spinal curvature, the prominent shoulder, and the 
 deformities of the lower limbs, points to rickets. 
 
 To return to Glisson's work, GUsson places his anatomical 
 observations under four headings : — 
 
 "I. Anatomical observations, the body not yet being 
 opened, which are outwardly visible upon the first appear- 
 ance of the naked dead body : — 
 
 1. An irregularity or disproportion of the parts ; namely, 
 
 the head bigger than ordinary and the face fat and 
 in good constitution in respect of the other parts ; 
 
 2. The external members and the muscles of the whole 
 
 * " Child-birtli, or the Happy Deliverie of Women, to which is added 
 a Treatise of the Disease of Infants and Young Children." written in 
 French by James Guillemeau, translated into English, London, 1612. 
 
^74 Rickets 
 
 body were slender and extenuated, as if they had been 
 wasted with an atrophy or a consumption ; 
 
 3. The whole skin, both the true and also the fleshy and 
 
 fattish membrane, appeareth lank and hanging loose 
 like a glove ; 
 
 4. About the joints, especially in the wrists and ankles, 
 
 certain swellings are conspicuous ; 
 
 5. The articles or joints and the habits of all the external 
 
 parts axe less firm and rigid and more flexible than 
 at another time they are observed to be in dead 
 bodies ; 
 
 6. The breast is outwardly lean and very narrow, especially 
 
 under the arms, and seemeth on the sides to be, as it 
 were, compressed ; the stern also is somewhat pointed 
 like the keel of a ship or the breast of a hen ; 
 
 7. The top of the ribs, to which the stern is conjoyned with 
 
 gristles, are knotty, like unto the joints of the wrists 
 and ankles ; 
 
 8. The abdomen is lean, but inwardly in respect of the 
 
 parts contained in it is somewhat sticking out, and 
 seemeth to be swelled and extended. 
 
 II. The abdomen being opened 
 
 1. The liver in all that we have dissected hath exceeded 
 
 in bigness, but was well coloured, and not much 
 hardened nor contaminated by any other remarkable 
 vice ; 
 
 2. The spleen for the most part not to be contemned ; 
 
 3. We have sometimes espied a whe5dsh water in the cavity 
 
 of the abdomen, but, indeed, not often, nor in any 
 great plenty ; 
 
 4. The stomach and guts are somewhat more infected with 
 
 flatulent humours than sound bodies usually are ; 
 
 5. The mesentery is sometimes faultless and sometimes 
 
 affected with glandulous excrescences ; 
 
 6. The kidneys, ureturs, and bladder, unless there be a 
 
 concomitancy of some other disease, are laudably 
 sound. We observe in general of all the viscera 
 contained in the abdomen that, although the parts 
 containing them are very much extenuated and 
 emaciated, yet are they as large and as full, if not 
 larger and fuller, than those seen in sound bodies, as 
 hath been said of the liver. 
 
 III. The stern being mthdrawn." 
 
 Various morbid conditions are described, such as pleuritic 
 adhesions, blocking of the air passages by thick humours 
 and enlargement of the mediastinal glands, but Glisson is 
 
Glisson and His Times 275 
 
 caxeful to observe that in cases dying from this disease not 
 all the conditions found post mortem can be ascribed to 
 rickets itself, but may be due to other complicating diseases 
 which invade the body before death. With shrewd observa- 
 tion he notes that the thymus is always found to be 
 great in childhood, but is perhaps greater yet in this disease. 
 
 "IV. The skull being opened." 
 
 The dura mater is described as being firmer and more 
 adherent to the skull than normcd. In some bodies between 
 the dura and the pia mater and in the very ventricles of 
 the brain wheyish and waterish humours have been found. 
 Sometimes he notes the condition is comphcated with 
 hydrocephalus. 
 
 The signs of rickets he discusses at length under five 
 headings : — 
 
 " (I.) the diagnostical ; 
 
 (II.) signs which belong to the disproportioned nourishment 
 
 of the parts ; 
 (III.) the signs which belong to the respiration ; 
 (IV.) those that appertain to the vital influx ; 
 
 (V.) certain vagabond and wandering signs." 
 
 The beading which takes place at the junction of the bony 
 end of the rib with the cartilage and the enlargement at the 
 epiphyseal ends of the long bones, with the general softening 
 and bending of the bones, are all accurately described. The 
 teeth, he notes, come forth slowly and with trouble; they 
 grow loose upon every slight occasion ; sometimes they wax 
 black, and even fall out by pieces. In their stead new ones 
 come again, though late and with much pain. Under the 
 diagnostical signs he gives the following excellent clinical 
 picture of the disease: — 
 
 " The younger children who are carried about in their 
 nurses arms when they are delighted and pleased with any- 
 thing do not laugh so heartily, neither do they stir themselves 
 with so nauch vigour, and shake and brandish their little 
 josmts, as if they were desirous to leap out of their nurses 
 hands ; also when they are angered they do not kick so 
 fiercely, neither do they cry with so much fierceness, as those 
 who are in health. Being grown greater, and committed to 
 their feet, they run up and down with a wayward uncheer- 
 
276 Rickets 
 
 fulness ; they are soon weary, and they love to play rather 
 sitting than standing, neither when they sit do they erect 
 their body with vigour, but they bend it sometimes forwards, 
 sometimes backwards, and sometimes on either side, seeking 
 some props to lean upon that may gratify their slothfulness. 
 They are not delighted hke other children with the agitation 
 of their bodies, or any violent motion ; yea, when the 
 disease prevaileth they are averse from all motion of their 
 limbs, crying as they are at any play that is never so little 
 vehement, and being pleased with gentle usage and quiet 
 rest. Their countenances are much more composed and 
 severe than their age requireth, as if they were intent and 
 ruminating upon some serious matter." A more accurate 
 picture of the young child suffering from well-marked rickets 
 could hardly be given, as they sit in their quaint cross-legged 
 attitude, Mke figures of the contemplative Buddha, anxious 
 only to remain still and to be left alone, and yet observant of 
 what is going on around. 
 
 The relationship of S3^hilis, scurvy and tubercle to 
 rickets is discussed at some length, and these diseases could 
 hardly be more accurately deUneated than in the words of 
 Glisson : " If the French pox chance to be complicated with 
 this disease, it is rather derived from the nurses infection, or 
 from the parents by inheritance. For it is a disease alto- 
 gether distinct from this, arid hath scarce any afi&nity with 
 it. The scurvy is sometimes conjosmed with this affect. It 
 is either hereditary or perhaps in so tender a constitution 
 contracted by infection, or, lastly, it is produced from the 
 indiscreet and erroneous regimen of the infant, and chiefly 
 from the inclemency of the air and cUmate where the child 
 is educated. For it scarce holdeth any greater commerce 
 with this disease than with other diseases of longer continu- 
 ance, wherein after the same manner the blood in time con- 
 tracteth for the most part this peculiar infection, yet it must 
 be granted that this effect doth somewhat the more dispose 
 to the scurvy in regard of the want of motion and exercise. 
 
 "The strumatical affect doth sometimes associate this 
 evil. But it is credible that it oweth more to other causes 
 
Glisson and His Times 277 
 
 proper unto it than to this precedent disease, although we 
 deny not but this may minister some occasion of invading, 
 in as much as it rendereth the humors more viscous and 
 gross." 
 
 It is a remarkable fact that Glisson in his work on rickets 
 was the first to describe another important disease in infants, 
 viz., infantile scurvy. His very clear and explicit descrip- 
 tion of the condition was lost sight of for considerably over 
 two hundred years, and no other writer makes any mention 
 of it. In the latter half of the nineteenth century the 
 material for the study of scurvy in adults was rapidly 
 diminishing, and but little interest was taken in the disease 
 till Sir Thomas Barlow, in 1883, described the condition 
 which came to be variously known as acute rickets, scurvy 
 rickets, or Barlow's disease, and the relationship between 
 infantile scurvy and the adult form was warmly discussed. 
 Two opinions prevailed after Barlow's description : (1) that 
 the disease was essentially rachitic in origin with the symptoms 
 of scurvy superimposed ; (2) that it was a true form of 
 scurvy, differing in no way from the adult variety. 
 
 The question can now be considered as settled, and 
 Ghsson's original view has been established that infantile 
 scurvy is a true scurvy and is entirely independent of rickets, 
 although both conditions are not infrequently present in the 
 same subject. 
 
 Both at home and abroad Glisson's work was widely read, 
 and was in itself so complete that for a long time nothing 
 very original was written about rickets. The literature is 
 encumbered with many unimportant treatises, many of them 
 graduation theses, published in Edinburgh, Leyden and 
 elsewhere. 
 
 Ghsson was convinced that he was dealing with a new 
 disease. He specifically states, " This is absolutely a new 
 disease, and never described by any of the ancient or 
 modern writers in their practical books which are extant at 
 this day of the diseases of infants. But this disease became 
 first known (as near as we could gather from the relation of 
 others after a sedulous inquiry) about thirty years since, in 
 
278 Rickets 
 
 the counties of Dorset and Somerset, lying in the western 
 part of England, since which time the observation of it hath 
 been derived unto other places, as London, Oxford, Cam- 
 bridge, and almost all the southern and western parts of the 
 kingdom ; in the northern counties this affect is very rarely 
 seen, and scarcely yet made known among the vulgar sort 
 of people." This was the general behef of the times, sup- 
 ported by the evidence of such names as Mayow, Sir Thomas 
 Browne, and later by Boerhaave. 
 
 It has been affirmed by some that the disease is co-existent 
 with civilisation, but this is certainly too wide a generalisa- 
 tion. It is true that rickets is common in all the highly 
 civilised communities in Europe, but the progress of civilisa- 
 tion does not necessarily involve the abandonment of 
 the principles of healthy living. The disease is a pro- 
 duct of industrialism, and industrialism as it exists to-day 
 in England, and Europe, and America, is a growth of com- 
 paratively recent times. But such is the stupefying influence 
 of familiarity, and the spirit of unwholesome and lazy 
 tolerance which it breeds, that it is difficult at the present 
 day to imagine the existence of a town without slums, or to 
 think of the existence of young infant life without rickets. 
 
 Unfortunately the growth of industrialism in Europe has 
 usually been spoken of as if it were synon57mous with the 
 advance of civilisation, and the progress of a nation has been 
 judged by the increase in wealth and the output of its fac- 
 tories. That this has been to the detriment of the health and 
 true happiness of nations has been lost sight of, and in the 
 struggle for increased industrial prosperity, efficiency has 
 been sacrificed with disastrous results. 
 
 The evidence is fairly conclusive that the disease is of 
 comparatively recent origin, but Glisson's definite statement 
 that it began in the south-west of England thirty years 
 before he pubUshed his book — that is, in 1620 — ^need not be 
 taken too hterally. It probably began to be prevalent in 
 England somewhere towards the end of the sixteenth 
 century. 
 
 That it was common in certain parts of the Continent 
 
Glisson and His Times 279 
 
 some time before that date seems fairly certain. Arnold de 
 Boot, as already noted, was well acquainted with the disease 
 on the Continent, and described it accurately and in some 
 detail before Glisson pubhshed his work. If no other 
 evidence were available than the works of the early masters 
 in painting, these would, in themselves, be suificient to estab- 
 lish the fact that rickets was known in Europe, on the Con- 
 tinent at all events, before that date. In the dawn of 
 painting in the thirteenth and fourteenth centuries, leading 
 up to the period of greatest achievement in the sixteenth 
 century, the Madonna and Child are very frequently por- 
 trayed. When we study the early Flemish painters the sliape 
 of the heads of the Virgin and Child is very striking. In 
 many the front olympien du rachitisme of the French is 
 exceedingly well marked, the forehead being high and square, 
 and often showing well-marked bossing in the region of the 
 frontal eminences. The type is repeated so frequently that 
 it must have been a national conformation, not an acci- 
 dental choice of models which led to its being so frequently 
 depicted. 
 
 To quote from examples in the National Gallery in 
 London alone, in the paintings of such early masters as 
 Boutts, Daret, Geeraert David, van der Goes, and, to a 
 lesser extent, Memhnc, all of the fifteenth century, typical 
 examples are numerous. In the works of the master from 
 Delft (1520) the heads of the female figures show gross 
 changes strongly suggestive of a rachitic deformation. The 
 same type is seen in the paintings of the Cologne school of 
 the fifteenth and early sixteenth centuries. It is also found 
 in later Dutch masters of the seventeenth century, such as 
 Nicholas Maes. Rubens, who rejoiced in lusty and vigorous 
 life, chooses a different type of model, and his robust figures 
 are mostly free from any such stigmata. Michael Sweertz 
 (seventeenth century), has an interesting portrait group of a 
 Dutch family in the National Gallery, where the heads of 
 the children are strongly suggestive of weU marked and active 
 rickets. 
 
 In the Italian school Leonardo da, Vinci (1452-1519) 
 
28o Rickets 
 
 and Bronzino in the sixteenth century painted heads 
 of a much more refined type, conve5dng no suggestion of 
 rickets. The same is true of the early Spanish school, and 
 Velasquez and Murillo in the seventeenth century, and 
 Goya in the eighteenth century, depict heads of a much 
 more dehcate order. Even in the wonderful series of court 
 dwarfs painted by Velasquez the rachitic type is wanting. 
 Nor would it be surprising if it were found that the disease 
 first developed in the bleak, low-lying and marshy land of 
 Flanders. Besides having a cold and wet chmate, Flanders 
 was then the hub of the industrial universe, and, in spite of 
 the increase in wealth, the pernicious influences of industrial 
 concentration were probably felt at an earlier date in that 
 country than elsewhere. 
 
 The decay of long-established diseases and the onset of 
 fresh maladies are common features in the world's history. 
 In and about this time, that is during the fifteenth century, 
 leprosy diminished greatly in Europe without any obvious 
 cause. Though the time and place of origin of syphilis have 
 not yet been definitely settled, there can be no doubt that 
 there was a sudden and widespread diffusion of the disease 
 throughout Europe at the beginning of the last decade of the 
 fifteenth century. Rickets probably first became an impor- 
 tant factor in England towards the close of the sixteenth 
 ' century, and when described by Ghsson had already spread 
 far and wide throughout England. In Flanders and the 
 Netherlands generally and the towns of North Germany 
 rickets had probably existed from the fifteenth century 
 onwards. The wide diffusion of this disease is generally 
 associated with dense populations. Europe through the 
 Middle Ages had been asleep, and was only now, in the fifteenth 
 century, awaking from her lethargy and entering upon the 
 struggle culminating in the Reformation. But this lethargic 
 state had not involved the northern towns. The Hanseatic 
 League, as is well known, was an association of towns in the 
 north of Germany and the adjoining States at first for the 
 protection of commerce at sea, which rapidly, however, 
 acquired great political power. Under its fostering influence 
 
Glisson and His Times 281 
 
 enormous towns grew rapidly, and many of the worst fea- 
 tures of industrial concentration were reproduced in the 
 change in the manner of life of the people and the crowding 
 together of dense masses of the population in slum areas. 
 Houses and workshops were huddled together in irregular 
 and winding lanes, because of the greater facilities offered 
 for business and trade by having everything within a small 
 compass. The vitiated air in those closely built towns, and 
 the lack of sunshine, and of the opportunities of exercise, 
 were especially injurious to the infant and to the young child. 
 Wealth was enormously increased, but the spread of luxury 
 and the better distribution of foodstuffs could not stay these 
 evils, which sapped the life of the nation at its very source 
 in that they bore most heavily on the infant. 
 
 In these great towns in Northern Europe I think it 
 probable that rickets developed as a national disease for the 
 first time in the history of the world. 
 
 Bruges as far back as the thirteenth century was the 
 central mart of the Hanseatic League, and in the fourteenth 
 century became the metropolis of the world's commerce. 
 Its population at this time amounted to upwards of two 
 hundred thousand. Liibeck, Hamburg and Bremen were 
 Hanseatic towns whose dictates could guide the policy of 
 Europe. In the fifteenth century Bruges declined and 
 Antwerp gained in importance, so that in the beginning of 
 the sixteenth century it was the commercial capital of the 
 world. These great populations, devoted to commerce and 
 industrial pursuits, had but little time to give to the refine- 
 ment of life, and it is but little wonder if in these densely 
 crowded and rude communities, living in low-lying country 
 with a cold and bleak climate, rickets found a ready habitat. 
 
 As will be seen later, in England there is a good deal of 
 actual evidence to be derived from collections of bones 
 throughout the country, which helps to fix the actual date 
 of the origin of the disease within fairly definite limits. 
 
 Notwithstanding the fact, then, that Glisson first de- 
 scribed the disease in England in 1650, the probability is 
 that rickets was prevalent in Flanders and the Netherlands 
 
282 Rickets 
 
 some considerable time before it became an important factor 
 affecting the health of the English community. 
 
 It is interesting to note that Glisson considers rickets a 
 disease of the rich, bred by luxury. This is probably true in 
 so far as the rich would be the first likely to come under the 
 vicious influences which tend to produce the disease. 
 
 In earlier times the general plan of life pursued by our 
 ancestors was more wholesome than that of our own time. 
 One of the worst features of the life was the total neglect of 
 sanitary precautions which was a prolific source of disease. 
 Writing on January 30th, 1453, Margaret Paston writes to 
 John Paston * : " There is no space beside the bed, though 
 the bed were removed to the door, to set both your board 
 and your coffers there, and to have space to go and sit 
 beside." When it is considered that this room referred to 
 was a draught chamber, that is it contained a privy, the want 
 of space was indeed a serious objection. But in most other 
 ways their life was healthier than the mode of living to-day. 
 They were early risers. Artificial lights did not tempt them 
 to steal from the hours of rest the time for either dissipation 
 or study. Dinner was at noon and after dinner it was cus- 
 tomary to take some additional rest. Even labourers 
 indulged in the afternoon rest, and by Act of Parliament it 
 was restricted in their case to a quarter of the year, from the 
 middle of May to the middle of August. •[■ Food was coarse 
 and without much variety when compared with the diet of 
 the lowest class of our population to-day. In the long winters 
 the ordinary commodities were not easily obtainable by the 
 very poor, and hunger and starvation were not uncommon. 
 But such is not the type of life that leads to rickets. Their 
 work was in the fields, and while it was light they hved much 
 in the open, for there was not much comfort to induce them 
 to remain indoors except for sleep. Not only the head of the 
 house worked on the land, but the mother and the children as 
 soon as they were able took part in the labour of the field. 
 
 * " The Paston Letters," 1422-1509 a.d.," edited by James Gairdner, 
 London, 1904. 
 f Loc, cit. 
 
Glisson and His Times 283 
 
 Glisson correctly maintains that rickets is not a con- 
 genital disease but is the result of environmental conditions 
 which operate on the child soon after birth. But he believes 
 that certain conditions in the life of the parents may render 
 the offspring prone to the disease. 
 
 " These," he says, " are first, the soft, loose, and effemi- 
 nate constitution of either or both parents. . . . Secondly, 
 an over-moist and full diet. . . . Thirdly, a delicate kind of 
 life abandoned to ease and voluptuousness, slothful, and 
 rarely accustomed to labour, danger, and care. Hither you 
 may also refer a total defect of manly exercise, immoderate 
 sleep, especially soon after meat, and any kind of sleepings 
 whatsoever, a sedentary, speculative life, intent upon soft 
 and quaint arts and sciences, as poetry, music, and the like ; 
 to these may be further added daily frequenting of comedies 
 and other plays, an assiduous reading of fables and romances, 
 and instead of manly recreations a loose expence of time in 
 carding and dicing. . . . We affirm that the rifeness of this 
 disease in England hath been much promoted by that long 
 and secure peace ... for by this the more wealthy families 
 which were first invaded by this evil, and which doth still 
 invest them more than others, had addicted themselves to 
 idleness and a loose effeminate life, and therefore they fall 
 into a moister, softer, and degenerate constitution and such 
 as was less purged and cleansed from excrementitious 
 humours." 
 
 Answering his own question as to why rickets is more 
 frequent in the southern and western parts of England, than 
 it is in Scotland and the northern counties, he shrewdly 
 remarks that there are probably many mild cases in Scot- 
 land and the northern counties which are not recognised; 
 but he explains the increased prevalence which he believes 
 to exist in the south-west by saying : " The cause of this 
 difference is the affluence of all good things in these southern 
 and western counties of England. For this part of the 
 kingdom is much the more fruitful, rich and flomrishing and 
 abounding with all manner of allurements to pleasure." 
 
 What was true of these counties in Glisson's time remains 
 
284 Rickets 
 
 true to the present day. Devon, Dorset and Somerset still 
 remain rich fertile counties famed for their dairy produce. 
 The farms and farm labourers are prosperous and their 
 tables are well supplied with rich and wholesome food, and 
 yet the disease is still quite common all over the south- 
 western counties of England. To-day rickets is not so pre- 
 valent amongst the wealthy in these counties as it was in 
 Glisson's time, though it is still by no means uncommon, 
 nor is the disease of so severe a type. But it is, to this day, 
 a well-marked affection, and has a far-reaching influence on 
 the physical and mental growth of the children affected. 
 
 It is always a matter of surprise, though by no means an 
 uncommon experience, to find that in beautiful country sur- 
 roundings with an amplitude of fresh air and most excellent 
 feeding, the children are frequently backward in teething, 
 in walking and in speech ; later they tend to be dull in 
 school, heavy of feature, and prone to the development of 
 adenoids and mouth breaking. Any one acquainted with 
 the west country knows how the wider stretches of Dart- 
 moor and Exmoor suddenly terminate on a sharp line, as it 
 were, and slope rapidly down into rich pastoral and agricul- 
 tural land. In Somerset, for instance, there is a beautiful 
 stretch of lull country Ijdng between the Quantocks and the 
 Brendon Hills and Exmoor on the one hand and the Bristol 
 Channel on the other. It consists of hill and vale and all 
 the conditions would seem to make for health. It is as rich 
 pastoral country as any to be found in England ; the stock 
 on the farms, cattle, sheep and horses, are in beautiful con- 
 dition ; milk, butter, eggs and vegetables are in ample 
 supply. Yet on these farms, and not only in the families of 
 the farm labourers, it is quite common to find the stigmata 
 of rickets well marked in the children. The mothers nurse 
 their infants at the breast, and if by any chance there is a 
 failure of the mother's milk, there is abundance of dairy supply 
 to meet the deficiency. With the present high prices of nulk 
 and butter the supply to the farm labourers is not so ample 
 as heretofore. Separated milk is largely used for the pur- 
 pose of the household because it is cheap and plentiful, but 
 
Glisson and His Times 285 
 
 this is used for the older children. As a rule the infant has 
 the best of everything. Separated milk is not an unwhole- 
 some diet, and even a high degree of separation does not 
 destroy its nutritive value, even from the point of view of 
 fat, when it is supphed in quantity. The farm laboxirers 
 keep chickens and supply their own vegetables ; cheese, 
 bread, and butter are commonly seen on their table. Pork 
 and bacon are more often used than beef and mutton. It is 
 difficult to understand how rickets can develop under such 
 conditions. 
 
 The explanation is to be found in the defective home 
 surroundings of the young infant. Farm labourers' cottages 
 are built more with a view to readiness of access, and to 
 suit the convenience of the builder, than from any broad 
 consideration of the principles of healthy living. As a 
 rule the cottage is built down in the valley, frequently close 
 to a running stream. In the south-west country there is 
 much rain and in the summer the air in the valleys is stag- 
 nant and oppressive and there is a heavy morning and even- 
 ing mist. The cottages are picturesque, and in Somerset- 
 shire, more than in Cornwall, are well and strongly built. 
 But the rooms are small and are often difficult to ventilate, 
 and the cult of fresh air has not yet made its way into the 
 homes of the people. Windows are meant to exclude air 
 and are not used for the purposes of ventilation. The 
 winters are long and severe, and the roads are only to 
 be attempted with difficulty owing to the mud from the 
 rain and snow. In the case of an infant bom in the month 
 of October, the probability is that, for the winter months, it 
 will be confined practically to one room. 
 
 It cannot be too clearly understood that, even with the 
 best hygienic surroundings, it is possible, in a climate 
 such as that of England, to reproduce all the vicious 
 environment of a slum. Rickets resembles goitre and 
 cretinism in its habitat, and the valleys Is^ng between the 
 hills are likely localities for both diseases. Slighter condi- 
 tions of goitre are by no means uncommon at the present 
 day in the county of Somerset and cretinism is not unknown. 
 
286 Rickets 
 
 Defective and carious teeth and hypoplasia of the enamel 
 are quite common in Somerset, certain evidence of serious 
 interference with the child's growth during the first two 
 years of life. 
 
 Local variations are of interest. Thus the children in 
 the little seaport towns of Watchet and of Minehead suffer 
 less severely from rachitic conditions than the children 
 of the farm labourers who live, perhaps, only six or 
 seven miles away. Both these seaports are pleasantly 
 situated on a rising slope facing the Bristol Channel, and, 
 though the conditions approximate those of a town, the 
 houses are well ventilated from the sea, and the children are 
 much less likely to suffer from continuous confinement 
 during the winter months than are the infants who live 
 further inland in the hilly parts behind. Both these small 
 ports are comparatively free from rickets, while in adjacent 
 towns, such as Bridgwater, Taunton and Dulverton in 
 Somerset, extending to Witheridge, South Molton and Tor- 
 rington in Devon, rickets is prevalent. It must be noted 
 that the disease is not more common in this part of Somerset 
 than it is elsewhere in the south-western counties, as has 
 been shown in discussing the geographical distribution of 
 the disease. In Padstow, a fishing and seaport town at the 
 mouth of the River Camel in North Cornwall, rickets is 
 prevalent. The main part of the town Ues huddled at the 
 foot of a hill and a good deal of the house property approxi- 
 mates what might be expected in the slum area of a large 
 town. 
 
 A factor worthy of note in discussing the development of 
 the people in the south-western counties is the intermarriage 
 which takes place in the country districts of Somerset and 
 still more markedly in Cornwall. Some of the harmful 
 effects of marriages between first cousins are said to be 
 marked decrease in fertility and a high infantile mortality. 
 Deaf mutism, insanity, albinism, hare-lip, and other deformi- 
 ties are said to occur with greater frequency than among 
 the general population. In South Africa, especially among 
 the Dutch, marriages within the family are quite common. 
 
Glisson and His Times 287 
 
 so that in certain communities one or two names may be the 
 prevailing names of the district, and all the members having 
 one name are more or less closely related. The motive of 
 these marriages is to some extent a desire to keep land within 
 the family. Prevalence of certain names is also seen in 
 Cornwall, though to a less extent than in South Africa, where 
 the communities are more isolated. In South Africa, how- 
 ever, rickets never results, for the conditions are not present 
 to produce the disease even in a defective offspring, and 
 often under the gravest disabilities as regards healthy feeding. 
 Such conditions as talipes equino-varus and certain degrees 
 of mental deficiency are, however, not uncommon. It is 
 not vmlikely, however, that this in-breeding, while it cannot 
 itself produce rickets, may so weaken the offspring as to 
 render it less resistant to the influences of an inimical 
 environment, and therefore more prone to the disease if the 
 conditions are favourable to its development. 
 
CHAPTER XX 
 Ancient Medicine and Rickets 
 
 Much has been made of a few allusions in ancient writings to 
 show that rickets was a disease known from the earliest 
 times. 
 
 Sir Thomas Barlow * suggests that it is coeval with civili- 
 sation. This is too wide a generalisation. The accumulating 
 evidence would tend to show that it was unknown in the 
 ancient civilisations of Babylonia, Egypt, and India. Rickets 
 is a disease of civilisation, it is true, but it would be more 
 accurate to say that, considered from a historical point of 
 view, it is a disease of industrialism, and is intimately asso- 
 ciated with the growth of great towns in Europe, during com- 
 paratively recent times. As already remarked, probably 
 Glisson's computation that the disease originated in England 
 about the beginning of the seventeenth century was not far 
 from the truth. It would be unwise to maintain that the 
 disease did not occasionally occur at any period of the 
 world's history. Doubtless, if a child one or two thousand 
 years ago had been exposed to the conditions which now 
 produce rickets the disease would inevitably have developed. 
 According to Findlay the earliest known example of rickets 
 in man or the lower animals occurred in the ape. Lortet, of 
 Lyons, described the disease in the remains of apes which 
 had been kept captive in one of the temples of Thebes, and 
 as Findlay remarks : " Should such be indeed the case it 
 would cause us no surprise, as in modern times young mon- 
 keys kept in captivity are Uable to develop rickets." t It 
 must be freely allowed that rickets may have occiurred and 
 
 * Barlow, " Keating's Cyclopaedia of Diseases of Children," Vol. II., 
 p. 224. 
 
 f " A Study of SociaJ and Economic Factors in the Causation of 
 Rickets," by Margaret Ferguson, M.A., with an Introductory Historical 
 Survey by Leonard Findlay, London, 1918, p. 12. 
 
 288 
 
Ancient Medicine and Rickets 289 
 
 probably did occur in individual cases at any time in man's 
 history, but the point is that the conditions which give rise 
 to the disease, as we know it, did not exist till a compara- 
 tively late period in the world's history. 
 
 The more closely the writings of the ancients are 
 examined, the more strongly is the conviction carried home 
 that the disease was unknown to them. This is the more 
 noteworthy in that the malady is one which would not be 
 likely to have escaped their skilled and accurate observation. 
 Rickets is a striking disease which is not easily missed. 
 Dwarfs and those with physical deformities were ever objects 
 of interest to men all the world over, up to quite recent times, 
 and the absence of allusions to anything that can be fairly 
 construed to signify rickets is very striking. The Hippo- 
 cratic system of medicine was essentially dependent on 
 observation, and it is not likely that so distinctive a disease 
 would have escaped the notice of both Hippocrates and 
 Galen if it had been prevalent in their time. 
 
 Hippocrates (460 B.C.), in his work on " The Articulations," 
 deals at some length with deformities of the spine. Galen, 
 who lived during the second century of our era, in his com- 
 mentaries on this thesis of Hippocrates, also deals very fully 
 with spinal curvature. 
 
 Hippocrates divided curvatures of the spine from internal 
 causes into three varieties : (1) posterior projection of the 
 spine or gibbosity, named by Galen, kyphosis ; (2) anterior 
 projection of the spine, to which Galen gave the name of 
 lordosis ; (3) lateral curvature or scoUosis. 
 
 Speaking of the posterior projection of the spine, Hippo- 
 crates says : " When the gibbosity comes on in infancy the 
 growth of the body is not stopped ; in this case, the spine 
 does not follow the progress of growth, but the arms and legs 
 develop completely, all being thinner. If the hunch is 
 above the diaphragm, the ribs do not develop in width, but 
 in front ; the chest becomes beaked instead of flattened. 
 There is difficulty in respiration and hoEirseness ; for the 
 cavities which receive and send back the breath are less 
 ample. Further, these individuals are forced to hold the 
 
290 Rickets 
 
 neck projecting forwards about the axis, so that the head 
 does not hang, and this bone tends to contract the throat 
 greatly by its incKnation in this manner. . . . Most often, 
 the individuals so affected, have in the lungs tubercles, hard 
 and coarse, so that the cause of the gibbosity is that the 
 tubercles are in communication with the spine through the 
 vertebral ligaments. When the gibbosity is below the 
 diaphragm the kidneys and bladder may be affected. The 
 hips are thinner than when the gibbosity is high ; the pubis 
 and skin acquire hair more slowly and less completely, and 
 there is less procreative power than when the gibbosity is 
 high." It is quite clear that in these cases Hippocrates is 
 dealing with caries of the spine. The extension of the disease 
 from the lungs to the spine by direct continuity by means 
 of the ligaments is confirmed by Galen. One slight passage 
 might be construed as referring to rickets in which he says : 
 " In some also the attitude assumed in bed contributes con- 
 jointly with the malady to produce lateral curvature. But," 
 he remarks again, " these conditions will be spoken of in 
 connection with disease of the limgs." 
 
 In his thesis " On Airs, Waters and Places," Hippocrates, 
 speaking of the effects on the inhabitants of a city which is 
 exposed to hot winds, states : " Infants are subject to 
 attacks of convulsions and asthma which they consider to 
 be connected with infancy and hold to be the sacred disease 
 (epilepsy)." 
 
 It is a matter worthy of note that Hippocrates lays the 
 greatest stress on the importance of environment in the 
 production of disease, and nowhere is this more directly 
 seen than in this treatise. To-day but little attention is 
 paid to such conditions ; for many years the only environ- 
 ment which has interested medical thought has been the 
 microbic one. There has been a complete swing of the 
 pendulum to the other side and environment is thought to 
 have little, if any, influence on germ plasm. Heredity is held 
 to explain everything and to be responsible for all that befalls 
 man, whether for good or ill. There is a tendency to a com- 
 plete divorce between heredity and environment as if they 
 
Ancient Medicine and Rickets 291 
 
 were opposing or at least dissociated factors. But heredity, 
 while it makes for continuity and opposes needless change 
 in response to constantly shifting conditions, itself shows 
 variation, and this can only be in response to environment ; 
 indeed, heredity is but the sum of the response of the organism 
 to environment. The stress only requires to be applied long 
 enough, and the response is certain. Circumcision is a factor 
 without significance in the ontology of the organism, and as 
 such can only have the slightest influence on the germ plasm. 
 If continued long enough it is conceivable that it might pro- 
 duce its effect in the course of the ages and absence of the 
 foreskin might become an inherited quality. Certainly, the 
 influence to be expected in a few thousand years is negligible. 
 But it is otherwise when conditions of environment which 
 threaten the germ plasm are concerned and where the race 
 continuity is endangered. The growth of large towns and 
 life in confined dwelhngs have, with the rapid extension of 
 industrialism, profoundly affected the greater part of our 
 population, and already within the last three centuries there 
 has been a marked effect produced on the industrial nations 
 of Europe. Not necessarily an improved race, but a people 
 better fitted to survive under a vicious environment is being 
 produced. It is reasonable to suppose that in rickets, as 
 indeed Ghsson held, the child is bom, not with the disease, 
 but with a debilitated constitution which will adapt itself 
 better to its evil surroundings than would the healthy and 
 strongly resistant individual. There is no true cleavage 
 between heredity and environment, If the debilitated off- 
 spring of the slum dweller is suitably fed and placed in whole- 
 some surroundings, rickets wiU not develop, but it must be 
 remembered that the greatest care may be taken with the 
 feeding of the infant, and yet the best breast milk in the 
 world will not prevent the onset of rickets if the child is kept 
 month after month in a damp and sunless basement, and in 
 a vitiated and polluted atmosphere. Such is a matter of 
 common experience, but fortunately the reverse side to con- 
 centration in great cities has also been taking place over a 
 similar period in our colonial expansion, where the effete and 
 
292 Rickets 
 
 worn out products of our towns have been rejuvenated in a 
 larger and healthier environment. 
 
 The converse is also true, for if the child be brought up 
 Tuider open-air conditions, exposed to fresh air and bright 
 sunlight in a mild and warm chmate, no errors in feeding 
 will produce rickets. Marasmus may, and frequently does, 
 supervene ; dysenteric affections may carry off the child, 
 and tuberculosis may be prevalent as it is in many of the 
 populous cities in the East, but the characteristic signs of 
 the rachitic state will not develop. 
 
 In the " Aphorisms," Hippocrates states : " At the 
 approach of dentition pruritus of the gums, fevers, convul- 
 sions, diarrhoea, especially when cutting the teeth, are apt 
 to occur and chiefly in those who are particularly fat and 
 have constipated bowels." The very fullness with which 
 Hippocrates and Galen deal with conditions of the bones 
 and joints without refeiring to anything which resembles 
 true rickets is valuable negative evidence that the disease 
 did not exist. 
 
 Soranus of Ephesus, the biographer of Hippocrates, to 
 whom we are indebted for most of the facts we know of the 
 life of Hippocrates, lived between a.d. 98 and 138. In one 
 passage in the work of Soranus on " Diseases of Women," 
 Findlay believes he has found a true description of rickets.* 
 It runs as follows : — 
 
 " How should the child be trained in standing and walking ? 
 
 " When the infant makes attempts to sit down and stand 
 up, one must assist his movements. For should he show 
 eagerness to sit sooner than is right or too often, he becomes 
 hunched, owing to the backbone bending while as yet the 
 body has no sinews to resist the strain. If he continue to 
 stand up with growing impetuosity, and wish to walk about, 
 his legs commonly become twisted at the thighs. 
 
 " Why the majority of Roman children are distorted. 
 
 " This is observed to happen more in the neighbourhood 
 of Rome than in other places. Some suggest as a reason that 
 the city is undermined by cold waters and that their {i.e., 
 
 * Loc. cit., p. 9. 
 
Ancient Medicine and Rickets 293 
 
 the children's) bodies are easily chilled. Others suggest 
 the frequent sexual intercourse of women, or intercourse 
 taking place after a drunken bout. The truth of the matter 
 lies in inexperience with regard to the rearing of children ; for 
 women in the city have not so great a love for their children 
 as to have regard to every particular as the women of purely 
 Greek stock do. If no one oversees the infant's movements 
 his limbs do in the generality of cases becomes twisted, for 
 the whole weight of the body rests on the legs, and the floor 
 or pavement on which he walks is hard and unyielding, being 
 for the most part laid with stones. When, therefore, he rests 
 upon a hard substance, the weight pressing on the limbs is 
 great, and the limbs which bear him up are frail ; the limbs 
 must then of necessity give way a little, since the bones are 
 not yet stiff. Hence, when he first begins to sit he must be 
 propped up by swathings of bandages to counterbalance the 
 ills that can gain the mastery over him, nor must he sit for 
 long at first. As he advances farther to the stage of creeping 
 and standing up for a little, then one should place him up 
 against a wall and leave him alone. But for purposes of 
 making him approach use a chair on wheels. Thus from a 
 gradual common growth of all the members he will practise 
 walking. So much for movement." 
 
 The passage is interesting as illustrating what was a 
 common and well-nigh universal belief which did much harm 
 to the growing infant for many centuries. It was believed 
 that the infant's body and limbs had to be trained into the way 
 in which they should grow. Such a thing as free play of the 
 limbs was entirely discouraged ; and Soranus, in pursuit of 
 his belief, that if the child is left unrestrained, the weight of 
 the body will inevitably cause bending of the spine and later 
 of the legs, recommends the swathing of the infant by binding 
 the whole body in bandages. With regard to the nourish- 
 ment of the child, Soranus is also meddlesome. He recom- 
 mends that the infant should be given no food for two days 
 unless it be a little cooked honey. Nursing should begin on 
 the third day, but for the first twenty days not by the 
 mother, but by a nurse. In the absence of the nurse, the 
 
294 Rickets 
 
 child should have honey and goat's milk for this period. So 
 long did this superstition persist, as to the supposed danger 
 of leaving the child the free play of its limbs and the necessity 
 of swaddling the infant effectively with bandages, that it was 
 not till that remarkable man Jean Jacques Rousseau 
 inveighed against this practice in the year 1762 that the 
 custom was first seriously attacked. 
 
 Like Voltaire, Rousseau was immensely interested in 
 medical and physiological subjects and wrote much on 
 them. Both these great writers collected material from far 
 and wide and, unlike the majority of physicians of even that 
 late period, they had entirely thrown off the trammels of 
 ancient theory and tradition. Their deductions founded on 
 a nice discrimination of information garnered from all 
 sources, with a shrewd observation of human behaviour, 
 led them to champion explanations which have stood the 
 test of time and showed them to be original thinkers far in 
 advance of their day. 
 
 In England swaddling was never a common custom, but 
 elsewhere throughout Europe the practice was very prevalent. 
 In a passage in " Emile," * pregnant with sound physio- 
 logy, Rousseau states : " The child has hardly left the 
 mother's womb, it has hardly begun to move and stretch its 
 limbs, when it is deprived of its freedom. It is wrapped in 
 swaddling bands, laid down with its head fixed, its legs 
 stretched out, and its arms by its sides ; it is bound round 
 with linen and bandages of all sorts so that it cannot move. 
 It is fortunate if it has room to breathe, and it is laid on its 
 side so that water which should flow from its mouth can 
 escape, for it is not free to turn its head on one side for this 
 purpose. The new-bom child requires to stir and stretch 
 his limbs to free them from the stiffness resulting from being 
 curled up so long. His limbs are stretched indeed, but he 
 is not allowed to move them. . . . Thus the internal 
 impulses which should lead to growth find an insurmountable 
 obstacle in the way of the necessary movements. The child 
 
 * " Emile ou De I'Education," par J. J. Rousseau, Citoyen de Geneve, 
 Amsterdam, 1762. 
 
Ancient Medicine and Rickets 295 
 
 exhausts his strength in vain struggles, or he gains strength 
 very slowly. He was freer and less constrained in the 
 womb ; he has gained nothing by birth. The inaction, the 
 constraint to which the child's limbs are subjected can only 
 check the circulation of the blood humours ; it can only 
 hinder the child's growth in size and strength, and injure its 
 constitution. When these absurd precautions are absent, 
 all the men are tall, strong, and well-made. When children 
 are swaddled, the country swarms with the hump-backed, 
 the lame, the bow-legged, the rickety, and every kind of 
 deformity. In our fear lest the body should become 
 deformed by free movement, we hasten to deform it by 
 putting it in a press." 
 
 It is not probable that constraining the child's limbs 
 would ever in itself produce rickets, as Rousseau suggests, 
 but there can be no doubt of its influence in preventing and 
 retarding the proper growth of the young infant. Where 
 the conditions conducive to rickets prevail, it would un- 
 doubtedly render the infant more liable to the disease and 
 would seriously aggravate the attack. 
 
 It is worthy of note that in early childhood, when growth 
 is taking place rapidly and there is an employment of energy 
 demanding constant repair, that the assimilative processes 
 are not easily over-taxed. The appetite is large and, pro- 
 vided the food is wholesome, the system easily rids itself of 
 excess. Most of the maladies which affect infancy are not 
 so much diseases in themselves as a failure in the processes 
 of growth and development, and in rickets the disease arises 
 in response to gross errors in the environment. Gastro- 
 intestinal infections are not common in breast-fed infants, 
 nor are the acute eruptive fevers. Characteristic diseases 
 of infancy are such conditions as marasmus and rickets. 
 
 In later life, on the other hand, there tends to be a failure 
 of the system, not in the process of assimilation, but in that 
 of excretion — ^in the getting rid of the waste products which 
 have accumulated as the result of the body metabolism. 
 Gout, errors in the renal secretion, failure in the functions 
 of the liver, are apt to occur. 
 
296 Rickets 
 
 It is a striking fact that ancient literature does not deal 
 with the diseases of infancy and early childhood as we now 
 know them, but concerns itself mainly with the diseases of 
 adult life and old age. The probability is, that in the best 
 periods of the Greek and Roman civilisation, with simpler 
 conditions, abundant food supply and an advantageous 
 cUmate, disease in infancy was not so prevalent as it is 
 now. The ancients were acute observers, for the whole of 
 their art depended on obseirvation, rather than on dissection 
 and experiment, and had such diseases been prevalent they 
 must have attracted their attention. 
 
 At no time in the history of the world has hygiene 
 reached so high a level as it did during the best periods 
 of the Greek and Roman civilisations. In Greece espe- 
 cially the care of the infant was begun, as it ought to be, 
 from the earliest period of the mother's life. The diet, 
 daily exercise and general physical culture of the girl, were 
 regulated with a view to fitting her for the healthy exercise 
 of her maternal functions. The greatest care was devoted 
 to the expectant mother. Her diet was prescribed according 
 to the dictates of experience, proper exercise was entailed, 
 and she was surrounded with comfort and elegance. Care 
 was taken to avoid anything which could, through the 
 mother, impress the infant unfavourably. From early 
 childhood , to manhood the children were systematically 
 trained in daily exercises under experienced teachers. Much 
 attention was paid to the hair and the hygiene of the skin. 
 The great offices of State were concerned with important 
 matters of hygiene, such as town planning and the proper 
 building of houses and streets to get the maximum benefit 
 from the sun. The supply of wholesome water and the 
 general principles of dietetics engaged the earnest thought 
 of the government.* It is usual to regard ancient states as 
 ideal forms of existence, when usually they were quite the 
 reverse. But it is true that in Greece the summit of physical 
 
 * " The Hygienic Idea and its Manipulations in World History," by 
 Professor Karl Sudhoff, University of Leipzig, " Annals of Medical History," 
 Vol. I., No. 2, Summer, 1917. 
 
Ancient Medicine and Rickets 297 
 
 excellence was attained and the virility and powers of resist- 
 ance of the whole nation were enonnously enhanced. Com- 
 pared with the attainments of Greece and Rome, the extolled 
 cult hygiene of the Egyptians, Babylonians, and even of the 
 Jews, falls very far behind. 
 
 The general idea that ancient races belonging to such 
 civilisations as that of Babylon and of Egypt lived a long 
 life of leisured ease and measured toil is far from the truth. 
 In an extensive examination of bodies from ancient Nubia 
 and Egypt the somewhat surprising result was obtained that 
 osteo-arthritis, in all its various stages, from lipping of the 
 articular edges of the bones to complete anchylosis of the 
 spine and of the other joints, was prevalent to a degree 
 unknown in the present day.* The disease was of an exceed- 
 ingly severe type and affected the joints at an early age, 
 even in the third decade. Tubercle, syphilis, and rickets, 
 are all diseases which tend to leave abundant traces of their 
 presence in the skeleton. In some six thousand bodies Dr. 
 Wood Jones found no traces of these diseases, and in his 
 opinion these three pathological factors, which are so 
 terribly prevalent to-day, were almost unknown in ancient 
 Nubia and Egypt from Predjmastic times to the first few 
 centuries after Christ. No evidence of malignant disease 
 was found, and they were wonderfully free from sepsis and 
 practically exempt from early decay of the teeth. Wood 
 Jones also found, what has been noted in other surveys, that 
 the proportion of bodies of young persons found was very 
 much smaller than would be expected from the relative rate 
 of incidence fovmd at the present day in adult and infantile 
 mortaUty. Such evidence must be received with caution, 
 because there may be other explanations than a small death 
 rate for the relatively small proportion of young bodies. The 
 bodies of young children tend to be less enduring than 
 mature bodies, and possibly the same amount of care was 
 not expended in their preservation. Taking these and 
 
 * " The Archaeological Survey of Nubia," Report for 1907-1908, 
 Vol. II., by G. Elliot Smith and F. Wood Jones, Cairo, 1910. " General 
 Pathology (including Diseases of the Teeth)," by F. Wood Jones. 
 
298 Rickets 
 
 other facts into account, however. Wood Jones beUeves that 
 this disproportion represents a true index of mortality in 
 these ancient times, and he suggests that the findings show 
 that the death rate of young persons was less than a fifth of 
 what it is in Egypt to-day. 
 
 If this is accurate, the facts are suggestive and tend to 
 confirm the opinion aheady expressed that the infants of 
 races Hving a free and primitive Ufe, are not subject to many 
 of the morbid conditions which accompany a state of civiU- 
 sation. The conditions tell in favour of the young child, 
 and diseases of nutrition and growth are less common, but, 
 in the adult, the severity of the conditions has a prejudicial 
 effect and conduces to the early onset of diseases, such as 
 chronic arthritis and atheroma, and tends to shorten life- 
 Mr. Elhot Smith strikes a note of caution as regards the 
 reputed absence of rickets in these ancient cemeteries, and 
 beUeves that many bones exhibit distortions difficult to 
 explain except through the medium of rickets. " It is 
 common," he says, " to find pecuUar, though sHght, bend- 
 ing of all the long bones. One naturally thinks of rickets 
 as the causal agent, and it is quite possible that this sugges- 
 tion may ultimately be justified ; the reason for hesitation 
 in adopting such a view is that clear, unmistakable evidence 
 of rickets has not been found in human bones in any ceme- 
 tery in Egypt or Nubia." Later, however, after making 
 due allowance for possible errors, the same observer writes 
 that " he is extremely doubtful whether rickets ever really 
 occurred in ancient Egypt," and he considers that " Ruffer, 
 not being aware of the extent to which the perfectly normal 
 femur can be curved, imagined he had found rickets in 
 ancient remains from the Soudan." * It is possibly not 
 justifiable to say that rickets, tubercle and syphilis did not 
 exist, as the result of the examination of these six thousand 
 bodies, but it is certainly justifiable to say that they were 
 far more rare than they are to-day. 
 
 In Europe, north of the Alps, the same opportunities have 
 
 * " Introductory Historical Survey to a Study of Social and Economic 
 Factors in the Causation of Rickets," by Leonard Findlay, London, igi8. 
 
Ancient Medicine and Rickets 299 
 
 not existed for the examination of old-world bodies. In 
 bones from the shores of the Baltic Sea, and in primitive 
 German skeletons, Virchow made his well-known observa- 
 tions on cave-gout (Hohlengicht), a condition which affected 
 both man and beast. Osteo-arthritis was found to be 
 exceedingly prevalent. 
 
 In the crypt under the church at Hythe, near Folkestone, 
 as will be more fully noted later, lie the bones of some four 
 thousand people, in an excellent state of preservation, dating 
 probably from the thirteenth to the sixteenth centiuies. 
 Examples of osteo-arthritis of a severe type are very common 
 and these peoples must have suffered greatly from the 
 condition. 
 
 No diet could well be more varied than amongst these 
 various races living along the banks of the Nile, the shores 
 of the Baltic Sea and the south coast of England. One 
 factor was common to all, namely, that the life of the people 
 was largely spent in excessively damp surroundings. These 
 were all sparse populations and their lives must have been 
 associated with great hardships. It is interesting to note 
 that in all these cases with this exceedingly extensive bone 
 disease, rickets is practically an unknown factor, and, 
 indeed, so far as the evidence of the teeth, jaws, skull and 
 long bones is concerned, it is directly against the existence 
 of the disease to any notable extent at any of these periods, 
 if it existed at all. 
 
 Celsus, known as the Roman Hippocrates, lived probably 
 in the reigns of Augustus and Tiberius at the beginning of 
 our era. He wrote eight books on medicine, besides trea- 
 tises on agriculture, rhetoric and military affairs. He deals 
 with caries of bone, but there is no hint in his work of any 
 rachitic condition. He makes the acute observation, which 
 accords with common experience, that in the tender foetus 
 no fat is found and in the mature foetus there is but little 
 fat present. It has been suggested by supporters of the 
 vitamin theory of the origin of rickets that the new-bom 
 infant is a store-house of fat and that the reason why such 
 a disease as rickets does not develop during the first few 
 
300 Rickets 
 
 months is that the infant is living on the store of fat and 
 associated vitamins laid up during intra-uterine Ufe. 
 
 There is an error of observation in this suggestion, which 
 is entirely contrary to common experience. In the first 
 few days after birth, after the free discharge of meconium 
 and urine, the child loses weight and the skin tends to be 
 loose and wrinkled, giving the appearance of old age so 
 commonly seen in the young infant. The skin can be picked 
 up in folds and contains but little subcutaneous fat. The 
 first milk of the mother after birth, the colostrum, has a 
 high fat content, but this is of value, not so much as a 
 nutrient, as for laxative purposes. The fat content of the 
 faeces of the infant is always high, ranging from 10 to 20 per 
 cent., while during the first week it is as high as 40 or 50 per 
 cent. After the colostrum has passed the mother's milk 
 tends to be thin and watery, and later on assumes its full 
 fat value. Not tiU some weeks or months after birth does 
 the child who is well nursed become fat. It is a matter of 
 every-day knowledge in practice, that in children subjected 
 to conditions likely to produce rickets, the disease fre- 
 quently first reveals itself as an estabhshed disease at the 
 same time that the child develops abundant subcutaneous 
 fat, and has the external appearance of looking plump and 
 robust. It is probably not till later, when delay in teething, 
 walking and speech are observed, that the mother seeks 
 advice and the child is found to be the subject of well- 
 marked rickets. 
 
 Another error in the above observation is contained in the 
 statement, conmionly made, that rickets does not develop 
 until some months after birth. The rachitic process, as a 
 rule, begins immediately after birth, and by the sixth or 
 eighth month the disease has made considerable progress, 
 and has already inhibited and perverted the process of 
 growth, so that pathological changes of a permanent nature 
 result in various tissues of the body. 
 
CHAPTER XXI 
 
 Some Parliamentary and Other Records and the Liter- 
 ature of Rickets following^ the Publication of 
 Glisson's Work to the close of the Eig^hteenth 
 Century 
 
 It has already been noted that rickets was first described as 
 a cause of death in the table of casualties in the Bills of 
 MortaUty for London in 1634. These form an interesting 
 record of the health of the nation and of the incidence of 
 disease in the seventeenth century, and not much use has 
 been made of the valuable and suggestive material they 
 contain. In his " Reflections on the Weekly Bills of Mor- 
 tality for the Cities of London and Westminster and the 
 Places adjacent," Capt. John Graunt brings forward many 
 interesting facts. The following list is selected from the 
 table of casualties in the weekly bills * and for the purpose 
 of comparison the causes of death have been placed so as to 
 show the relative increase or decrease in the number of deaths 
 resulting from various allied conditions : — 
 
 Causes of Death in the Cities of London and Westminster and 
 the Places adjacent for the Years 1629 — 1658. 
 
 Rickets. 
 
 Liver-grown 
 
 Spleen and 
 
 Rickets. 
 
 Convul- 
 sions. 
 
 Teeth and 
 Worms. 
 
 Consump- 
 tion and 
 Cough. 
 
 1629-1632 
 1633-1636 
 1647-1650 
 1651-1654 
 1655-1658 
 
 o 
 
 "3 
 
 780 
 
 i,igo 
 
 1.598 
 
 392 
 356 
 213 
 269 
 191 
 
 498 
 
 1.734 
 2,198 
 2,656 
 3.377 
 
 1-751 
 2,632 
 2,502 
 3.436 
 3.915 
 
 5.157 
 8,266 
 
 8,999 
 
 9,194 
 
 12,157 
 
 Several interesting features arise from a consideration 
 
 of these tables. The number of deaths from rickets rises 
 
 steadily, especially towards the beginning of the second half 
 
 of the century. This is probably partly due to more accurate 
 
 * " National and Political Observations on the Bills of Mortality," by 
 Captain John Graunt, F.R.S., reprinted from the sixth edition in 1676. 
 
 301 
 
302 Rickets 
 
 diagnosis of the condition which obtained in London as the 
 result of the pubUcation of Glisson's book. This is borne 
 out by the fact that there is a co-existing diminution in the 
 indefinite morbid state placed under the single heading of 
 " Liver-grown Spleen and Rickets." The increase in the 
 number of deaths from convulsions is very notable, from 
 498 for the four years from 1629-1632, to 3,377 for the four 
 years from 1655-1658. There is also an increase in the 
 deaths from Teeth and Worms from 1751 to 3,915 for the 
 corresponding periods. These are both conditions intimately 
 associated with rickets, and, taken in conjunction with the 
 increase in the number of cases actually listed under that 
 disease, show that there was a very remarkable increase in 
 the disease in London during the years 1634^-1658. 
 
 The large number of deaths directly due to rickets in the 
 four years from 1655-1658 is evidence of the severity of the 
 type of disease which occurred at that time. Rickets is a 
 malady which, in itself, seldom causes death at the present 
 day, and this large mortality bears out the description of the 
 disease as given by contemporary writers ; one and aU 
 describe it as a serious malady, inimical not only to the 
 health but to the very life of the sufferer. If the first four 
 columns are added together for the period of four years from 
 1655-1658 over nine thousand deaths are recorded due either 
 directly to rickets or to conditions associated with it. The 
 growth in the mortality from consumption and cough is also 
 notable, a disease which, like rickets, increases in frequency 
 and severity in direct relation to the degree of over-crowding 
 and defective housing. 
 
 In the reign of Queen Elizabeth a proclamation of 1580 
 was designed to check the irregular growth of London, 
 and the placing of mean houses anyhow and any^vhere. 
 This proclamation, dated at Nonsuch on July 7th of that 
 year, sets forth that great inconveniences having arisen 
 from the vast congregations of people in London, and 
 greater being likely to follow — namely, want of victuals, 
 danger of plagues, and other injuries to health — she orders 
 that no further buildings shall be erected, by any class of 
 
Some Parliamentary and other Records 303 
 
 people, within the limits of the said city, or within three 
 miles from any of its gates ; that not more than one family 
 shall live in one house, and that such families shall not 
 take inmates. No idea of the value of fresh air and open 
 spaces occurred to the Legislature, but every now and then 
 the dangers of over-crowding were brought home by severe 
 outbreaks of plague or other epidemic disease, and not 
 infrequently householders were indicted on the ground of 
 over-crowding. Over-crowding which was the rule during 
 Queen Elizabeth's time seems to have grown worse under the 
 Stuarts, and James I. had scarcely come to the throne when 
 he ordered all such houses as had been erected contrary to 
 Queen Elizabeth's proclamation, to be pulled down and 
 demolished. Cromwell went to the extreme measure of 
 ordering a fine of one year's rent against any offender who 
 had erected a house having less than four acres of land 
 attached to it, and of one hundred pounds against any one 
 who had erected a house without land. Many such firm 
 edicts were promulgated to check the irregular growth of 
 London, but as no provision was made for its regular growth, 
 no one took any notice of any of them. 
 
 The failure of legislation in this respect was largely 
 due to the fact that it was quite unintelligent. Fear, 
 and not sound hygiene, was at the bottom of all these 
 Acts and proclamations to prevent the growth of London. 
 To show how little Parliament appreciated the rudiments 
 of healthy living the notorious window tax was introduced 
 on March 25th, 1696. At first it was levied only on houses 
 with ten windows and upwards, but in the reign of George IV., 
 1746, the tax was levied on the several windows of a house. 
 This naturally resulted in the building in of windows by 
 stone, brick, or lath and plaster, for nothing less would 
 satisfy the Act. An Act more directly against public policy 
 could hardly be imagined, and yet it was not till 1803 that 
 the tax was abolished. 
 
 Fortunately the present century has seen the adoption 
 of daylight saving by the passage of the Summer Time Act, 
 1916, the first clause of which runs : " During the prescribed 
 
304 Rickets 
 
 period in each year in which this Act is in force the time for 
 general purposes in Great Britain shall be one hour in 
 advance of Greenwich Mean Time." An exquisitely simple 
 provision considering the magnitude of the changes it 
 involves. The advantages gained by this extra hour of 
 daylight in the best months of the year are of the greatest 
 service to the community and the Act is a health-giving 
 measure to the children and to the infants of the nation. It 
 must be remembered that in a cold, bleak, and damp climate 
 such as that of England, the rearing of a healthy infant is 
 ever an anxious problem and a matter of extreme difficulty. 
 Even under the most favourable social conditions it is not 
 easy to avoid the occurrence of rickets, and in the crowded 
 slums of our great industrial centres, where the infant 
 is confined during the winter months to a sunless and ill- 
 ventilated room or basement cellar, where there is no 
 provision for exercise and the child is constantly breathing 
 a vitiated atmosphere, the disease cannot be avoided. For 
 a long period of the year it is necessary for the mother or 
 nurse to keep watch for every available hour of sunshine. 
 Fresh air in the open is one of the crying needs of the young 
 infant, and the Summer Time Act, by extending the oppor- 
 tunity for such exercise in the open at a time of the year 
 when sunshine and a warmer air are available, is of the 
 greatest value. I know of no measure of equal importance 
 which is fraught with greater benefit to the community 
 and which entails fewer inconveniences than this simple 
 Act. 
 
 For a long time after the publication of GHsson's book in 
 1650 no very notable advance was made in the study of the 
 disease, largely due, as already stated, to the fullness and 
 completeness of the work. GHsson's publication became the 
 model for the ordinary inaugural thesis required for gradua- 
 tion, and in Edinburgh, Leyden, Vienna and elsewhere on the 
 Continent, these were produced in large numbers. Notably 
 in Edinburgh towards the close of the eighteenth century 
 many such theses were published indicating that much 
 interest was being taken in rickets at that period. 
 
Some Parliamentary and other Records 305 
 
 By the end of the eighteenth century a great mass of 
 literature had already grown up round the subject, as may 
 be seen from a study of de Plouquet's Digest of Medical Litera- 
 ture, published in 1809.* Most of these theses were naturally 
 short papers, usually devoid of original research, and were 
 frequently httle more than extracts from Glisson's work. 
 Their chief claim to interest is frequently their age and 
 period. There were, of course, notable exceptions. 
 
 John Mayow was such an exception. Mayow (1643- 
 1679) was educated at Oxford, and in 1660 was elected to a 
 fellowship of AU Sotds. He graduated in law, but made 
 medicine his profession, and in 1678 he was elected a Fellow 
 of the Royal Society. In 1668 he pubhshed at Oxford, 
 " Tractatus de Respiratione," and in 1669, " Tractatus de 
 Rachitide," both of which were afterwards pubhshed by the 
 University of Oxford in his now celebrated " Tractatus 
 Quinque," f in the year 1674. In this large treatise it is 
 remarkable how many important physiological discoveries 
 are contained. Mayow held advanced views on respira- 
 
 * " Literatura Medica Digesta sive Repertorium Medicinae Practicae 
 Chirurgiae atque rei obstetricas," Guilielmus Godofredus de Plouqnet 
 Tubingae, 1809. 
 
 Besides de Plouquet's " Medical Digest,'' the Index Catalogue of 
 the Library of the Surgeon-General's Office, United States Army, should 
 be consulted by those interested in the history of the disease ; the Royal 
 Society of Medicine, the College of Physicians, the College of Surgeons, 
 and especially the British Museum in London, are all rich in the early 
 literature of rickets. Besides the treatises dealt with in the text the 
 following are a few of the earlier works beloiiging to the seventeenth and 
 eighteenth centuries which I have been able to peruse and handle : — 
 Schoengast, Christoph. Andreas, " De Rachitide," Leipsic... 1668 
 Ersfeldius, Nicholas Wilhelmus, " De Rachitide," Helm- 
 
 stadii 1682 
 
 Vaux, Georgius, " De Rachitide," Lugdini Batavorum ... 1704 
 Wieseler, Casp. Joh., " De Rachitide," Helmstadii ... 1716 
 
 Buchner, J. Petri, " De Rachitide," Strassburg 1754 
 
 Nooth, Joannes Mervin, " De Rachitide," Edinburgh ... 1766 
 Bromfield, Wm., " Chirurgical Observations and Cases," 
 
 Vol. IL, pp. 25-41 1773 
 
 Nasmyth, Thomas, " De Rachitide," Edinburgh 1777 
 
 WatsonrSproule, Joannes, " De Rachitide," Edinburgh ... 17S7 
 Tmka de Krzowitz, Wencesla, " Historiae Rachitidis," 
 
 Vienna 1787 
 
 M. Pouteau, " CEuvres posthumes de," Tome Premier — 
 
 Cinquieme Memoire, Paris 1783 
 
 ■f " Tractatus quinque medico-physici, quorum primus agit de sal-nitro 
 et spiritu nitro-aero. Secundus de respiratione. Tertius de respiratione 
 foetus in utero. Quartus de motu musculari et spiritibus animalibus. 
 Ultimus de rachitide." Joannes Mayow, Oxonii, 1674. 
 
 X 
 
3o6 Rickets 
 
 tion^ and he gave a wonderfully accurate anatomical descrip- 
 tion of its mechanism. Under the name of spiritus igneo- 
 aereus or sometimes nitro-aereus he discovered the existence 
 of oxygen, and proved by experiment that it was required 
 to maintain the light of a candle, and was also necessary for 
 the maintenance of life by respiration. His work was dis- 
 regarded and it remained for Priestly and Lavoisier to make 
 the same discovery one hundred years later. Mayow was 
 only thirty-six years of age when he died, and had he lived 
 the normal span, there is but little doubt that he would have 
 short-circuited the discovery of oxygen by a century. 
 
 In 1790 Thomas Beddows rediscovered Mayow's work,* 
 and places his name alongside those of Sir Francis Bacon 
 and Sir Isaac Newton. Writing in 1908, Francis Gotch f 
 describes Mayow as one of the greatest scientific men of the 
 seventeenth, or, indeed, of any century. In 1685 an 
 English translation of Mayow's " de rachitide " was pub- 
 lished at Oxford.! In the preface, written by Mayow 
 himself, he states : " The renowned Glisson is the only man 
 (as far as I know) who hath written anything touching 
 rickets, which may seem to be very strange, since a disease 
 for the most part doth scarcely spread so much as the habit 
 of writing concerning it." Mayow practised in Bath during 
 the summer, where he acquired a considerable practice, and 
 he agrees with Glisson that the disease had its first rise in 
 the western parts of England a,bove forty years ago. The 
 age of invasion of the disease is, he states, from six to twenty- 
 four months. Unlike Glisson, he does not consider rickets 
 a disease of the blood, because if it were he would have 
 expected all parts would be affected alike. He believes it 
 proceeds from an obstruction of the spinal marrow. He 
 accounts for the bending of the bones in a somewhat quaint 
 fashion by supposing that while the muscles and nerves do 
 not grow, as the result of the interference with the spinal 
 
 * " Chemical Experiments and Opinions extracted from a Work 
 published in the Last Century," Thomas Beddows, 1790. 
 
 t " Two Oxford Physiologists, Richard Lower and John Mayow," by 
 Francis Gotch, Oxford, 1908. 
 
 { " A Tract of the Disease Rha,chitis, commonly called the Rickets," 
 translated into English by William Sury, Oxford, 1685. 
 
Some Parliamentary and other Records 307 
 
 marrow, the bones continue to grow at the ordinary rate. 
 The bone being thus held down at each end, becomes bent 
 like a bow of which the contracted muscles and nerves form 
 the cord. The article on rickets is the least important of 
 the five theses pubUshed by Mayow. His work on respira- 
 tion was based on experiment, and his conclusions had gone 
 far ahead of what he could yet prove, though their accuracy 
 was established by later discovery. Mayow was only 
 twenty-six years of age when he wrote " De Rachitide," 
 and cannot have had much experience of practice. He 
 followed in the main Glisson's work, and it cannot be claimed 
 that his deductions added anything important to our know- 
 ledge of this disease. 
 
 In the early part of the eighteenth century, Boerhaave, in 
 his " Aphorisms," * speaks of rickets. He lent the weight 
 of his great authority to GUsson's view that it was a new 
 disease, and thinks it arose about the middle of the sixteenth 
 century, originating in the inland parts of England, from 
 whence it spread throughout the kingdom and over the 
 northern part of Europe, where, he states, it is now a 
 very common disease. In his description of the causation, 
 signs and symptoms, he follows Glisson, and with him 
 believes that it is a disease of luxury rather than of 
 deprivation. It is best cured, he maintains, with a light, 
 dry, less fat diet. 
 
 In 1741 J. L. Petit f insisted on early weaning as a 
 cause of rickets. He gives in his treatise a good description 
 of the macroscopic appearances of the diseased bone, and 
 describes the rough inequalities that arise on the surface of 
 the bone, and the increase in volume of the orifices of the 
 blood-vessels. * 
 
 Levacher de la Feutrie | separated rickets from osteo- 
 malacia, affections which till then had been confused. 
 " One knows," he says, " that the soft and supple bones of 
 children which become curved from weakness differ consider- 
 
 * " Boerhaave' s Aphorisms concerning the Knowledge and Cure of 
 Diseases," translated from the last edition printed in Latin at Leyden in 
 i'7i5 by J. Delacosse, London, 1715. 
 
 t " Traits des maladies des os," J. L. Petit, Paris, 1741. 
 
 J " Traite du Rakitis," Levacher de la Feutrie, Paris, 1772. 
 
3 o8 Rickets 
 
 ably from the dense and brittle bones of the adult, which 
 bend as a result of softening." 
 
 Zeviani, an Italian writer of the eighteenth century, is 
 an authority whose work is frequently quoted.* His 
 treatise was first pubhshed at Verona in 1761. Zeviani 
 combats the view that rickets is a new disease, and believes 
 that it was known in ancient times, although he is not able 
 to support his behef . He does not consider rickets a common 
 disease in Italy, but states that it occurs in Lombardy and 
 Tuscany, regions where it is prevalent to this day. No 
 mention is made of the disease occurring in Naples. His 
 views as to the etiology of the disease are of interest in that 
 he was one of the earliest writers to suggest that an acid 
 circulating in the blood was the essential cause of the condi- 
 tion. This acid, he considers, is produced from acrid and 
 sour milk, but he gives no explanation of the formation 
 of any particular acid. Conditions in the parents such 
 as obesity predispose to the disease in his opinion, and 
 mental states such as worry, bad temper, etc., may con- 
 tribute, presumably through their effect on the milk of the 
 nursing mother. 
 
 Towards the close of the eighteenth century Antoine 
 Portal wrote an interesting monograph f in which he states 
 the disease is exceedingly common in Paris and the sur- 
 rounding country, affecting, he believed, one fifth part of 
 all children. He first stated a view, which has frequently 
 been brought forward since his time, that rickets is not a true 
 entity in itself, but is merely the end result of many diseases. 
 
 In accordance with this view he describes six varieties of 
 
 rickets : — 
 
 (1) the venereal ; 
 
 (2) the scrofulous ; 
 
 (3) the scorbutic ; 
 
 (4) that following eruptive disorders ; 
 
 (5) that accompanjdng or following intestinal lesions ; 
 
 (6) the rheumatic or gouty variety. 
 
 * " Delia Cura De' Bambini attacati Delia Rachitide Trattato," del 
 Dottor Giovanni Verardi Zeviani, Napoli, 1775. 
 
 t " Observations sur la Nature et sur le Traitement du Rachitisme," 
 par Antoine Portal, Paris, 1797. 
 
Some Parliamentary and other Records 309 
 
 In consequence of this view he deals with such conditions 
 as caries of the spine, and tubercular lesions of the abdomen 
 and chest as if they were part of the disease. In the treat- 
 ment of the disease he advocates the use of mercury for the 
 venereal variety, and he also mentions the use of phosphorus. 
 Change to a pure and dry air at an altitude he considers of 
 value. 
 
 In the seventeenth century there is but little record of 
 the life of the great mass of the population except such as 
 can be collected from poor law and prison records. But 
 from the private correspondence of the wealthier classes, 
 which has, fortunately, every now and then been carefully 
 preserved, valuable information can frequently be culled. 
 The lower classes had but httle chance of correspond- 
 ing, even if they had had the ability or the incUnation, 
 and most of these letters belong to the higher classes of 
 society. When a servant writes, and there is much ex- 
 cellent writing by trusted servants, the letter is usually 
 concerned with the affairs of the family to which he or she 
 was attached. 
 
 One point is very striking in this correspondence, namely, 
 the high mortality which occurred among infants and 
 young children even in wealthy and high-born families, 
 where the conditions must have been as favourable as 
 they could be expected to be ansrwhere. Not lack of 
 food and attention, but an overweening anxiety and 
 care on the part of the parents was the usual fault in 
 the up-bringing, for life was known to be precarious 
 in children of tender age. The very precautions taken 
 to guard the infant from harm were unhappily the very 
 causes which contributed to much ill-health and a high 
 death rate. 
 
 Another factor of importance was the early age at which 
 marriages took place in noble famihes. The marriage was 
 a matter of arrangement by the parents, and it was quite a 
 common thing for a child to be married at the age of thirteen. 
 Usually in such a case the young wife continued her educa- 
 tion for a year or two while her husband went to Oxford or 
 
310 Rickets 
 
 travelled abroad.* Even so the child became a wife and a 
 mother at a very early age, and both mother and child were 
 exposed to an increased risk during pregnancy and parturi- 
 tion, as the result of the parent's immaturity. If the child 
 were safely delivered the chances of the mother being able 
 to suckle her infant satisfactorily were greatly diminished. 
 
 It must be remembered that artificial feeding and the feed- 
 ing bottle are of quite recent origin. The feeding bottle 
 was not in common use till well on in the nineteenth century. 
 In the seventeenth century the difficulties of the nursery, 
 even in the wealthiest famihes, were enormously greater 
 than they now are. If the mother's milk failed, no other 
 course was open but to place the child with a wet nurse. 
 From the earliest times in medical writings, instructions 
 were given as to the selection of a suitable foster mother. 
 Galen deals with the subject, and Soranus of Ephesus is very 
 explicit in his directions in his work on gynaecology. In the 
 numerous works which were written for the instruction of 
 midwives, and of the general public, from the times of 
 Thomas Phaire, who wrote the first English nursing manual 
 in 1551, t the choice of a suitable wet nurse is always given 
 an important place. As a result of the demand for wet 
 nurses large numbers of young women became mothers of 
 illegitimate children, who were immediately placed in baby 
 farms while the mothers nursed more fortunate infants. 
 The mortality in these baby farms was enormous. Wet 
 nursing, and its concomitant, baby farming, were great evils 
 in the sixteenth and seventeenth centuries. Cow's milk, 
 as we have already noted, was not used because of the 
 insanitary conditions in which cows were kept. Frequently 
 in London they were kept in foul cellars, and it was found 
 that the infantile mortality from intestinal infections where 
 milk was used was very excessive, and Phaire expressly 
 cautions against its use. 
 
 • " Home Life Under the Stuarts, 1603-1649," by Elizabeth Godfrey, 
 London, 1903. 
 
 t " The regiment of life, whereunto is added a treatise of the pestilence, 
 with the Booke of Children," newly corrected and enlarged by Thomas 
 Phaire, London, 1553. 
 
Some Parliamentary and other Records 311 
 
 The class of mother who is willing to undertake the suck- 
 ling of another child for monetary gain is not a desirable one. 
 Luigi Tansillo, an Italian writer of the sixteenth century, in 
 his poem " The Nurse " * points out the folly of being — 
 
 " Hopeful that pity can by her be shown 
 Who for another's offspring quits her own." 
 
 But there was no alternative between breast-feeding and 
 spoon-feeding from the pap-boat or porringer, which formed 
 so important an article in the nursery of those early times. 
 Many of these in wood, pewter and silver, are preserved in 
 museums to-day. 
 
 The memoirs of the Verney family give many interest- 
 ing glimpses into the life of the times of the Common- 
 wealth and later. Writing on August 10th, 1647, three 
 years before Glisson's book on rickets was published, 
 Mary Verney writes from England to her husband. Sir Ralph 
 Verney, who was in exile in France in the Royalist cause, f 
 " I must give thee some account of our own babyes heare. 
 For Jack his legges are most miserable, crooked as ever I 
 saw any child's, and yett thank God he goes very strongly, 
 arid is very strayte in his body as any child can be ; and is 
 a very fine child all but his legges, and truly I think would be 
 much finer if we had him in ordering, for they lett him eate 
 anything he hath a mind toe, and he keeps a very ill diett ; 
 he hath an imperfection in his speech, and of all things he 
 hates his booke, truly 'tis time you had him with you for he 
 learns nothing heare. You would be much pleased with his 
 company, for he is a very ready witted child and is very good 
 of company, and is so fond of the name of his father and 
 mother." A most excellent and lively picture of the rickety 
 cMd, direct and plain, such as could not be extracted from 
 tl^ whole of the far-fetched allusions which can be culled 
 f^m Hippocrates or Galen, or, indeed, from any writer till 
 ofe comes to Europe about the seventeenth century. Jack 
 V«riey at the time this letter was written was nearly seven 
 
 % " The Nurse," a poem translated from the ItaUan of Luigi Tansillo by 
 Wiwam Roscoe, Liverpool, 1798. 
 
 fl," Memoirs of the Verney Family during the Civil War," by Frances 
 GartUenope Verney, 2 vols., London, 1892. 
 
3 12 Rickets 
 
 years of age, and was evidently, now that he had forsaken 
 the nursery, with all its pampering and its debihtating 
 influences, taking his own path in life, and was, in conse- 
 quence, in spite of the continuance of his very ill diet, 
 developing into a strong sturdy boy with that touch of self- 
 will so commonly seen in the older rickety child. 
 
 AH the Vemey children were delicate, evidently from 
 the same cause, and about this time one of two daughters 
 who were sharing the father's exile died at Blois. Nor were 
 his troubles then at an end. Within two months of the date 
 of Mary Verney's letter, on October 3rd, 1647, Dr. Wm. 
 Denton, physician to Charles I., writes to inform the afflicted 
 Sir Ralph Verney of the death of his infant boy in England. 
 " Your own wofull experiences," he writes, " have prepared 
 you for any disorders that any of Job's comforters can 
 present to you, God hath taken away what He gave, I meane 
 your youngest son by convulsion fitts." This child was only 
 a few months old. 
 
 John Evelyn in his diary under the date, January 27th, 
 1657-1658,* records : " After six fits of a quartan ague, with 
 which it pleased God to visit him, died my dear son Richard, 
 to our inexpressible grief and affliction, five years and three 
 days only, but at that tender age a prodigy for wit and 
 understanding." He proceeds with a father's fondness to 
 recount his son's attainments, which were indeed of a mar- 
 vellous order, including a knowledge of Latin and Greek. In 
 the same entry he states : " In my opinion, he was suffocated 
 by the women and maids that attended him, and covered him 
 too hot with blankets as he lay in a cradle, near an excessive 
 hot fire in a close room. I suffered him to be opened, when 
 they found that he was what is vulgarly called liver-grown." 
 The next entry in Evelyn's diary, February 15th, of the same 
 year, records the death of his infant son, aged eight months. 
 " The afflicting hand of God being still upon us," he states, 
 " it pleased Him also to take away from us this morning my 
 youngest son, George, now seven weeks languishing at nurse, 
 
 * " The Diary of John Evelyn," with an Introduction and notes by 
 Austin Dobson, 3 vols., London, 1906, Vol. II., p. 127. 
 
Some Parliamentary and other Records 313 
 
 breeding teeth and ending in a dropsy." There was no 
 want of care bestowed in the rearing of these children, 
 indeed, as Evel5m shrewdly suggests, the very excess of 
 anxiety produced by the high mortality in young children 
 defeated its own ends and provoked the very results it meant 
 to avoid. The ordinary cradle of the period, familiar to all 
 up to quite recent times, was a massive wooden structure on 
 rockers. This was piled up with pillows and blankets, and 
 on the shghtest approach of cold, was placed near a fire. 
 Windows were made, not for ventilation, but to exclude 
 fresh air, and were kept constantly closed. All the condi- 
 tions, viz., over-rich feeding associated with defective 
 hygiene, which Ghsson presents as contributing to the 
 disease, were present in wealthy families at this period, and 
 it is among these children that Glisson found the disease 
 most prevalent and assuming the severest type. Artificial 
 foods were, of course, at this time quite unknown. 
 
 In " Psedotrophia," a sixteenth century poem of much 
 interest, by Scevole de Sainte Marthe (1536-1623), which 
 resembles the writing of the Italian poet TansiUo, much 
 excellent advice is given on the rearing of infants. He 
 agrees with John Evelyn that much harm is done by excessive 
 care wrongly bestowed on the young infant : — 
 " Misguided fondness makes our nurses err 
 By heating infants, and excluding air 
 Hence are their limbs relax'd, their spirits weak, 
 Hence oft the thread of life itself will break."* 
 
 The death of the son of Francis the Second Duke of 
 Brittany, described by him, resembles that of Evelyn's son 
 Richard : — 
 
 " But, while the parents, bUnded by their love, 
 Who best could rear the child together strove, 
 While, thus misgiiided, sedulous they try 
 From cold to save him, and a wintry sky, 
 The hapless infant, kept in constant heat, 
 Deny'd fresh air, and still immers'd in sweat, 
 Soon breath'd his last ; and they the death lament, 
 Brought on by what, they hop'd, would fate prevent." 
 
 * " Paedotrophia, or the Art of Nursing and Rearing Children," a poem 
 in three books, translated from the Latin of Scevole de St. Marthe by H. W. 
 Tytler, M.D., 1797. Book II. 
 
314 Rickets 
 
 Both these sixteenth century poets, de Sainte Marthe in 
 France, and Tansillo in Italy, were serious-minded reformers, 
 who by their poetry attempted to instruct mothers in their 
 duty to their offspring. 
 
 The disease to-day is one which shows a definite tendency 
 to affect chiefly the lower classes of society. Among all 
 classes in the seventeenth century in England rickets was 
 spreading rapidly to the great consternation of the general 
 public. More especially the homes of the wealthy were 
 invaded and the most severe cases were found there. In 
 those ruder times it was only the child of the wealthy who 
 could be effectually screened according to the ideas then 
 prevalent. The fear of miasmatic conditions led to the 
 rigorous exclusion of fresh air from the young infant, and the 
 pampering and coddling of the child in over-heated and badly 
 ventilated nurseries. The feeding was good and the infant 
 was suckled at the breast either by the mother or by a foster 
 mother. 
 
 Isaac Walton lived at the same period as GHsson. Even 
 in his well-conducted household in Chancery Lane, Walton 
 — the gentlest of men, assiduous and prosperous in his 
 business — ^found it impossible to rear healthy children. He 
 was twice married. By his first marriage he had seven 
 children, all of whom died in infancy. Two of the children 
 of his second marriage, however, survived and lived to adult 
 years. In such a home there was no want of inteUigent care 
 in the feeding of the infant, but there was a complete 
 ignorance of the value of fresh air and good general hygienic 
 conditions in the rearing of young fife. Recurring attacks 
 of plague and other epidemic diseases had led to an excess of 
 care which defeated its own object. Such was a common 
 experience aU over England at this time in good-class homes. 
 
 Rickets, as with many diseases on their first appearance, 
 assumed a degree of severity which often led to a fatal issue. 
 In the course of the generations, however, the disease 
 became more attenuated, at the same time that it became 
 more diffuse and more widely spread throughout all classes. 
 It suggests the rapid elaboration of a defensive mechanism 
 
Some Parliamentary and other Records 315 
 
 which could be readily called into play to meet environmental 
 conditions which threatened the very continuity of the Hfe 
 of the community as a whole. 
 
 The feeding of the children of the poor, on the other hand, 
 was often very defective but the general conditions, if more 
 rigorous, were more wholesome for the developing child than 
 in the better class homes. It was not until the great in- 
 dustrial development took place, especially the development 
 of the cotton industries in Lancashire, that rickets became 
 essentially the disease of the common people and of slum 
 areas. 
 
 Writing in 1773, Dr. Fordyce makes the following com- 
 ment on rickets in London in his time. He states * : " I 
 speak within the bounds of truth when I assert that there 
 must be near 20,000 children in London and Westminster 
 and the suburbs ill at this moment of the hectic fever, 
 attended with tun-bellies, swelled wrists and ancles, or 
 crooked limbs, owing to the impure air which they breathe, 
 the improper food on which they live, or the improper 
 manner in which their fond parents or nurses rear them up : 
 for they live in hot bed chambers or nurseries, they are fed 
 even on meat before they have got their teeth, and what is, if 
 possible, still worse on biscuits not fermented, or buttered 
 rolls, or tough muf&ns floated in oiled butter, or calves feet 
 jelhes, or strong broths, yet more calculated to load all their 
 powers of digestion ; or are totally neglected." It is 
 interesting to note that rickets is still held to be a condition 
 associated with surfeit of food, especially of rich foods, 
 accompanied by a tendency to coddle the child in over- 
 heated, badly ventilated rooms and houses. 
 
 * " A New Inquiry into the Causes, Symptoms and Cure of Putrid 
 and inflammatory Fevers, yfiih. an Appendix on the Hectic Fever and on 
 the Ulcerated and Malignant Sore Throat," by W. Fordyce, M.D., London, 
 1773. P- 207- 
 
CHAPTER XXII 
 
 Economic Factors in Relation to Rickets from Early 
 Times to the Roman Occupation of Eng-Iand 
 
 Ancient literature is strikingly deficient in anything which 
 would suggest that the writers were familiar with rickets. 
 The very absence of allusion to so definite a disease is, as 
 already stated, valuable negative evidence that the disease 
 was not common, and probably hardly existed at all in those 
 times. Positive evidence bearing out the same fact is not 
 wanting. Rickets is rightly considered to be a general or 
 systemic condition, but the most marked signs of the disease 
 are due to the defective lapng down of calcium through- 
 out the body in the early stages of the development of the 
 young infant. In an enquiry into the economic conditions 
 under which ancient races lived, few more useful records 
 can be obtained than is found in the examination of the 
 skeleton, skull and teeth. In rickets the examination is of 
 special value, in that it is on this durable record that the 
 history of the disease is written. 
 
 In Egypt systematic examination of ancient burials on 
 a large scale shows, as we have already seen, that diseases 
 of a modem type were quite common. The rate of incidence 
 of various diseases, however, varied greatly from what occurs 
 at the present day. Thus developmental conditions and 
 errors of growth in the infant and young child were of 
 notably infrequent occurrence, while adult types of disease, 
 such as failures of ehmination, associated in some cases with 
 evidence of infection, such as pyorrhoea, were quite common. 
 These excavations in Egypt show that the commonalty 
 lived under conditions of great hardship as regards undue 
 toil and defective feeding. But, notwithstanding these 
 facts, rickets seems to have been a disease entirely unknown. 
 
 316 
 
Economic Factors 3^7 
 
 In examining a number of bones it would be misleading to 
 draw any direct inference from the absence of such charac- 
 teristic signs of rickets as the arching of the tibia at the 
 junction of its lower and middle thirds, or the bowing of the 
 femur, or the enlargement of the epiphyseal ends of the long 
 bones, or the beading of the ribs. In the long bones many 
 of these signs tend to disappear as adult life is approached. 
 The long bones straighten out and the swelhngs at their 
 epiphyseal ends rapidly diminish, but, as we have seen, certain 
 of the other bony signs, notably the thickening of the skull and 
 deformations of the bones of the face and of the chest and 
 pelvis, often remain remarkably persistent even into late 
 adult life. If, say, two thousand long bones were examined 
 and no rickety signs were found the evidence would be 
 fairly conclusive that the disease had not been present 
 amongst those people. But it would be unwise to lay much 
 stress on the absence of rickety signs from, say, one hundred 
 long bones without further confirmatory evidence. A much 
 more reliable criterion is found in the skull and especially in 
 the jaws and teeth. 
 
 As we have already seen, there is a marked tendency in 
 rickets to overgrowth of lymphoid tissues. Adenoids and 
 enlargement of the tonsils are very characteristic of the 
 rachitic state and are most commonly a direct result of it. 
 Mouth breathing, with all its evil consequences, is of fre- 
 quent occurrence. Besides the deformities of the jaws and 
 the irregularity of the teeth, two other dental conditions are 
 notably associated with the rachitic state, viz. : — 
 
 (1) a tendency to early decay which is exceedingly 
 
 common and widespread ; 
 
 (2) hypoplasia, or defective development of the 
 
 enamel, which is present in about twenty per cent. 
 
 of rickety subjects. 
 
 These changes have already been dealt with in previous 
 
 chapters. 
 
 Writing in 1672,* in the work already mentioned, " A 
 
 * " English Men of letters : Sir Thomas Browne," by Edmund Gosse, 
 London, 1905. 
 
3i8 Rickets 
 
 Letter to a Friend," and referring to the death of the intimate 
 friend, the occasion of the letter. Sir Thomas Browne 
 observes : "In the years of his childhood he had languished 
 under the disease of his country, the rickets ; after which, 
 notwithstanding, many have become strong and active 
 men ; but whether any have attained unto very great 
 years, the disease is scarce so old as to afford good observa- 
 tion. Whether the children of the English plantations be 
 subject unto the same infirmity, may be worth the observing. 
 Whether lameness and halting do still increase among the 
 inhabitants of Rovigno in Istria, I know not ; yet scarce 
 twenty years ago Monsieur du Loyr observed, that a third 
 part of the people halted : but too certain it is, that the 
 Rickets encreaseth among us." In another part of the same 
 work, Browne makes the shrewd observation : " The lS,gyp- 
 tian mummies that I have seen, have had their mouths 
 open, and somewhat gaping, which affordeth a good oppor- 
 tunity to view and observe their teeth, wherein it is not easy 
 to find any wanting or decayed : and therefore in Egypt 
 where one man practised but one operation, or the diseases 
 but of single parts, it must needs be a barren profession to 
 confine unto that of drawing of teeth, and little better than 
 to have been tooth drawer unto King P57rrhus, who had but 
 two in his head." 
 
 Caries of the teeth certainly existed among the ancient 
 Egyptians. The late Marc Armand Ruffer even makes a 
 statement, from an observation of twenty-four bodies dating 
 from about two thousand years ago, that the liability to 
 decay was much the same as it is now. The number of 
 bodies examined is small, and he notes that the third molar 
 is more often decayed than the first and second. To-day 
 it is the first molar which is most commonly decayed or 
 absent.* In nine Coptic bodies belonging to Antinoe in 
 Upper Egypt, dating from the fifth and sixth centuries of 
 our era, Ruffer found serious lesions of the teeth with evi- 
 dence of pyorrhoea alveolaris. In these studies Ruffer 
 
 * " On Osseous Lesions in Ancient Egypt," by Marc Annand Rufier 
 and Arnoldo Rietti, Journal of Pathology and Bacteriology, Vol. XVI., 
 1911-12. 
 
Economic Factors 319 
 
 showed the common occurrence of arthritis, spondyhtis 
 deformans, dental caries, raref5dng periodontitis, pyorrhoea 
 alveolaris, and, what is most surprising of all, well-marked 
 arterio-sclerosis, which was commonly present.* The asso- 
 ciation of pyorrhoea, arthritis and arterio-sclerosis suggests 
 the probability of some endemic infective condition affect- 
 ing the communities from which these bodies were drawn. 
 The suggestion that decay of the teeth was as common in 
 ancient Egypt as it is in England to-day is not supported 
 by other observers. The number of bodies observed by 
 Ruffer is too small, and the areas from which they were 
 drawn too localised to allow of general deductions. 
 
 Moodie believes that paries of the teeth is the rarest form 
 of pathology in ancient times, and that early races of man 
 have been singularly free from the disease, f 
 
 Turner and Bennett made some careful observations on 
 435 ancient Egyptian teeth belonging to about three 
 thousand years ago.J Unfortunately these were loose 
 teeth and were not in situ in the skull. These observers 
 point out the danger of mistaking post-mortem cavities 
 in the teeth for true caries, which Ruffer had evidently 
 done. It is noted that the jaws from which the teeth 
 came were well formed and the dental arches particularly 
 free from irregularity, and that the jaws were also free 
 from evidence of oral sepsis. 16* 78 per cent, of these 
 teeth showed evidence of caries. The part of the tooth 
 most commonly affected differed from to-day in so far 
 as it was not present at the abutment point, where 
 adjacent teeth touch, but was most commonly found at the 
 neck of the tooth (58 cases out of 70). In a smaller pro- 
 portion (12 out of 70) the decay affected the biting surface 
 of the tooth. Discussing the condition of decay in the 
 
 * " studies in Palseopathology in Egypt," by Marc Armand Ruffer, 
 ibid.. Vol. XVIII., 1913-14- 
 
 t " New Observations in Palseopathology, " by Roy L. Moodie, Ph.D., 
 Department of Anatomy, University of Illinois, Chicago. "Annals of 
 Medical History," New York, Vol. II., 1919, ;p. 241. 
 
 J " Some Specimens of Caries from Ancient Egyptian Teeth, about 
 3,000 Years ago," by J. S. Turner, F.R.C.S., L.D.S., and F. J. Bennett, 
 M.R.C.S., L.D.S. "Trans. Intemat. Cong. Med. 1913," London, 1914, 
 Sect, xvii., Stomatol., Part 2, 1-5. 
 
320 Rickets 
 
 teeth as compared with the present day, these observers 
 state that the comparison is overwhehningly in favour of 
 the ancient Egyptians. This is in accord with the experi- 
 ence of practically all observers. The cause of the better 
 condition of the teeth is attributed by these observers to the 
 fact that the people ate coarse cereals, and it is suggested 
 that the stagnation of coarse granules round the necks of 
 the teeth determined the decay to this site. The usual 
 explanation of decay is that it is due to the lodgment of 
 starchy and saccharine particles from the food, allowing of 
 the fermentation of these substances and the production of 
 acids which act as a solvent to the tooth. It is probable that 
 the cause lies much deeper, and is to be found in the failure 
 of the first defences of the teeth, that is in the actual laying 
 down of the enamel, and one of the commonest causes of 
 this failure is rickets. The bad state of the teeth seen in 
 our great cities, such as Glasgow, is not due to soft water, 
 nor, in the first instance at least, to want of attention to the 
 hygiene of the mouth, but is due to the extraordinary pre- 
 valence of rickets which interferes with the regular la5dng 
 down of the enamel. Another explanation of the decay in 
 the Egyptian teeth may be, as already suggested, that it 
 began as an infective condition affecting the gums, and this 
 may have determined the locality of the decay to the neck 
 of the tooth. In any case a large part of the immunity from 
 caries of the tooth among the ancient Egyptians, as com- 
 pared with the population in England to-day, is to be found 
 in the absence of rickets. In all these observations from 
 Turner and Bennett, and from RufEer, there is no sugges- 
 tion of rickets. Indeed the well-formed dental arches 
 and regularity of the teeth indicate that this disease did not 
 affect these people, though there were extensive signs of 
 other bone affections such as osteo-arthritis. 
 
 So common is the tendency to early decay of the teeth 
 and malformation of the dental arches and hard palate in 
 the rachitic state, that if in a large series of crania it is 
 found that the dental arches and palate are well developed, 
 the full number of teeth present and not decayed, though they 
 
Economic Factors 321 
 
 may be, and usually are, much ground down, if the edges 
 of the teeth meet and do not overlap, and if hypoplasia 
 is absent, it is safe to infer that rickets was not a disease 
 which affected these people. If one hundred skulls were 
 examined from one community without any other bones 
 of the skeleton, a very accurate opinion could be formed 
 as to the presence or absence of rickets. 
 
 Now the condition of the jaws and teeth just described 
 is characteristic of the crania of nearly all the primitive 
 races and of the native races to-day still living in their 
 natural state. Still more striking is the fact that up to 
 about the beginning of the seventeenth century the same 
 type persists in England, and from that time forwards the 
 jaws and teeth begin to assume the modern type. Indeed, 
 so widespread is the disease, that there can be but little 
 doubt that a profound change has actually occurred in the 
 formation of the skull within comparatively recent times, 
 say, from about the beginning of the seventeenth century, 
 with a tendency to produce the lantern-jawed type of indi- 
 vidual with a deformed upper and a diminished lower jaw. 
 This change, which, according to our present nomenclature, 
 must be termed pathological, is in reality a normal response 
 to an altered environment, and is a factor which must be 
 taken into account in measurements of the skull by anthro- 
 pologists. 
 
 In 1603, 319 years ago. Queen Elizabeth died, and at that 
 time the population of England and Wales is estimated to 
 have been 3^ millions. To-day the population is 33J mUHons. 
 and the strain of life has increased enormously under modem 
 conditions. So large a growth of population in a restricted 
 area, in so short a period, called for a tremendous readjust- 
 ment and for a great power of adaptability. The whole 
 trend of life was altered. In place of a series of compara- 
 tively small communities scattered all over England, each 
 of which was compelled to be largely self-supporting owing 
 to the very limited means of distribution, a vast industrial 
 England arose where whole towns and districts specialised 
 in supplying the needs and wants of other sections of the 
 
322 Rickets- 
 
 population. At first each community lived almost entirely 
 on the land. Each family supplied its own wants, even to 
 the spinning of the wool necessary for the making of the 
 clothes of the family. The husband worked as a labourer 
 on the farm, while the wife and children were employed with 
 the work of the house and on the plot of ground which 
 surrounded it. The life was strenuous but was healthy. 
 
 In industrial England, on the other hand, the people 
 were drawn from the land into the towns ; in place of the wife, 
 with the aid of the elder children, contributing her share to the 
 support of the family by work in the home or on the plot of 
 ground surrounding it, all were compelled to take their place in 
 the factory to earn sufficient money to supply the bare family 
 needs. The enornious populations of the towns had to be 
 housed, and this was done in dwellings destitute of comfort 
 and devoid of any idea of hygiene or of healthy living in 
 their construction. Jerry-built houses placed back to back 
 and noisome courts and alleys became common features of 
 the larger towns, and all over the country these slum areas 
 remain features of our large manufacturing towns to-day, 
 forming a constant menace to the health of the population 
 and extorting an enormous penalty from young injfant life 
 in a high mortaUty, and irregular and stunted growth in the 
 children who struggle through. Food, while the popula- 
 tion depended on the farms, was wholesome and usually 
 fairly abundant, and the clothing was made at home. In 
 the industrial populations everything had to be bought, and 
 food and clothing were dear. Besides being dear the food 
 was poor in quality and was frequently adulterated. In 
 many respects the failure of the population to adapt itself 
 to so wide and so vast a change was fairly complete, and it 
 is from this failure that we are suffering largely to-day. 
 
 A study of what have been well termed the four elemen- 
 tary requisites of national healthiness, namely, food supply, 
 house accommodation, physical surrovmdings and industrial 
 circumstances, as they affected the people of England before 
 the seventeenth century and after, cannot fail to be of value 
 in helping to elucidate the causes for these changes. 
 
Economic Factors 323 
 
 Sir Arthur Keith, in his recently published work on 
 " The Antiquity of Man," speaking of the Coldrum collection 
 of Neolithic men, draws an interesting comparison between 
 Neolithic and modern man as regards their teeth.* 
 
 " Amongst modern Kentish folk, as is the case all over 
 modern Britain, there is a tendency to crowding and irregu- 
 larities of the teeth ; the palate and jaws do not grow and 
 expand sufficiently in youth to give room for a symmetrical 
 eruption of the teeth. The nose is narrow and the palate 
 contracted, and its vault is high. The teeth are not worn 
 down as in Neolithic men ; they are very liable to be attacked 
 by caries. The front teeth, when the jaws are closed, do 
 not meet edge to edge as in primitive races ; like the blades 
 of scissors, they overlap, the lower passing behind the upper. 
 In the Neolithic people all these modern characters are 
 absent. Abscesses or gum-boils at the roots of the deeply- 
 ground teeth were, however, common ; but there is not a 
 single carious tooth to be seen in the Coldrum collection. 
 The teeth are regular in their arrangement, the palates were 
 well formed, but in actual size the teeth possess the same 
 dimensions as those of modern English people. All these 
 changes, which are appearing in the teeth and jaws of 
 modern British people, arise, we suppose, from the soft 
 nature of our modern diet. We believe that were modern 
 men to resume a Neolithic diet their teeth and palates would 
 again be moulded in the ancient manner." 
 
 The difference is, however, hardly capable of such easy 
 solution. Rickets was probably a disease unknown among 
 Neolithic infants, as is largely the case among native races 
 to-day, notwithstanding frequent privations as regards 
 food. Contrast the life of Neolithic men living under 
 primitive conditions, rising with the sun and going to rest 
 at sunset, and living in small communities scattered over 
 wide areas, with that of the slum conditions under which so 
 large a proportion of our population lives to-day. 
 
 Loss of function of any organ naturally impairs its 
 development, but the causes of hypoplasia and the tendency 
 
 * "The Antiquity of Man," by Arthur Keith, London, 1915. 
 
324 Rickets 
 
 to early decay of the teeth must be due to other causes than 
 the neglect of the proper use of the teeth and jaws. Making 
 a rough estimate, I would say that 90 per cent, of the cases 
 of failure in the formation of the enamel in the second 
 dentition occur as the result of errors of growth in the first 
 year of life. Already by the end of the first year the stunting 
 of the growth of the incisors, canines and first molars of the 
 second dentition has taken place, and the dentine is by this 
 time either exposed along the biting edges of these teeth, 
 or is very incompletely covered by a thin layer of imperfect 
 enamel. The germs of these teeth lie deep in the jaws of 
 the infant, and naturally loss of function can play no part. 
 
 The malformation of the maxillae occurs later, it is 
 true, and it is conceivable that the child who subsists entirely 
 on pap food, and does not use the muscles of mastication, 
 will naturally tend to have poorly-developed jaws. But I 
 do not believe this plays any important part in the collapse 
 of the upper jaw, leading to the projection of the central 
 incisors and the overcrowding of the lateral incisors and 
 canines. Rather I attribute these conditions to the softening 
 of the bones, and the muscular debility which are such 
 prominent features of rickets. Nor would it be desirable, 
 if we could, to return to a primitive diet. Even as late as 
 the seventeenth and eighteenth centuries the teeth were 
 used to masticate food for which they were never adapted 
 by nature. Not only were the molars used for grinding, 
 but even the incisors and canines are quite commonly 
 ground down flat at an early age, so that the pulp cavities 
 are exposed. True, the dental arches are, as a rule, well 
 formed, and the palate is low and broad, but this is due to 
 the absence of rickets in the first two years of life, and 
 not to the unnatural work which these teeth were made to 
 perform in later years. 
 
 It is important, then, to note that irregularity of the 
 teeth, the tendency to decay and hypoplasia associated with 
 a narrow and high-arched palate and an altered bite, are all 
 conditions which only became common within comparatively 
 recent times. They are the usual conditions associated with 
 
Economic Factors 325 
 
 rickets. The condition of the teeth and jaws described by 
 Sir Arthur Keith as characteristic of Neolithic man extended 
 right up to and beyond mediaeval times, and is indeed a 
 striking feature of skulls right up to Reformation times and 
 later. Somewhere about the beginning of the seventeenth 
 century a profound change began to take place in the 
 development of the people in England which has left its 
 mark in the growth of the skeleton, but more particularly 
 in the bones of the skull. The contracted dental arch and 
 high-vaulted palate, with marked irregularity and early 
 decay of the teeth, the occurrence of hypoplasia and the 
 tendency to the production of a long-faced lantern-jawed 
 type of individual with a contracted lower jaw, are charac- 
 teristics very common in the skulls of to-day, and probably 
 date back not further than the end of the sixteenth or the 
 beginning of the seventeenth century. This type is fre- 
 quently associated with the long narrow-chested develop- 
 ment and the sloping shoulders and arched back so often seen 
 in the modem town dweller. The stature of the long barrow 
 men of the NeoUthic period is given as 5 feet 5J inches, 
 while that of the round barrow men of the Bronze Age, which 
 succeeded the Neolithic, is 5 feet 7^ inches. The difference 
 cannot be attributed wholly to better conditions of life and 
 feeding in the Bronze period, though these had undoubtedly 
 advanced enormously. The two types are probably of a 
 different race, for the long barrow men belong to a long- 
 headed or dolico-cephalic type, while those of the round 
 barrows are short-headed or brachy-cephalic, and the 
 difference in stature may have been partly racial, though in 
 all probability it was also largely a question of improved 
 feeding and environment. A fairly reliable criterion as to 
 the conditions during these two periods can be found in the 
 relative stature of the men and women. Thurnham calcu- 
 lated that the average age of the Neolithic people whose 
 skeletons he examined was not more than forty-five. The 
 average height of the men was about 5 feet 6 inches and of 
 the women only 4 feet 10 inches. The difference between 
 the sexes in civilised communities is only about half as much. 
 
326 Rickets 
 
 This marked difference of stature bears testimony to the 
 severe struggle for food, for in savage races, in times of 
 famine and stress, the woman fares worse than the man. 
 Besides, early child-bearing retards her growth, while the 
 labour of the community falls largely to her lot. In the 
 Bronze Age which followed the Neolithic period, conditions 
 were more favourable to longevity and the position of the 
 woman was probably improved. Not only was the disparity 
 in stature between men and women much less, but Thurnham 
 finds the average life of the round barrow people whose 
 skeletons he examined was fifty-five.* Enquiry into the 
 life of NeoUthic man may appear at first remote from the 
 subject of rickets. In reality it is most apposite. The 
 evidence we have points fairly clearly to the absence of this 
 disease from those early people while their life was a stern, 
 continuous struggle for the means of subsistence. Nor must 
 it be thought that the Neolithic period is wholly a thing of 
 the past. At the present day most of the conditions of life 
 in Neolithic Europe are reproduced at some part of the 
 globe's surface. Thus, as Sir John Lubbock (afterwards 
 Lord Avebury) points out,f the communities of the Stone Age 
 who gave rise to the kitchen-middens (Kjokkenmoddinger) 
 of the Danish coast lived much the same life as the inhabi- 
 tants of Tierra del Fuego do to-day. These great heaps con- 
 sist of shells, chiefly oyster shells, and have accumulated on 
 the sites of these early Neolithic settlements. In these heaps, 
 flint implements, bows and fragments of pottery are found. 
 The dog was the only domesticated animal and the other 
 bones found in the heaps are the product of the chase, the 
 stag, roedeer and wild deer. They had no knowledge of 
 agriculture, and though wild berries and nuts would help to 
 eke out the scanty fare in times of famine, their lives must 
 have been associated with frequent periods of great priva- 
 tion and stress. As with all native and savage races, the 
 supply of fat was a great difficulty, and the frequency with 
 
 * Nature, November 22iid, 1894, p. 92. 
 
 t " Prehistoric Times," by the Right Hon. Sir John Lubbock, London, 
 1890. 
 
Economic Factors 327 
 
 which the long bones are spUt for the extraction of the 
 marrow shows with what care they made use of every avail- 
 able source of supply. In the same way, the life of the 
 Neolithic lake-dwellers in Switzerland is reproduced in the 
 existing pile-villages of New Guinea and other Asiatic islands. 
 These Swiss lake-dwellers had some rude ideas of agriculture 
 and made use of cereals, and they had probably domesticated 
 several animals besides the dog. Great Britain at the 
 beginning of the NeoHthic period had become an island, 
 separated from the Continent. The cUmate was temperate 
 and rather moist. Under favourable conditions, even at 
 this early period, men had learned to tame animals and to use 
 them for domestic purposes ; they cultivated wheat ■ and 
 textile plants and used the bow. It is important to remem- 
 ber that even as late as the middle of the eighteenth century 
 one-third of the habitable globe had not advanced beyond 
 the Stone Age period. Rickets did not exist amongst 
 Neolithic people, nor does it exist amongst native races living 
 under native conditions to-day. In South Africa the natives 
 have been intimately associated with European races ever 
 since the surgeon, Jan van Riebeek, first landed in Table Bay 
 with his expedition in 1652, and cannot now be said to be 
 living under native conditions. Even so, neither in the 
 larger towns nor on the veldt in South Africa have they 
 developed rickets. In America, on the other hand, rickets 
 is so prevalent amongst the negroes of New York and 
 Chicago that it is stated that practically every child suffers 
 from it, many of them severely. 
 
 The natives of India, though they hve habitually near 
 the border line of want and are subject to recurring devas- 
 tating famines, widespread and most destructive to human 
 life, do not develop rickets. 
 
 It has been shown that the life of primitive peoples is 
 only reconstructed with difficulty, but even when we get to 
 historical times it is exceedingly difficult to find the material 
 which will provide data for a picture of the manner in which 
 the common people lived. 
 
 The Roman historians give only occasional scraps of 
 information concerning the social life of the races whom 
 
328 Rickets 
 
 they conquered. At the time of the Roman occupation the 
 population of England dwelt apart in many separate tribes, 
 and hunting and inter-tribal warfare were their chief 
 occupations. " Their whole Ufe," says Caesar, " is composed 
 of hunting expeditions and military pursuits : from early 
 boyhood they are zealous for toil and hardship. For agri- 
 culture they have no zeal and the greater part of their food 
 consists of milk, cheese and flesh." * Probably the masses 
 were in a state of semi-serfdom and pohtical power lay in the 
 hands of the chiefs and the druids. In the south-eastern 
 part of England hf e was probably more stable and the coimtry 
 was comparatively prosperous. In 54 B.C. Cssar, as he 
 marched through the country, was struck with the density 
 of the population in Kent and their apparent wealth. " The 
 population," he wrote, " is immense : homesteads closely 
 resembUng those of the Gauls, are met with at every turn ; 
 and cattle are very numerous, "f They fed on a little bread 
 ground from corn in a hand-quern and on a great deal of 
 flesh meat, boiled or roasted on the ashes or on spits. Their 
 houses were mean habitations constructed chiefly of wooden 
 planks and of reeds or wicker-work covered with a heavy 
 thatch of straw, and as Strabo, the geographer, says, were 
 circular in form. J They had one opening for the door on 
 the sunny or sheltered side and a central hearth. 
 
 Such were the huts in which Poseidonius was made 
 welcome when he travelled in Gaul. Describing their cus- 
 toms he asserts that, like beasts of prey, they took up whole 
 joints, biting off portions, and if any part were too difficult 
 to be torn off by the teeth, they cut it off with a small knife 
 which, sheathed in a case, lay beside them.§ In the fourth 
 and fifth centuries, when Rome had been compelled to with- 
 draw her troops from Britain to guard her Empire from the 
 barbarians who assailed her frontiers, evil times fell upon the 
 
 * " De Bello Gallico," Book VI., pp. 21, 22. Vita omms in venationi- 
 bus atque in studiis rei militaris consistet : ab parvulis laboti ac duritiae 
 student. Agriculturas non student, majorque pars victus eorum in lacte, 
 caseo, came consistet. 
 
 f " Hominum infinita multitude crebemmaque aedifica fere Gallicis 
 consimilia, pecoris magnus numerus," B.G., V., 12, par. 3. 
 
 I " Strabo," lib. IV., c. 4, par. 3. 
 
 § " Poseidonius, apud Athenaeus," lib. IV., p. 152. 
 
Economic Factors 329 
 
 Briton when the hand of the master was removed. For a 
 century and a half darkness falls on the history of the 
 country, and it is not till the latter half of the fifth and the 
 first half of the sixth century that history again emerges, 
 when we find the country in the hands of the true English 
 of to-day, who are mostly descended from the conquering 
 Angles and Saxons. The Anglo-Saxons came not, hke the 
 Romans, to administer a new country, but were bent on a 
 purely destructive work. They swept away everything 
 before them and replaced the old civilisation of Britain by 
 a new social organisation of their own. These invaders could 
 not brook the life of towns — they were fitted only for an 
 open-air life in the country where each man owned his house 
 with a small piece of land surrounding it, while the country 
 around belonged to the community. The Roman settle- 
 ments which they attacked and destroyed they did not 
 inhabit, and indeed even such considerable towns as Canter- 
 bury, and Bath, and London itself, seem to have been deserted 
 for a time, and were left to crumble away.* 
 
 In " Crania Brittanica," published in 1865, Davis and 
 Thurnham give the results of the examination of a large 
 number of skulls taken from ancient British barrows and 
 from burial grounds dating from Roman and early English 
 times. Drawing their conclusions the authors state : " It 
 may be observed that we have met with comparatively few 
 instances of disease among the bones of the ancient Britons. 
 The probability is that diseases of the bones are not common. 
 No morbid appearances such as would be the result of 
 syphihs have presented themselves to our notice." f In an 
 examination of the beautiful series of reproductions of 
 Roman and early EngHsh skulls in " Crania Brittanica," 
 one of the most remarkable features is the excellent state 
 of preservation of the teeth. The hard palate and dental 
 arches are roomy and well formed, and the teeth are mostly 
 all present. They show evidence of rough usage. They 
 are much worn down and are ground flat so that even the 
 incisors and canines have lost their biting edge. Sometimes 
 
 * " A History of England," by Charles Oman, Chapter II. 
 
 I " Crania Brittanica," by Davis and Thurnham, 1865, p. 233. 
 
33° Rickets 
 
 the pulp cavities are exposed in the grinding process, but 
 there is little, if any, evidence of decay. The weU-marked 
 bony developnaent of the jaws, the excellent preservation of 
 the teeth and the freedom from decay all bear definite testi- 
 mony to the absence of rickets amongst these peoples. The 
 evidence is scanty, but is written on an enduring record — the 
 bones and teeth — and forms a reliable testimony that rickets 
 was not a disease which prevailed during that long period if 
 it existed at all. 
 
 Much interest attaches to the recently discovered 
 Rhodesian skull from the fact that the teeth of the upper 
 jaw present appearances resembUng true caries. This skull 
 exhibits the usual characteristics of primitive skulls in the 
 great, wide, roomy, flat palate, while the teeth are set regularly 
 in a generous sweep. The teeth are large and well formed, 
 and are considerably ground down, and there is a well- 
 marked formation of secondary dentine. On the adjacent 
 part of the left lateral incisor and the left canine there is an 
 area on each tooth which strongly suggests caries during life. 
 This is quite unusual in early primitive skulls, though signs 
 of abscesses at the roots of the molars, which are present in 
 this skull, are by no means uncommon. Part of the second 
 left molar has been eroded, but this is much more suggestive 
 of disintegration occurring during the long period in which the 
 skull has lain hidden than of caries during hfe. Even should 
 the decay of the front teeth prove to be true caries, this need 
 occasion no surprise, and would but serve to emphasise the 
 fact that in ancient and primitive skulls such a condition is 
 exceedingly rare. There is certainly no suggestion of the 
 rachitic state in the enormous facial bones of the Rhodesian 
 skull. The tibia and femur found with it are pecuUarly 
 sUght and gracile, the former bone being straight and well 
 formed, while the portions of the femur suffice to show that 
 there was no increase in the natural curve of the bone. 
 
 The study of anthropology is peculiarly helpful in the 
 elucidation of many problems of developmental disease, for 
 normal processes of growth in one organism may appear as 
 pathological variations in another, and may arise in response 
 to altered and perverted environment. 
 
CHAPTER XXIII 
 
 Economic Factors in Relation to Rickets from the 
 Roman Occupation to tlie Close of the Eig-hteenth 
 Century 
 
 Throughout England there is an interesting record, of 
 which not much notice has been taken, of the physical condi- 
 tion of the English people in past centuries, to be found in 
 numerous collections of bones in different parts of the 
 country. These have been gradually accumulated in charnel 
 houses, and are sometimes in an excellent state of preserva- 
 tion. In pre-Reformation times, churchyards as a rule were 
 small, and to malce room for fresh burials the bones of some 
 forgotten occupant had frequently to be removed and were 
 placed reverently in the charnel house — a vault either under 
 or near the church which was built for this purpose. In 
 this way, in the course of generations, churchyards would be 
 dug over time and again, and a gradual accumulation of 
 bones took place. Such a collection is found in the crypt 
 under the church at Hythe. This collection is well-known 
 because it is near a favourite seaside resort not far from 
 London. But it in no way differs in its origin from other 
 collections throughout the country. Usually, local tradi- 
 tion cherishes the conceit that some great battle has been 
 fought in the neighbourhood or that a holocaust has taken 
 place as the result of plague. At Hythe, various skulls are 
 shown with injuries presumed to have been caused in battle, 
 but examination has proved that the spade and mattock 
 of the sexton, long after death, have in most* cases been the 
 cause of the injury.* These injuries from much handling 
 
 * " Notes on the Crypt and Bones of Hythe Church," by the Rev. H. D. 
 Dale, Vicar of Hsrthe, and F. G. Parsons, F.R.C.S., Professor of Anatomy 
 in the University of London, Hythe, Kent, 19 17. 
 
 331 
 
332 Rickets 
 
 often become smooth and polished and resemble very closely 
 healed injuries. The history of the collection at Hythe 
 shows that the bones have been under the church since the 
 year a.d. 1600 and were probably placed there much earlier. 
 At least four thousand people — men, women and children — 
 are represented. The death rate of Hythe considering the 
 population could not, for several centuries, have accounted 
 for more thaji forty burials yearly. It is probable that these 
 bones were dug up during the fourteenth, fifteenth and six- 
 teenth centuries, possibly as early as the thirteenth century, 
 and the stack was completed during the sixteenth century. 
 The bones are in an excellent state of preservation and many 
 of the pathological changes are still well marked. Osteo- 
 arthritis of a severe type is common, and the inhabitants of 
 Hythe must have suffered greatly from this condition. 
 About twelve cases show well-marked syphilitic lesions of 
 bone, caries of the spine is to be seen, and union of fractures 
 of the long bones in faulty position is present in several cases. 
 But there is no evidence of rickets. Speaking of this collec- 
 tion, Mr. Parsons says : " I have seen the rickety tibia noted 
 by Dr. Knox, but apart from that I have come across no 
 evidence of the disease which I could recognise." * An 
 examination of the teeth shows the usual characteristics 
 which are associated with prehistoric, early English, and 
 mediaeval skulls. The palatal and dental arches are well 
 formed, comparatively few teeth are lost, and caries is con- 
 spicuously absent. The teeth are ground down flat and are 
 much worn away, but they are not decayed. Such a condi- 
 tion one might imagine would go with a robust healthy 
 constitution, but enquiry shows that the physique of the 
 people to whom these bones belonged was much inferior to 
 that of the inhabitants of Hythe at the present day. Mr. 
 Parsons f found that the stature of the men averaged 5 feet 
 5| inches, while that of the women was only 5 feet 1 inch. 
 The interesting fact is brought out that with a life of great 
 
 * " Report on the Hythe Crania," by F. S. Parsons, Journal of the 
 Royal Anthropological Institute, Vol. XXXVIII., 1908. 
 t Loc. cit. 
 
Economic Factors 333 
 
 hardship, with a coarse and frequently insufficient diet, pro- 
 ducing defective growth and nutrition, these people were 
 free from rickets, while to-day, though the people are much 
 better fed and of better physique, rickets is found to be 
 prevalent at Hythe. The state of the teeth is identical 
 with those in another collection of skulls found under St. 
 Peter's Church at Dover, a collection which dates from the 
 thirteenth and fourteenth centuries. 
 
 At Rothwell, near Kettering, in Northamptonshire, there 
 is a collection considerably larger than that at Hythe. The 
 vault was discovered two hundred years ago, and from five 
 thousand to six thousand individuals are represented. The 
 bones are not so well preserved as those at Hythe, and thus 
 the pathological conditions in the bones are masked. The 
 physique of those people was evidently under the present- 
 day standard — the women average 5 feet 2 inches in height, 
 but the teeth show the usual characteristics of being ground 
 down and free from decay.* Speaking of the teeth found in 
 these mediaeval collections, Mr. Parsons f makes the inte- 
 resting observation that they form a marked contrast with 
 the skulls which he examined from a disused churchyard 
 under the site of the Bluecoat School in Newgate Street. 
 These belonged to Londoners of the seventeenth century, 
 and not only were the teeth found to be much less ground 
 down, but caries was much more common ; that is, already 
 in the seventeenth century the teeth of the Londoner 
 resembled those of the population at the present day. 
 
 In the Royal College of Surgeons there is a series of 
 skulls and long bones taken from Clare Market which show 
 an interesting transitional type. In all probability these 
 skeletons belong mostly to the eighteenth century, though 
 some were added as late as the first half of the nineteenth 
 century. Out of 117 skulls examined, 34 may be said to 
 have a contracted and high palatal arch, the arch in the 
 remainder being either moderate or wide, approaching to 
 
 * " Report on Rothwell Crania," by F. E. Parsons, Journal of Royal 
 Anthropological Institute, Vol. XL., igio. 
 t " Report on the Hythe Crania," loc. cit. 
 
334 Rickets 
 
 the native type. The teeth were, on the whole, better than 
 those of the modern Londoner, that is to say, decay was not 
 so frequent. In many cases these teeth were of a transi- 
 tional type, between the mediaeval ground-down teeth with- 
 out much evidence of decay, and the modern type where 
 the teeth were not ground down but were frequently decayed. 
 The tendency to overcrowding and irregularity of the teeth, 
 owing to malformation of the dental arch, was noted in 
 several cases. These skulls differed markedly from those 
 of the Hythe collection. In the Hythe skulls the jaws gave 
 an impression of strength. The dental arches and the 
 palate were wide and well formed, the teeth were regular 
 and met without overlapping, and, though much ground 
 down, there were comparatively few absent and decay was 
 quite uncommon. In the Clare Market skulls the teeth 
 were frequently decayed and sometimes irregular. The 
 dental arches tended to be much more contracted, and 
 the palate was frequently high and arched instead of 
 being flat and roomy as in the Hythe skulls. In at least 
 ten of the long bones belonging to the Clare Market 
 skeletons rickets was well marked ; syphilitic osteitis and 
 ulceration of the bones and osteo-arthritis were present in 
 several cases. 
 
 In a recent study of a series of bones found in White- 
 chapel and Liverpool Street, belonging in all probability to 
 seventeenth century plague pits. Professor Karl Pearson 
 and Miss Julia Ball, speaking of the femur alone, found that 
 out of seven hundred Whitechapel femora, ten showed 
 evidence of probable rachitic changes, whilst out of 217 
 Liverpool Street femora, three showed a similar condition.* 
 Speaking of the stature of the Londoner, Professor Pearson 
 makes the interesting comment that the seventeenth cen- 
 tury Londoners were distinctly shorter than the nineteenth 
 century commonalty, and proposes the problem whether 
 migration, nutrition, or natural selection accounts for the 
 
 * " A study of the Long Bones of the English Skeleton," by Karl 
 Pearson, F.R.S., and Julia Ball, M.A. 
 
Economic Factors 335 
 
 difference. Evidence is brought forward to show that the 
 modern British femur differs from that of the seventeenth 
 century Londoner in being a larger but, at the same time, a 
 more gracile bone. 
 
 Two factors are of considerable importance in consider- 
 ing these differences, namely, the quality of the feeding 
 and the housing conditions. 
 
 There has been considerable improvement in the quality 
 and quantity of the food supply ; within modern times cases 
 of extreme want and deaths from starvation are rare. A 
 large proportion of the population in the East End of 
 London, however, still lives on foods which are deficient all 
 round in the various constituents necessary for the support 
 of vigorous health and growth. Notably there is a deficiency 
 in proteids and fats. For this reason, in children suffering 
 from malnutrition, the addition of one tablespoonful of 
 cod-liver oil to the diet, as is commonly done, has not nearly 
 the same beneficial action as the addition of a pint of milk, 
 which makes good the deficiency of all the constituents 
 necessary to a proper diet. 
 
 Among the Jewish population in the East End of 
 London there is no want of fat in the diet. The general 
 nutrition of these children is excellent, but the incidence of 
 rickets is about the same as amongst the non-Jewish section 
 of the community. Their good nutrition modifies the 
 severity of the disease, but does not diminish the frequency 
 with which the children are attacked. In other words, 
 there is some other factor than the food factor respon- 
 sible for the disease, and this is to be found in the very 
 defective housing conditions under which both the Jewish 
 and the non- Jewish sections of the community live. 
 Housing conditions have improved in the town populations 
 generally, but only to a hmited extent. Effective sanita- 
 tion, it is true, has banished many diseases, but over-crowd- 
 ing of families in one, two, or three rooms, deficient in light 
 and ventilation and the means of exercise, is still very 
 common, and, indeed, tends to become exaggerated as the 
 population increases in density. This faulty environment 
 
336 Rickets 
 
 still has a profound effect on the growth of the infant and 
 the young child. The improvement which has taken place 
 in the national stature is probably to be attributed to 
 improved feeding, but with this increase in growth, though 
 there has been a modification in the type of rickets, the 
 malady is probably more frequent and more widely spread 
 to-day than it has ever been in the past. 
 
 Overcrowding is a relative term, and, while, with a popu- 
 lation of thirty-three millions in England and Wales, it can 
 readily be understood how slum areas arise, it is not so 
 readily comprehended that in Queen Elizabeth's time, with 
 a population of three and half millions, similar influences 
 were already at work or were beginning to make their 
 appearance. The essential and constant factors producing 
 the exceedingly wide diffusion of rickets at present found in 
 Europe and in North America within the temperate zone 
 are the enormously rapid growth of population within the 
 short space of three hundred years, and the concentration 
 of this population into huge industrial areas. It cannot be 
 too frequently reiterated that rickets is a disease of early 
 infancy, and in studying the conditions which produce it, 
 the first place must be given to those factors which act most 
 intensely on the young infant. 
 
 It is obvious that under the conditions of Ufe up to 
 Elizabethan times, with a sparse population almost entirely 
 dependent on agriculture, an infant was brought up in an 
 entirely different environment from that which surrounded 
 the child born in a basement cellar in Manchester, or Liver- 
 pool, or in a crowded slum area in the East End of London 
 to-day. In the first case the child frequently lived, it is true, 
 in a mean hut or hovel devoid of comfort, but such hardships 
 do not breed rickets. The life of the whole community was 
 regulated by the sun, and the greater part of the day was 
 spent in arduous toil in the open. At as early a date as 
 possible the young infant shared in the open-air life of the 
 community, and accompanied the mother in her varied 
 activities. In a disease centre such as Manchester or the 
 East End of London the child may hardly move from one 
 
Economic Factors 337 
 
 close, confined, sunless room for weeks or months during the 
 inclement winter. 
 
 A study of the economic factors which bear on the pro- 
 duction of great cities and modern housing conditions has 
 an important bearing on the aetiology of rickets. Even in 
 Queen Elizabeth's time these conditions were beginning to 
 come into evidence, though the true development of modern 
 conditions did not occur till a much later period, being 
 associated with the development of modern industries, 
 notably the cotton industry. 
 
 Already, in Queen EUzabeth's time, a complex problem 
 had arisen in the number of idle and indigent poor, for 
 whom no provision was made. The passage from manorial 
 rights, with the disappearance of the last traces of serfdom, 
 which was only completed in the sixteenth century, was 
 not altogether to the advantage of the agricultural 
 labourer. It threw a large number on the labour market 
 at a time when the demand for labour was limited. 
 Industrial capital hardly existed in England in the 
 fifteenth century, in the sense of ready money for wages 
 used by an emploj^ing class who held the command of 
 capital and used it in industrial pursuits. At the same 
 time a growth of capital in agriculture began which tended 
 to convert much of the agricultural land into grazing for 
 sheep. These enclosures, with their accompanying evictions, 
 produced a struggle between the small farmer working his 
 holding and the large holder who had a sheep farm. These 
 two classes, the disbanded retainers who belonged to the old 
 serf class, who had not yet been able to find a market for 
 their labour, and the evicted agricultural worker who had 
 been rendered homeless, formed themselves into vagrant 
 robber bands who rapidly became a terror to the com- 
 munity. 
 
 In 1601 the celebrated Poor Law of Queen Elizabeth 
 came into force whereby it was provided that the able- 
 bodied vagrant should be made to work or, in default, go to 
 prison, but those who, through age or sickness, were unable 
 to work, had to be supported from rates levied on the parish 
 
338 Rickets 
 
 to which the vagrant belonged. The enactment against 
 the sturdy rogue is important as showing that it was not 
 only the distressing amount of poverty which produced the 
 measure, but the desire of the community to protect itself 
 against the lawless bands who were infesting the country, 
 maJiing the roads vmsafe, and property and even life itself 
 insecure. For a time the position was greatly eased. 
 Colonial enterprise and increase of trade had added immensely 
 to the wealth of the nation, and had helped to settle many 
 grave social problems which had arisen. But it is to be 
 noted, that this increase of wealth mostly benefited town 
 populations and did not affect the rural populations in any- 
 thing like the same degree. Work was found in towns for 
 a large number of unemployed. 
 
 It is from the time of Queen EHzabeth that the growth 
 in importance of ' the urban population as against the rural 
 must be reckoned. This is a factor in England of ever 
 increasing importance, and has a very direct bearing on 
 the enquiry into the cause of rickets. The end of the 
 sixteenth and the beginning of the seventeenth centuries 
 formed a period of comparative prosperity throughout 
 the country. The rural population had not actually out- 
 grown the needs of the agricultural community; indeed, 
 the farmers called out for labour. The increased wealth of 
 the towns, with the development of trade generally, had 
 largely increased the demand for artisans, who were rela- 
 tively well paid, and had drawn on the class who were likely 
 to become vagrants and robbers and a menace to the security 
 of the community. But in the seventeenth century changes 
 were rapidly occurring. The population of England had 
 increased in the second half of the seventeenth century to 
 five miUions, and the increase was greater in the northern 
 than in the southern shires. It is computed that four-fifths 
 of the common people were employed in agriculture.* Agri- 
 culture was England's chief industry, and, in the " Working 
 Life of Women in the Seventeenth Century," Miss Alice 
 
 * Macaulay's " History of England," " State of England in 1685." 
 
Economic Factors 339 
 
 Clark divides the agricultural community into three 
 classes * : (a) farmers who had sufficient land for the com- 
 plete maintenance of the family; (6) husbandmen whose 
 holdings were only able to maintain the family in part, and 
 who had to supplement by working for wages ; (c) wage- 
 earners who had no land and depended completely on their 
 wages. The wage of the agricultural labourer was exceedingly 
 low, about 3s. 6d. per week. On such a wage it was admittedly 
 impossible for the head of a house to support a wife and 
 family, for, even under the system of poor relief, 4s. to 5s. 
 a week was considered necessary for an adult's maintenance. 
 The wage was intended to be merely supplementary while 
 the family earned their food from the croft. It had always 
 been the policy of Government administration under the 
 Tudors to support the responsible yeoman and not to 
 encourage the wage-earner, who, instead of . becoming a 
 defender of his country, was ever likely to become a burden 
 on his parish. 
 
 The wages were not regulated by the law of supply and 
 demand but were regulated by the magistrates at Quarter 
 Sessions, and the wage was, in the first instance, purposely 
 made small so that the labourer would be dependent on the 
 farmer for pa5niient in kind in foodstuffs. Food on the 
 farms was relatively abundant. At no time was the farmer 
 independent of the labourer. Means of transport were 
 exceedingly limited, so that each district depended on its 
 own supply of corn. At harvest time the whole community, 
 men, women and children, was employed in the fields, and, 
 directly or indirectly, much of the food of the rural popula- 
 tion came from the farms. When the labourer had an allot- 
 ment, the woman of the house and the children worked out 
 of doors, cultivating the garden, and tending pigs and cows, 
 while the husband worked on the neighbouring farm. Where 
 there was no allotment, the woman's time would be employed 
 in spinning and making cloth, for the clothing of the house- 
 hold was made at home and not purchased. The life was of 
 
 • " Working Life of Women in the Seventeenth Century," Alice Clark, 
 1919. 
 
34° Rickets 
 
 the hardest, and, in the case of the labourer without land, 
 he was ever working on the borderline of starvation. But 
 probably too gloomy a view is taken of the life of the labourer 
 in the seventeenth century. Information is but scanty as 
 regards the conditions of the common people and has been 
 mostly derived from the records of poor relief and of the 
 magistrates' courts at Quarter Sessions. These records do 
 not tend to give the enquirer a natural perspective. Sir 
 Wm. Temple, one of the most astute politicians of the time, 
 and one who had travelled much, states, in the work pub- 
 lished by Swift after his death, " An Essay upon Health and 
 Long Life," " I have heard and very credibly, of many in 
 my life above a hundred years old, but have observed most 
 of them to have been of Derbyshire, Staffordshire or York- 
 shire, and none above the rank of common farmers. Health 
 and long Ufe are usually blessings of the poor, not of the 
 rich, and the fruits of temperance rather than of luxury. 
 And, indeed, if a rich man does not hve like the poor, he will 
 certainly be the worse for his riches." * 
 
 The same rapid spread of rickets which occurred in the 
 seventeenth century in England can be watched going on in 
 new countries to-day. Rickets is not a disease indigenous 
 to America, but has developed rapidly in the United States 
 in proportion as the towns have grown in size and density 
 and industrial conditions have developed. Negro races, Mke 
 all native races, tend to occupy the worst parts of the large 
 towns, and so common is rickets amongst them in New York, 
 that one hardly sees a negro child without some evidence of 
 the disease. In Australia, till comparatively recently, the 
 disease was unknown, but is becoming more common for the 
 same reason. 
 
 The disease has lasted for so many generations, and has 
 been so prevalent a scourge throughout Europe, that it is 
 difficult to realise that a population free from it is a possi- 
 biUty, and that rickets comes within the class of preventable 
 
 * " Miscellanea," the Third Part, Essay II. — " An Essay upon Health 
 and Long Life," published by Jonathan Swift, A.M., Prebendary of St. 
 Patrick's, Dublin. I^ndon, 1701. 
 
Economic Factors 34 1 
 
 diseases, just as it is hard to believe that a town can exist 
 without slums or a successful industry without inflicting 
 hardship on the workers who contribute to its success. 
 
 The seventeenth and eighteenth centuries saw the strange 
 anomaly of huge industries rising and developing with great 
 rapidity and producing enormous wealth, while, at the same 
 time, the workers who were engaged in producing this wealth 
 were becoming relatively poorer and the conditions of their 
 lives more and more miserable, and, finally, unbearable, 
 culminating in the industrial revolution at the end of the 
 eighteenth and the beginning of the nineteenth centuries. 
 
 In the seventeenth century, the growth of towns and 
 industry were on a comparatively small scale when com- 
 pared with present-day conditions. But the process had 
 already made considerable progress and much misery existed. 
 At the time of the Domesday Book, 1086, there were hardly 
 any towns. 
 
 Speaking of the progress of population in England, 
 Rogers * maintains that during the fourteenth, fifteenth and 
 sixteenth centuries the population remained almost sta- 
 tionary and amounted to about two and a half millions. At 
 the close of the fourteenth century, England and Wales 
 together had a population of under two and a quarter 
 millions, while the following was the population of the chief 
 towns : — 
 
 London 
 
 York 
 
 .. 11,000 
 
 Bristol 
 
 .. 9,500 
 
 Coventry 
 
 .. 7,000 
 
 Norwich 
 
 .. 6,000 
 
 Lincoln 
 
 .. 5,000 
 
 No other town had over five thousand inhabitants. 
 Nine-tenths of the population were employed in agriculture. 
 Kent had for long been a prosperous county. Caesar's 
 surprise at its wealth and density of population has already 
 
 * " The Industrial and Commercial History of England," by James 
 E. Thorold Rogers, Professor of Political Economy in the University of 
 Oxford, and of Economic Science and Statistics, King's College, London. 
 London, 1905. 
 
342 Rickets 
 
 been noted. In the first half of the sixteenth century, the 
 population in nine Kentish hundreds on the eastern side of 
 the county was 14,813, and had remained so for two centuries. 
 It was still prosperous and has remained so to this day. In 
 these hvmdreds there were no large towns and there are none 
 now, though the population in 1861 was 80,080 — that is, six 
 times as much as it was three centuries before. Up to the 
 sixteenth century, with a population of two and a quarter 
 millions for England and Wales, the conditions for the 
 development of rickets did not exist. But the conditions 
 of life of the people were rapidly changing. " I have been 
 convinced," says Rogers, " that no material increase of the 
 English population took place during the last half of the 
 sixteenth century. Now it is certain that at the end of the 
 seventeenth century the population is more than double 
 that which I have calculated was in England at the close of 
 the sixteenth century." These figures agree with Macaulay's 
 estimate of five millions during the second half of the seven- 
 teenth century. This increase in population was partly due 
 to improvement in agricultural methods and increased 
 production, but was mainly due to the fact that weaving — 
 especially woollen weaving — was developing rapidly in the 
 north of England. The anons^nous author of " The Interest 
 of Scotland," writing in 1732, speaks of the growth of woollen 
 manufactures in Yorkshire, and of linen and of similar 
 fabrics in Lancashire. 
 
 As has already been seen, industrial capital hardly 
 existed in the fifteenth century, and it was not till the time 
 of Queen Elizabeth that the urban population began to 
 rival the rural population in importance. From this time 
 began the growth of industrial centres. London in 1685 
 had half a million of inhabitants and had been for half a 
 century the most populous capital in Europe. In the reign 
 of Charles II. (1660-1685) no provincial town in the king- 
 dom contained thirty thousand inhabitants, and only four 
 contained so many as ten thousand. Small though these 
 numbers are, they show even at this date a tendency to the 
 formation of industrial centres. Bristol, the first English 
 
Economic Factors 343 
 
 seaport, contained twenty-nine thousand inhabitants ; 
 Norwich, the first English manufacturing town and the 
 centre of the cloth industry, about the same number. York, 
 the capital of the north, and Exeter, the capital of the west, 
 each had about ten thousand inhabitants, Worcester and 
 Nottingham about eight thousand, and Manchester had 
 under six thousand people. Leeds was already the centre of 
 the woollen manufactures of Yorkshire and contained about 
 seven thousand souls. In the City of London, after the 
 Great Fire, houses of better quality were built and brick 
 was used, but elsewhere, houses were made of wood covered 
 with thatch. Sheffield in the seventeenth century was the 
 little capital of a district familiarly known as Hallamshire. 
 
 In 1554 the inhabitants of Sheffield represented to the 
 Queen that the fourteen hamlets within the parish were 
 never devoid of plague and other evil diseases, which they 
 attribute to the great number of poor and impotent persons 
 inhabiting them. A realistic description of the life is given 
 in a survey of the town of Sheffield made January 2nd, 1615, 
 by twenty-four of the most sufficient inhabitants.* The 
 report states : " there are in the town of Sheffield 2207 
 people : of which there are 725 who are not able to live 
 without the charity of their neighbours. These are all 
 begging poor : 100 householders which relieve others, 
 though the best sort are but poor artificers : 160 house- 
 holders, not able to relieve others. These are such (though 
 they beg not) as are not able to abide the storm of one 
 fortnight's sickness but would thereby be driven to begging : 
 1222 children and servants of said householders the greatest 
 part of which are constrained to work sore to provide them 
 necessaries." In 1685 the population had increased to four 
 thousand. For long the chief industry had been the manu- 
 facture of whittles or coarse butcher's knives. The severe 
 labour required in some departments of the Sheffield manu- 
 factures is said to have occasioned an unusual number of 
 distorted limbs. 
 
 * " Hallamshire," by Joseph Hunter, 1819. 
 
3+4 Rickets 
 
 The chief industries in England in the seventeenth 
 century were the textile industries. These were : (1) woollen ; 
 (2) linen; (3) miscellaneous, such as silk. The cotton 
 industry with its factory system was not organised on a 
 large scale till the following century, and was the chief 
 factor which led to the industrial revolution at the close of 
 the eighteenth century. For long, weaving had been carried 
 on at home by the woman of the house for the manufacture 
 of the clothes of the family. 
 
 In the second half of the seventeenth century the increase 
 in the population and the growth of textile industries com- 
 plicated matters, and not only encouraged the growth of 
 industrial centres, but established the system of the hired 
 labourer paid entirely by a wage which was the whole support 
 of himself and his family. The wage-earner who was 
 dependent solely on his wages suffered great hardship. 
 Three shillings and sixpence to four shillings a week was the 
 wage of an agricultural labourer ; workmen employed in 
 manufactures had higher wages, up to Is. per day, though 
 they were often compelled to work for less. The low wage 
 which had sufficed for the agricultural labourer in earlier 
 times, and which had been considered merely supplementary, 
 now formed the basis in calculating a man's earning capacity. 
 
 To make it possible to live, the woman of the house had 
 to work under conditions which ignored her rights as the 
 mother of cliildren. Child labour prevailed in the seven- 
 teenth century to an extent which — compared with the 
 extent of the manufacturing system — seems almost incredible. 
 At Norwich, the chief seat of the clothing industry, a little 
 child of six years old was thought fit for labour, and even 
 philanthropists of that time mention with exultation that 
 in that single city, boys and girls of very tender age created 
 wealth, exceeding what was necessary for their own sub- 
 sistence, of £12,000 a year. The bricklayer, . mason and 
 carpenter were equally poorly paid. Writing about 1840, 
 Macaulay in his history states : "It seems clear that the 
 wages of labour, estimated in money, were, in 1685, not 
 more than half of what they now are ; and there were few 
 
Economic Factors 345 
 
 articles important to the working man of which the price 
 was not, in 1685, more than half of what it now is." 
 
 Beer was cheap and abundant. Meat was also cheap, 
 but was still too dear for the labourer to buy from his small 
 earnings. By the great majority of the common people of 
 England it was partaken of only once or twice a week. Pork 
 was more common, and had indeed from very early times and 
 for many centuries throughout Europe been the only animal 
 food in general use. 
 
 Bread was made from wheat flour, was coarser than it is 
 now and was too dear for general use, and the great majority 
 of the common people lived on rye, barley and oats.* 
 
 Food was abundant in England, and in towns such as 
 London and Bristol merchants were noted for their rich 
 hospitality and the excellence of their tables both as regards 
 foodstuffs and excellent wines. The inns of England were 
 famous throughout Europe for their liberal entertainment, 
 and wines and good food were obtainable even in small 
 village inns at a moderate charge. In the seventeenth 
 century, England abounded with well-conducted inns of 
 every rank. 
 
 But this was no help to the labourer, and in the industrial 
 centres he had great difficulty — even by continuous and 
 assiduous toil — ^in earning enough money to buy sufficient 
 wholesome food for the sustenance of himself and his family. 
 
 The rise of the textile industries was the beginning of 
 industrialism as we now understand it. The wages were 
 continued on the basis set by the wage of the agricultural 
 
 * The following is a chart of the children's diet in Christ Church 
 Hospital in the year 1704 : — 
 
 For breakfast ... Bread and beer. 
 
 For dinner ... Sunday, Tuesday, Thursday, boiled beef and 
 
 pottage. 
 Monday, milk pottage. 
 
 Wednesday, furmity or frumenty (hulled wheat 
 boiled in milk and seasoned with cinnamon, 
 sugar, etc.). 
 Friday, old pease and pottage. 
 Saturday, water gruel. 
 For supper ... Bread and cheese, or butter for those who cannot 
 
 eat cheese. 
 Sunday supper ... Legs of mutton. Wednesday and Friday, 
 pudding pies. 
 
346 Rickets 
 
 labourer, but obviously without the chance of free food. 
 Throughout the country it was becoming increasingly diffi- 
 cult to obtain adequate housing accommodation. But one 
 of the worst featiires of the textile industries was that it 
 employed women and children very largely. Norwich and 
 Norfolk generally formed, as has been seen, an important 
 centre of the wool industry in the seventeenth century. It 
 is computed that about eight women and children were 
 employed to one man. To eke out the small wage of the 
 father the wife made the clothes for the family at home and 
 also earned a little by her spinning. At as early an age as 
 possible the children were set to work, and even in such a 
 heavy industry as the iron industry at Sheffield young 
 children were employed with the most disastrous results. 
 The evil influences which had already begun to sap the 
 health of the common people in the seventeenth century may 
 be classed under three heads : (1) slum dwellings and over- 
 crowding, with all that this impHes in defective hygiene, 
 loss of sunshine and fresh air and want of exercise, especially 
 in the first two years of the Hfe of the growing infant; 
 (2) excessive labour on the part of the mother and children, 
 who had also to work continuously to eke out the small 
 wage of the father ; (3) deficient and defective feeding. 
 
 These conditions are exceedingly complex, and the fact 
 that they usually present themselves in comlaination renders 
 it necessajy to examine each in very great detail before 
 deciding on any one factor as the actual cause of the disease. 
 In the Middle Ages the conditions of life were in many com- 
 munities very severe ; houses were huts and hovels devoid of 
 comfort, but had this virtue that they encouraged life out of 
 doors, for not much comfort was to be found indoors. Food 
 was rough and coarse and was often scanty, but rickets was 
 absent, for no matter what the diet the disease does not 
 develop when the life is regulated by the sun and is spent in 
 the open. It might be argued that the very coarseness and 
 roughness of the food would at least mean that the accessory 
 food factors were present in adequate quantity and so 
 inhibited the disease. Ample reasons exist for considering 
 
Economic Factors 347 
 
 such a view untenable. The inadequacy of the diet in these 
 early times led to dwarfing of the individual when com- 
 pared with present-day standards. Later in the seventeenth 
 century rickets became prevalent throughout all classes And 
 was noted as specially frequent and severe amongst the 
 children of the wealthy and in association with luxury. 
 Excess of rich feeding and the confinement of the young 
 infant for months in succession in warm, stifling, and 
 badly ventilated rooms were the conditions which were 
 present, and were the factors blamed by all contemporary 
 observers of note for the production of the disease; the 
 confinement ended then, as it does now, in the production of 
 rickets. The conditions reproduced in such a nursery were 
 those which exist in our slum areas to-day, where families are 
 herded together during the winter months in one or two rooms. 
 
 Among the poor in early times, when life was much in the 
 open, scanty and insufficient diet was incapable of producing 
 the disease. Among the rich in the seventeenth century 
 adequate and wholesome diet could not protect the child 
 from the onset of the disease in its severest form when the 
 infant was kept indoors in a vitiated and debilitating atmo- 
 sphere. In the seventeenth and eighteenth centuries among 
 the poor in large centres where the food was insufficient in 
 quantity and poor in quality, and the worst features of slum 
 dwellings were present in ever increasing measure, the disease 
 became a national evil, which had far-reaching and disastrous 
 effects on the health of the whole community. 
 
 It is important to realise the part played by the various 
 factors. Defective feeding and insufficiency of food did not 
 then, and do not now, produce rickets, though they un- 
 doubtedly aggravate the condition when present, as they do 
 any other morbid state, especially when it involves malnutri- 
 tion and failure of development. Deaths from starvation 
 and marasmus in young infants were quite common, and in 
 both these conditions rickets was then, as it is now, con- 
 spicuously absent. 
 
 Child labour produced marked signs in the rachitic child, 
 but did not produce the disease, which arose then, as now. 
 
348 Rickets 
 
 almost immediately after birth. The causes of the disease 
 will be discussed more fully later. Suffice it to say now, that 
 the essential causes of the disease lay in the excessively un- 
 hygienic conditions in which these infants were reared from 
 birth to the end of the second or third year of life, at a time 
 when fresh air, sunlight, and exercise are more important 
 than at any other period of life. 
 
 It has already been noted that at the end of the seven- 
 teenth century the population had doubled as compared 
 with what it was at the close of the sixteenth century. 
 During the eighteenth century the population was again 
 nearly doubled. This century saw the rise of the great 
 cotton industry which was to pour wealth into the hands of 
 the manufacturer, while it grudged the pittance of a wage 
 paid to the worker who produced this wealth — a pittance 
 barely sufficient to support himself in the most meagre 
 fashion, and quite inadequate to support himself and his wife 
 in anything like decency or comfort. During the first sixty 
 or seventy years of the eighteenth century the new agricul- 
 ture produced abundance, wages rose somewhat, and the 
 position was a little easier. But as the population increased 
 towards the close of the century, so it sank deeper and 
 deeper into misery. There is but little doubt that this 
 misery was largely the fault of the legislature, and of such 
 old abuses as the justices' assessments of wages, and of the 
 enclosures and the appropriation of the commons. The 
 extraordinary position was maintained that the worker, 
 whose labour produced the wealth of the country, was at the 
 same time a burden to the community in that his wages did 
 not sufELce to maintain himself and his family. In place of 
 raising the wage, the only remedy that suggested itself to 
 the Government was the fatal policy of quartering the 
 workers permanently on the rates under the allowance 
 system. Nowhere was the life of the worker more deplorable 
 than in the large towns of Lancashire and in connection with 
 the cotton industry. 
 
 These conditions which arose at this time are the actual 
 conditions which persist to-day, which still have a profound 
 
Economic Factors 349 
 
 effect on the physical growth and well-being of the nation. 
 The grosser and more evident evils such as existed in the 
 employment of child labour and of women in these early days 
 have been swept away. Factories are more carefully con- 
 structed and are regulated and inspected to ensure that the 
 surroundings of the worker are made as wholesome as possible. 
 Death from starvation is no longer common in our large 
 towns ; but the basic evils connected with overcrowding 
 and slum dweUings persist to-day on a larger scale than 
 ever, and blight the growth of the infant from the day of 
 its birth. After the age of three these conditions, though 
 still harmful, press less heavily on the child. From this 
 time onwards the child is allowed the freedom of the streets, 
 but for the first two years it is brought up under conditions 
 entirely inimical to its proper development and growth, at a 
 period when growth is more rapid than at any other time, 
 and when a relatively enormous increase is taking place in 
 the brain and nervous system. 
 
 About 1760 the cotton industry began to oust the woollen 
 industry from what is now peculiarly the cotton district. 
 In the earlier days of the cotton industry a considerable 
 number of weavers worked on their own account, owning 
 their own looms, and at the same time held small pieces of 
 land. Specialism, however, rapidly severed this connection. 
 The making of finer and more complicated fabrics could not 
 be suitably combined with farming. But the spirit of the 
 times was centraUsing management before any mechanical 
 changes of a revolutionary kind had been devised. 
 
 Speaking of the end of the eighteenth century and the 
 beginning of the nineteenth century, Butterworth states 
 that in Oldham a large number of weavers possessed spacious 
 loom-shops, where they not only employed journeymen 
 weavers but a considerable proportion of apprentice children. 
 In 1769 Arkwright obtained his first patent for a machine 
 for spinning cotton yam. Crompton's spinning mule followed 
 in 1775, Cartwright's power loom in 1787, and Eli Whitney's 
 famous gin in 1793. Water power was required to drive 
 Arkwright's machinery, and this tended to cause a decen- 
 
35° Rickets 
 
 tralisation of the industry. Thus in 1788 there were 143 
 water mills in the cotton industry of the United Kingdom 
 distributed as follows : — 
 
 Lancashire . . . . . . 41 
 
 Derbyshire . . . . . . 22 
 
 Nottinghamshire. . . . . . 17 
 
 Yorkshire . . . . . . . . 11 
 
 while the remainder were scattered throughout Scotland and 
 England. Ultimately, the steam engine, first used in the 
 cotton industry in 1785, drew all branches of the industry 
 into towns and centralised it in the cotton districts proper. 
 The manufactures were entirely taken out of the English 
 cottages and farm-houses. 
 
 The sudden development of manufacturing, and the sub- 
 stitution of mere mechanism for the skill of the individual 
 operative, resulted in a demand for cheap child workers. 
 The employment of children soon became general, and large 
 numbers were crowded together in factories before the change 
 had attracted much attention. It began with the apprentice 
 system, children being procured from the workhouses of 
 London, Birmingham and Northern England. Arrangements 
 which would now be considered revolting were often made 
 between the manufacturers and the parish workhouses for 
 bands of children for a number of years, in which the con- 
 dition of the children was totally disregarded. Such, for 
 example, were the provisions whereby it was agreed that 
 with every twenty sound children, one idiot child should be 
 taken. 
 
 A long struggle now began to improve these conditions, 
 but so different was the point of view, that in the first half 
 of the nineteenth century it may be said that every political 
 economist opposed factory legislation, and the manufac- 
 turers were unanimous in opposition to any abridgment of 
 the right to employ children. In 1784 the magistrates of 
 Lancashire passed a resolution that apprentices should no 
 longer work in the night or more than ten hours a day. In 
 1802 Sir Robert Peel secured the passage of a bill abolishing 
 
Economic Factors 351 
 
 the apprentice system, while the Act of 1818 is still con- 
 sidered an excellent code for factory legislation. In 1833 
 an important measure was passed curtaiUng the abuse of 
 child labour, enforcing some education, and providing for 
 factory inspectors, of whom there were at first only four. The 
 Act of 1844 included women under the term " young per- 
 sons." The proportion of young persons, women and 
 children, engaged in the cotton industry is so high that most 
 regulations affecting them, for example, those relating to the 
 hours of labour, must practically be extended to all cotton 
 operatives. This Act killed night work, for young persons 
 and children were not allowed to work at night. In 1847 
 the ten hours Act was passed, and a further reduction of the 
 hours to 56^ was secured in 1874, which was cut down by 
 another hour in 1901. 
 
 An exceedingly complex state of affairs had now arisen, 
 the consideration of which is of the first importance in con- 
 sidering the aetiology of rickets, and the measures which are 
 required for its prevention and cure. 
 
 Sanitation as understood to-day was non-existent ; food 
 was dear, and the reward of labour was such that the worker 
 lived on the verge of starvation, and at all times his food was 
 insufficient in quantity and poor in quality. The workers 
 lived in jerry-built houses in courts and alleys under con- 
 ditions which were prejudicial to the health of the parents, 
 and were pecuUarly dysgenic in that they bore heavily on 
 the pregnant and nursing mother, and on the young infant. 
 Not only were these conditions inimical to health, but they 
 were contrary to all sense of decency. 
 
 The first two factors, sanitation and feeding, improved 
 enormously during the nineteenth century ; the housing 
 question has unfortunately stood still and remains the essen- 
 tial factor which tends to pervert the growth and develop- 
 ment of the nation to-day. 
 
CHAPTER XXIV 
 
 Conditions Present in Slum Areas which Tend to Pro- 
 duce Rickets. The Conditions in North-East London, 
 with a Statistical Enquiry into the Incidence of 
 Rickets in this Area 
 
 The vile conditions which had been allowed to invade the 
 slum areas of all large towns naturally brought retribution in 
 their train. The state of health of the inhabitants was 
 deplorable, and the mortality, especially the infant mortality, 
 was high. But what alarmed the nation was that these 
 areas formed centres from which epidemics of infective 
 disease spread. It began to be realised that it was not 
 possible to set the slum areas apart, and to treat them as if 
 they did not exist. They forced themselves on the attention 
 of the wealthy by invading their homes. Typhus is a disease 
 peculiarly dependent on overcrowding, want of ventilation, 
 filth, debility, and privation, and epidemics were common 
 up to as late as 1815. Typhoid fever, which was only 
 differentiated from typhus by Jenner in 1850, is clearly 
 traceable in earlier records. Epidemic diarrhoea was a 
 frequent scourge. Want of ventilation and light are conducive 
 to a high mortality from diarrhoea. Among the common 
 conditions which are harmful in this way are narrow, dark 
 courts and streets, obstructive walls or buildings, back to 
 back houses, overcrowding, and neglect of ventilation of 
 rooms.* Smallpox was rife, and had been so for a long 
 period. The " bills of mortality " show that upon the 
 average 7 to 9 per cent, of the persons buried in London 
 during the seventeenth and eighteenth centuries had died 
 from smallpox, and in epidemic years the proportion often 
 rose to 13, 15 or even 18 per cent. During the thirty-one 
 
 * " Hygiene and Public Health," by B. Withers Whitelegge. London, 
 iSgo. 
 
 352 
 
Conditions Present in Slum Areas 353 
 
 years 1770-1800, smallpox caused 59,253 out of the 626,530 
 deaths in London, or 9-i per cent. 
 
 Such were some of the acute conditions which helped to 
 swell the mortaUty tables, and which drew the attention of 
 the Government to the urgent need for reform. It can 
 readily be understood that in such areas healthy normal 
 growth was and is impossible. Severe and fatal epidemics 
 are sensational episodes in the life-history of a nation, and 
 cannot be ignored. But conditions which blight the mental 
 and physical growth of the people without producing a high 
 mortality have been lightly passed over. It is only since the 
 late war, when an urgent call was made upon the effective 
 manhood of the nation, that it was realised how alarmingly 
 the country fell short of what, under happier conditions, 
 might reasonably have been expected. Nor is the falling 
 off due to gross disease so much as to defective growth 
 and development, an insidious process sapping the very 
 vitaUty of the nation. 
 
 The constant recurrence of typhus and other infective 
 diseases in these slum areas and their frequent spread to the 
 houses of the well-to-do, at length alarmed the nation, and 
 in 1844-1845, a Royal Commission reported on the state of 
 the large towns and populous districts, and the conditions 
 which led to high mortality. Some striking pictures are 
 drawn of the unhappy conditions under which the working 
 class of that time, throughout the whole country, lived and 
 laboured. 
 
 Dr. Duncan deals with the conditions met with in Liver- 
 pool.* The census of 1841 showed the population to be 
 223,054, of whom 160,000 belonged to the working class. 
 Large numbers of these lived in courts and cellars. Courts 
 usually consist of two rows of houses facing each other, with 
 an intervening space of from nine to fifteen feet, having from 
 two to six or eight houses in each row. The court com- 
 municates with the street by a passage or archway about 
 
 * " On the Physical Causes of the High Rate of MortaUty in Liverpool," 
 by W. H. Duncan, M.D., 1844, Appendix to First Report of the Com- 
 missioners of Inquiry into the State of Large Towns and Populous Districts, 
 1844. 
 
 A A 
 
354 Rickets 
 
 three feet wide. The further end of the court may be built 
 in by a high wall or may be blocked up by the back or side 
 of an adjoining house. The court forms a cul-de-sac with a 
 narrow opening which prevents the entrance of fresh air 
 and effectually interferes with its circulation. The houses, 
 three stories high, contain three rooms of about ten or 
 eleven feet square, and are usually built back to back, so 
 that no through draught is possible. In 1842 the town 
 council estimated that there were in Liverpool 1,892 courts 
 containing 10,692 houses and 55,534 inhabitants. That is 
 to say, one quarter of the whole parochial population and 
 more than one third of the working classes were resident in 
 courts. It was estimated that there were 6,294 inhabited 
 cellars in Liverpool containing 20,168 inhabitants. These 
 cellars were from ten to twelve feet square, generally flagged, 
 but frequently having only the bare earth for a floor, and 
 were sometimes less than six feet high. There was often no 
 window, so that light and air gained access only by the door. 
 The streets, the report states, in the working-class areas are 
 on an average eight yards wide. Each house is occupied 
 by two or more families exclusive of the cellar, and most of 
 the densely peopled lodging-houses are in the street. There 
 is no place for the disposal of refuse, and Dr. Duncan states 
 that he does not know of a single court in Liverpool which 
 communicated with the street or with a sewer by a covered 
 drain. The soil of the courts and streets became saturated,, 
 and contaminated the walls of the cellars in which large 
 numbers of the population lived. Dr. Duncan points out 
 that these conditions contribute to a high mortality : (1) by 
 deteriorating the general health of the inhabitants and 
 rendering them prone to the attacks of nearly all diseases ; 
 (2) by inducing the common fever of the country — typhus 
 fever ; (3) by their effects , on the organs of respiration. 
 Before the same Royal Commission, Dr. P. H. Holland gives 
 evidence dealing with the working-class area of Chorlton- 
 upon-Medlock, one of the townships of the borough of Man- 
 chester. He divides the streets into three classes, the third 
 being the worst. The houses in each class of street he also 
 
Conditions Present in Slum Areas 
 
 355 
 
 divides into three, the first being of ample size and having 
 yards, lobbies and kitchens and water laid on. These houses 
 exceed £20 a year in rent. The second class of house is the 
 better sort of cottage with a back door, while the third or 
 worst conditioned class has no back door allowing of through 
 ventilation, and there is no yard and no privy and no water 
 laid on. The mortality in the best houses of the first class 
 of streets is 1-9 per cent, per annum, while in the third-class 
 houses of the worst streets it is 4 per cent, per annum. 
 Worked out over a period of five years ending June, 1843, 
 the mortality in the various classes of houses and streets 
 may be shown as follows : — 
 
 Classes of 
 Streets. 
 
 Classes of 
 Houses. 
 
 Computed 
 Population. 
 
 Rate of 
 Mortality. 
 
 I ... 
 
 2 
 
 3 
 
 ( I 
 { \ 
 
 1 I 
 
 ■2 
 
 3 
 
 5.143 
 
 4.350 
 
 980 
 
 1.431 
 5.094 
 2,780 
 
 820 
 4.074 
 
 Per cent. 
 1-95 or I in 51 
 2-2 „ I „ 45 
 2-7 .. I .. 36 
 
 1-8 „ I „ 55 
 2-6 „ I „ 38 
 2-8 „ 1 „ 35 
 
 2-8 „ I „ 35 
 4 .. I .. 25 
 
 Dr. Holland observes that the worst class are the worst 
 fed, being the poorest, and that the individuals are fre- 
 quently dissipated and improvident. The poor districts 
 have a higher proportion of children than the wealthier dis- 
 tricts. But Dr. Holland, like all the other observers, agrees 
 that it is the housing condition and not want of food which 
 is the cause of the greater mortality and incidence of ill- 
 health. Holland closes by stating : " When we find the 
 rate of mortality four times as high in some streets as in 
 others, and twice as high in whole classes of streets as in 
 other classes, and further find that it is all but invariably 
 high in those streets which are in bad condition, and almost 
 invariably low in those whose condition is good, we cannot 
 
3S6 Rickets 
 
 resist the conclusion that multitudes of our fellow-crea- 
 tures, hundreds of our immediate neighbours, are annually 
 destroyed for want of the most evident precautions." 
 
 In 1855, Dr. A. Schoepff Merei, who had practised in 
 Buda Pesth, and who afterwards practised for some years 
 in Manchester, wrote a very valuable book on the subject of 
 rickets.* In both towns he had made a special study of the 
 disease, which was exceedingly common in the Pesth division 
 of Buda Pesth and also in Manchester. He finds it more 
 common in Manchester than in almost any other town in 
 England, and markedly more so than in Liverpool, which is 
 only thirty miles away. He comes to the conclusion that 
 neither climate nor unsuitable diet accounts for the great 
 frequency of its occurrence, though the conditions of life are 
 such that both these factors exert a more powerful influence 
 than they otherwise would, had the housing conditions been 
 less defective. The essential cause of the disease, he believes, 
 is to be found in the vast extent of overcrowded narrow 
 quarters. The air of these vast central quarters of Man- 
 chester and Salford, he states, is charged with animal exhala- 
 tions, and carbon and sulphur vapours from the smoke, and 
 as we pass away from these centres the disease decreases in 
 frequency. 
 
 In 1844, Frederick Engels f describes the state of the 
 working class in Manchester, but unfortunately he tends to 
 exaggerate what required no elaboration but only a simple 
 statement to be convincing, and he attempts to deal with 
 the intimate life of the common people, with which, from 
 the nature of things, he could not have been very familiar. 
 But making allowance for this tendency to over-statement, 
 the picture he draws is vivid enough to convince one that 
 it is not far from the truth. Forty to fifty thousand persons 
 are stated to dwell in cellars in Manchester and its suburbs, 
 equal to about 12 per cent, of the working class. The 
 streets are described as filthy and narrow in the slum areas, 
 
 * " On the Disorders of Infantile Development and Rickets," by 
 A. Schoepff Merei, London, 1855. 
 
 t " Condition of the Working Class in England in 1844," Frederick 
 Engels, London, 1892. First published in Germany in 1845. 
 
Conditions Present in Slum Areas 357 
 
 with offal lying around everywhere, and swine in the streets 
 feed on decayed vegetables. The streets are badly drained. 
 The houses have no useful windows and no ventilation, and 
 if the windows did open to admit of air from the outside, the 
 air of the streets is also foul and putrid. The clothing of the 
 people is inadequate ; there is very little wool and no linen. 
 The working classes have no property of their own. The 
 dwellings are everywhere badly planned and badly built, 
 and are allowed to fall into disrepair. The inhabitants are 
 confined to the smallest possible space, and at least one family 
 usually sleeps in each room. The food is in general bad, 
 often almost unfit for use, and in many cases, at least at 
 times, it is insufficient in quantity. From the vitiated air 
 of the streets the still more vitiated air of the rooms con- 
 taining whole families has to be replenished. The cellars 
 are damp and garrets leak, and the unfortunate inmates live 
 in the greatest discomfort. Such are some of the conditions 
 described by Engels as prevailing in Manchester in 1844, 
 and it is not surprising that he notes that the inhabitants 
 are narrow-chested, with pale, sallow complexions. A 
 similar type, he states, is to be met with in London. 
 
 D. B. Reid * reports on the northern coal mine district, 
 including Newcastle, Gateshead, North Shields, South 
 Shields, Sunderland, Durham, and Carlisle. He shows that 
 the towns and villages present abundant evidence of the 
 causes of the high rate of mortality. Leading streets may 
 be moderately favourable, but on turning into the lanes and 
 courts and alleys frequented by the poor, the conditions 
 indicate the accumulated influence of evils that must have 
 been progressing over a long period, and augmenting with 
 the increase in density of the population. He finds these 
 habitations for famiUes destitute alike of adequate accom- 
 modation for the separation of the sexes, and even of those 
 conveniences which common decency requires ; the absence 
 of a sufficient and easily accessible supply of wholesome water 
 
 • " Report on the Northern Coal Mine District," by D. B. Reid, 
 Appendix to Second Report of the Commissioners of Inquiry into the State 
 of Lrarge Towns and Populous Districts, 1845. 
 
358 Rickets 
 
 and the utter inefficiency of the means resorted to for 
 cleansing, drainage and sewerage, are evils that press 
 heavily upon a large number of the humbler classes in every 
 one of these towns. A vast amount of misery, disease, 
 poverty and death might, according to Reid, be prevented 
 by the introduction of suitable sanitary regulations. 
 
 Such were some of the conditions prevailing in the first 
 half of the nineteenth century. It will be useful now to sketch 
 some of the conditions under which the working classes of the 
 present day live, in this the first part of the twentieth century. 
 
 In London at the present day there is a rich field for the 
 study of the social conditions of the working class. The 
 industrial side of London differs very largely from that of 
 the provinces. In London there is no staple industry, such as 
 cotton in Manchester, wool in Yorkshire, or shipbuilding 
 and engineering at Newcastle. Trades decline in London 
 and shift their locality, but the body of trade shows no 
 decrease, and the industrial position of London, both as 
 regards variety and magnitude, remains unique. An interest- 
 ing feature of industry in London is that there is still a large 
 class of small workers who carry on trade at their own homes, 
 either supplsdng the material, or having it supplied to them. 
 This is a quaint relic of an older industrial system which still 
 has a strong hold in London. In the provinces the trades 
 are larger and more completely centralised. In London 
 one half of the population lives, as it were, on the other half, 
 and there is an advantage in having these small methods of 
 business which allow of close touch with both customers and 
 employees, and which, if they fail and are superseded, cause 
 comparatively little economic disturbance. These smaller 
 businesses come and go and alter in a way that larger under- 
 takings could not do. The tendency to physical deteriora- 
 tion in London is being constantly stemmed by the influx of 
 fresh blood from the provinces. If left to itself, the industrial 
 force of London would rapidly decay, and as it is, the physical 
 deterioration of its workers tends to produce a supply of 
 workers who are inefficient, and therefore ill-paid, and who 
 tend to keep down the wages of the more efficient. 
 
Conditions Present in Slum Areas 
 
 359 
 
 The presence of the alien in such trades as jewellers, 
 furriers and tailors, also tends to add to the stress on indi- 
 vidual wage-earners, though, as Booth points out, this process 
 is not necessarily inimical, for this influx may actually 
 create new industries, or may attract trade to London 
 from the efficiency of the labour in certain directions. 
 
 Fig. 9. 
 
 Charles Booth * has made a very valuable and extended 
 
 study of the conditions of the labouring class in London, 
 
 and has produced a work which will always be a valuable 
 
 mine of information for the social worker. In the accom- 
 
 panpng diagram a sector of London is taken lying between 
 
 * " Life and Labour of the People in London," by Charles Booth, 
 Macmillan & Co., London, 1902. 
 
360 Rickets 
 
 Kingsland Road, running due north, and the River Thames, 
 which may be roughly taken as lying at right angles. A 
 circumference drawn three miles outside the city boundary 
 encloses a quadrant which comprises within its boundaries a 
 large, populous, industrial area of London (see Fig. 9) . In the 
 upper or northern half of Hackney the houses are large and 
 commodious, and accommodate the richer class from the 
 city who find it convenient to live near their work, such as 
 those who work in the various city markets, stockbrokers, 
 city clerks and so on. This portion of Hackney is healthily 
 situated on the northern heights of London, and from the 
 summit it slopes down northwards and eastwards to the wide 
 marshes of the valley of the River Lea. The Hackney 
 Marshes extend eastwards, and are still but little built upon. 
 
 But the remainder of Hackney, and from there south to 
 the river, is densely packed with an industrial population of 
 the poorer type, among whom lives a large Jewish alien 
 population, which adds a touch of oriental colour to what is 
 often a drab and dreary prospect. 
 
 Booth calculates that the population of this sector is 
 909,000, and he divides the community into eight divisions, 
 which may be represented as follows : — 
 
 (A) lowest class of occasional labourers, "i _ «, j^ ^qq 
 
 loafers and semi-criminals ; — , , or 
 
 (B) class with casual earnings — very poor ; 
 
 (C) class with intermittent earnings ) 
 
 (D) class with small regular earnings J P°°'' 
 
 (E) class with regular standard earnings ; 
 
 (F) higher class labour ; 
 
 (G) lower middle class ; 
 (H) upper middle class. 
 
 35 
 
 per cent, 
 classes in 
 poverty ; 
 
 577,000. or 65 
 per cent, 
 classes in 
 comfort. 
 
 Naturally, the proportion varies in different districts. Thus, 
 St. George's in the East, which is the poorest district, has 
 23,000, or 49 per cent., of its population living in poverty, 
 while only 24,000, or 51 per cent., live in comparative comfort. 
 When two or more persons make their home in one room, or 
 four or more in two rooms, or six or more in three rooms, 
 overcrowding is considered to exist, and these persons are 
 
Conditions Present in Slum Areas 361 
 
 considered poor. Speaking generally, the family consists of 
 4| to 5 members in the labouring classes, and of 3^ to 4J in 
 the professional classes. Taking the family as a unit con- 
 sisting of 4'33 per cent., the term " poor " is held to apply 
 to those where the wage of the head of the family does not 
 exceed from 18s. to 21s. weekly. The " very poor " are 
 those who live three or more in one room, and whose wages 
 fall below this standard. In the poorer parts of London 
 most of the houses have a frontage of from twelve to fifteen 
 feet only, and of this about three feet is devoted to entrance 
 passage and stairs. The front room on the first floor has 
 usually two windows, and occupies the whole breadth of the 
 house. This may be repeated on the floor above. The other 
 rooms are all somewhat smaller. The largest size commonly 
 found is about twelve feet by fourteen feet, and the smallest 
 about eight feet by eight feet. The height from floor to 
 ceiling varies from eight feet to ten feet. It is in rooms of 
 this character that 314,000 persons in this one sector of 
 London are living two or more in one room. The majority 
 of these persons are not in actual want. As Booth states, 
 though they are neither ill-nourished nor ill-clad, according 
 to any standard which can reasonably be used, their means 
 are barely sufficient for decent independent life, and their 
 lives are an unending struggle and lack comfort. 
 
 Tested by the conditions of overcrowding in which they 
 live, street-sellers, coal porters and dock labourers are the 
 poorest section of the population. The following classes are 
 taken from all over London, and not only from the north- 
 eastern sector, and the tables show the degree of overcrowding 
 present in the various classes : — 
 
 
 Families living two 
 
 Families living three 
 
 
 or more m one room. 
 
 or more in one room. 
 
 (1) street-sellers 
 
 ... 69 per cent. 
 
 36 per cent. 
 
 (2) Coal porters 
 
 ... 65 „ 
 
 30 „ 
 
 (3) Dock labourers 
 
 ... 63 
 
 28^ „ 
 
 (4) General labourers 
 
 ... 58J „ 
 
 26^ „ 
 
 (5) Carmen 
 
 ... 56 
 
 27 „ 
 
 In this scheme the figures in the first column naturally 
 include those in the second column. These five sections of 
 
362 Rickets 
 
 the labouring community include in all 88,469 heads of 
 famihes, or a total of 399,690 persons, of whom no fewer than 
 235,281 exist under crowded conditions, that is two or more 
 in one room, and of these 109,390 are so crowded as to be 
 Uving three or more persons in one room. These figures 
 indicate an appalling amount of poverty and discomfort 
 among those engaged in these occupations. Not only is 
 there poverty and discomfort, but ill health and increased 
 mortality are the necessary accompaniments. Nowhere do 
 these conditions teU more directly than on the young infant. 
 In these houses when the family lives in two or three rooms 
 there is no proper kitchen, and the cooking and washing have 
 to be done in the living rooms. Such a thing as a bath is 
 unknown. For long periods during the winter months the 
 child is kept continuously indoors in a close and confined 
 and vitiated atmosphere. Sunshine, fresh air, and exercise 
 are all lacking at this, the most critical period of its growth. 
 The child Uves in a close and foul atmosphere, in which one 
 would not dream of attempting to grow the hvunblest form 
 of plant life. As regards food, the baby may not fare so 
 badly. Whoever goes short, care as a rule is taken that 
 the infant receives its due share of nourishment. What- 
 ever milk is obtained is reserved for the infant. 
 
 To revert to the north-east quadrant of London already 
 marked out, the following statistics are the result of an 
 enquiry to ascertain the rate of incidence of the disease, 
 among some fifteen hundred of the London Coimty Council 
 school children living in this area. It was found that rickets 
 was exceedingly common. It is not an easy matter to get 
 uniform statistics as to the degree of prevalence of rickets 
 throughout the country. Rickets is eminently a curable 
 disease and tends to end in recovery. If in school statistics 
 only children actually suffering from rickets at the time of 
 examination are shown, the figures wiU be very misleading, for 
 by the time the children reach school age, from three to five, 
 they are making their way towards partial recovery. In the 
 East End of London, by taking into consideration the stigmata 
 of rickets left in the skeleton, teeth and elsewhere, it was 
 
Conditions Present in Slum Areas 363 
 
 found that 80 per cent, of the children examined were 
 suffering or had suffered from rickets in the first two or three 
 years of their lives.* So commonly is this disease found that 
 it may be stated that practically all children living under the 
 slum conditions which prevail in the East End of London 
 have to struggle through a rickety phase of their existence, 
 during which the whole tide of growth is profoundly dis- 
 turbed, and permanent damage is done to the body tissues 
 and skeleton, and even to the sensitive tissues of the central 
 nervous system. The only means by which rickets can be 
 diagnosed with certainty is by making a histological exami- 
 nation of the bones themselves. Schmorl found in the post- 
 mortem examination of 386 children djdng under the age of 
 four years that 345, or 89-4 per cent., presented histological 
 evidence of rickets. These figures agree with the rate of 
 incidence of the disease found clinically in the East 
 End of London. Before statistics can be relied upon 
 there must be a uniform standard for observers, and it is 
 essential in examining children after the age of three or four 
 that consideration should be given to the signs of past rickets, 
 for many children who have had the disease are by that time 
 making rapid strides towards recovery. In making the 
 above-mentioned examination the card given on page 364 
 was used for record purposes. 
 
 For the first enquiry, one thousand children were taken 
 from schools in the districts of Whitechapel and Stepney. 
 These schools were largely filled by the alien population 
 resident in these parts, and about 80 per cent, of the children 
 were Jewish. But it must not be supposed that the disease 
 is more common among the Jewish children than among 
 the non-Jewish. Rickets was found to be equally common 
 among the non- Jewish children, and was of a notably 
 severer type than among the better-fed Jewish section. 
 Indeed, race and feeding seemed to have no effect on the 
 incidence of rickets, but, as might be expected in a nutri- 
 tional disease, feeding had a marked effect on the severity 
 
 • " Defective Housing and the Growth of Children," by J. Lawson 
 Dick, London, 1919, Chapter II., p. 22. 
 
Name 
 
 RICKETS. 
 
 Date of birth 
 
 Address 
 
 School 
 
 Standard 
 
 Age 
 
 Height 
 
 Weight 
 
 Mental capacity 
 
 Bright 
 
 Average Backward 
 
 Breast fed 
 
 
 Delayed 
 
 Walking 
 
 
 development 
 
 Speech 
 
 
 Beaded ribs 
 
 
 Cranial signs 
 
 
 Catarrhal signs 
 
 
 Hypoplasia 
 
 Deciduous 
 
 
 Permanent 
 
 
 Other defects 
 
 
 Nutrition 
 
 
 Remarks 
 
 
 364 
 
Conditions Present in Slum Areas 365 
 
 with which the individual child was affected. The excellent 
 state of nutrition of the Jewish child is a factor of much 
 importance in considering the part played by the nutrition 
 of the child on the severity of rickets. Jewish women make 
 excellent mothers, in so far as their children are well fed and 
 clothed. Indeed, the tendency is to overclothe the child, 
 and it is often difficult to persuade the mother to discard the 
 extra waistcoats and jerseys with which the child is ham- 
 pered. But the essential point is that these children do not 
 suffer from cold, bleak winters to the same extent as 
 poorly-clad non- Jewish children. The fat nutrition of these 
 children is usually very good, and yet, in spite of excellent 
 nutrition, rickets is exceedingly common. 
 
 Early Feeding during Infancy. — Of these one thousand 
 children : — 
 
 814 per cent, were breast fed, 
 18-6 „ „ artificially fed. 
 
 Almost all bottle-fed children were brought up on cow's 
 milk ; comparatively few Jewish mothers use patent foods 
 or condensed milk. Breast-fed children are children who 
 were suckled on the breast for a period of six months or 
 more ; if they were not suckled for six months, they are 
 included among the children who were not breast-fed. Of 
 children nursed on the breast the following is the duration 
 given in percentage results : — 
 
 2 per cent, suckled from 6 to 9 months. 
 17 „ „ 9 to 12 
 
 61 „ „ 12 to 18 
 
 20 „ „ 18 to 24 
 
 That is, 81 per cent, of these mothers gave their children the 
 breast for periods varying from twelve months to two 
 years. This prolonged lactation is important, but care must 
 be taken not to exaggerate its influence, as from eight to 
 nine months onwards the mother gives additional food from 
 the general table besides the breast milk. But breast milk 
 is the main support of the child for the first eighteen months 
 or two years. On the other hand, at the Hackney Centre 
 
366 Rickets 
 
 for mothers, where the mothers are ahnost entirely Chris- 
 tian, out of three hundred attending during the year : — 
 
 57-5 per cent, nursed their babies entirely on the breast, 
 20-5 per cent, nursed their babies partly on the breast and 
 
 partly on the bottle, 
 22 per cent, were bottle fed. 
 
 Unfortunately many of these mothers were out working 
 during the day, and so had to give the baby the bottle during 
 the day, reserving the breast feeding for the night. The 
 Jewish mother seldom goes out to work in this way. Among 
 the non- Jewish mothers the use of patent foods, especially 
 condensed milk, is common. Yet even in the case of the 
 Christian mothers the figures show that 78 per cent, nurse 
 their children either wholly or partially on the breast. The 
 poorer classes of mothers, Jewish or Christian, do their duty 
 to their babies in the matter of breast feeding. The fault so 
 far does not lie with the mother. 
 
 Of the one thousand children examined : — 
 
 798 were rickety = 80 per cent. 
 202 were not rickety = 20 
 
 It must be understood that these 798 children were not 
 necessarily suffering from rickets at the time of the examina- 
 tion ; indeed, the majority had recovered, but showed signs 
 of having suffered at one time from rickets, and these 
 rickety stigmata persisted through the child's school life. 
 Rickets is essentially a disease of the first two years of life ; 
 but its consequences are far-reaching, and the persistence of 
 the recognisable physical signs affords an index to the last- 
 ing damage done to delicate tissues, especially those of the 
 nervous system. 
 
 It is still taught that, for all practical purposes, breast 
 feeding excludes rickets. This is a grave error. Of breast- 
 fed children 72*5 per cent, were rickety ; while of bottle- 
 fed babies 87 per cent, were rickety. A percentage of 14"5 
 fewer children showed signs of rickets amongst those who 
 were breast fed ; but this still left 72-5 per cent, breast fed 
 who showed evident signs. 
 
Conditions Present in Slum Areas 367 
 
 Nutrition of the Rickety Children. — The state of nutrition 
 of those eight hundred children who showed evident signs of 
 rickets may be assessed in three groups : — 
 
 (1) of very good nutrition, of which there were 23 per cent. ; 
 
 (2) of good nutrition, of which there were 57 per cent. ; 
 
 (3) of bad nutrition, of which there were 20 per cent. 
 
 In only one-fifth of these children was the nutrition 
 decidedly poor. This result is very good, and would, in the 
 East End of London, be obtained only in a Jewish school. 
 For this reason Jewish children were purposely selected, for 
 here we have a natural experiment at hand, where good 
 nutrition, notably good fat nutrition, is associated with 
 extremely defective housing conditions as regards want of 
 ventilation, overcrowding, and disregard for general clean- 
 liness. 
 
 Beaded Ribs and Chest Deformities. — ^The chest signs of 
 rickets are the most common and most constant. Beading 
 of the ribs, if slight and if present alone, was not taken as a 
 sign of rickets, unless there were chest deformities or cranial 
 signs to confirm the diagnosis. In the ordinary inspection 
 of school children beading of the ribs will be found in over 
 80 per cent, if carefully sought. With this beading of the 
 ribs certain chest deformities are frequently associated. 
 Asymmetry of the chest is common, such as a tendency to 
 flattening at the left apex, with a compensatory projection 
 to the right side of the lower part of the sternum, where it 
 meets with the lower true ribs. This is usually the result of 
 a slight lateral curvature, which, in the milder cases, can 
 often be diagnosed more easily from the front than by 
 examination of the spine itself. Which apex is flattened and 
 which shoulder is elevated will vary with the form of lateral 
 curvature present. It is noteworthy that impairment of 
 the resonance at one or other apex, with flattening, is fre- 
 quently due in school children to distortion of the chest and 
 not to tubercle. Another of the slighter deformities of the 
 chest is an elevation of the manubrium stemi at the sterno- 
 clavicular joints, so that the whole chest seems as if it were 
 tilted forwards and raised. The everted edge of the margin 
 
368 Rickets 
 
 of the ribs where it has been pushed outwards by the enlarged 
 abdominal organs, and the associated transverse Harrison's 
 sulcus associated with falling in of the ribs above this margin 
 are well known. Not infrequently the whole sternum is 
 pushed forwards, and the ribs tend to sink in at the sides, to 
 produce the various forms of pigeon breast so characteristic of 
 rickets. When all the ribs are soft the whole sternum proj ects, 
 and the chest is furrowed laterally as high as the second rib. 
 Not infrequently, however, the upper part of the chest is 
 moderately well expanded, and the somewhat keel-shaped 
 protrusion of the sternum is confined to the lower end, and 
 the retraction of the ribs to the infra-mammary region. The 
 beading of the ribs is probably Nature's attempt to buttress 
 up the weak point at the junction of the ribs with the costal 
 cartilages. The constantly varying strains on this part tend 
 to produce an irritative overgrowth, the result of which 
 becomes palpable very early in the child's Hfe, and which is 
 greater on the inner side of the ribs than it is on the outer. 
 
 These defects are common in children not at first 
 suspected of rickets. 
 
 Antero-posterior flattening of the chest is very common, 
 and is often associated with the stooping shoulders and 
 arched back so commonly seen in rickety subjects. 
 
 Cranial Signs. — ^These are only second to the chest signs 
 in frequency and importance. Of the eight hundred rickety 
 children both cranial and beaded ribs were present in 70 per 
 cent. ; beaded ribs alone were present in 24 per cent. ; cranial 
 signs alone were present in 6 per cent. 
 
 In the early months of infancy, when rickets is in active 
 progress, the cranium typically has a somewhat expanded 
 appearance as if the bones were thinned out. The widely 
 open f ontanelle and the thin skin with the blue veins showing 
 through over the prominent forehead form a characteristic 
 picture. When we have to deal with children of school age, 
 the expanded appearance is lost, and the head is now 
 massive-looking, and gives an impression as if the bones 
 were greatly thickened, as is usually the case, especially along 
 the lines of the sutures. There is a characteristic heaping-up 
 
Conditions Present in Slum Areas 369 
 
 of bone in the region of the anterior fontanelle, and from 
 that in a somewhat broad band along the line of the coronal 
 suture. Often the whole frontal bone appears thickened 
 and the forehead prominent and projecting, but there is not 
 the same tendency to bossing on the frontal region as in 
 congenital syphilis. Very common and striking is the bossing 
 over the parietal regions behind, which forms one of the most 
 characteristic and persistent signs of rickets in the child's 
 skull. (See Fig. 3, p. 119.) 
 
 Tonsils and Adenoids. — Tonsils and adenoids are com- 
 monly associated with rickets. Thus, of eight hundred 
 rickety cases, 21 per cent, suffered from either enlarged 
 tonsils or adenoids. 
 
 Of these children suffering from either tonsils or 
 adenoids : — 
 
 14 per cent had enlarged tonsils, 
 
 20 per cent, had adenoids, 
 
 66 per cent, had both conditions. 
 
 Ancsmia was found to be marked in 20 per cent, of the 
 rickety children. 
 
 Catarrh. — Associated with the conditions of tonsils and 
 adenoids, and anaemia, is that of catarrh, which was carefully 
 enquired into, to ascertain what influence rickets might have 
 in producing catarrhal conditions likely to predispose to 
 tubercle. Catarrh was present in 18 per cent, of the rickety 
 children, mostly cases of persistent bronchial catarrh and 
 nasal catarrh, the bronchial condition being much the more 
 common. Cases of acute coryza and ordinary coughs and 
 colds which might be accidental were not included. These 
 catarrhal defects were common among Jewish children, but 
 still more so among the poorer non- Jewish children. This 
 difference in favour of the Jewish children is possibly due to 
 their good fat nutrition, which tends to prevent their deve- 
 loping catarrhal conditions. 
 
 Other Defects associated with Rickets. — Of other defects, 
 several were characteristic, but were not present in sufficient 
 numbers to be set down in percentage results. Stooping 
 
37° Rickets 
 
 shoulders and lateral curvature are common, though, as 
 already stated, the slighter forms of lateral curvature are 
 more often suggested by flattening at one apex and pro- 
 minence of the opposite side of the chest, with raising of one 
 shoulder, than by an actual examination of the spine itself. 
 Syphihs and rheumatism were exceptionally found in a few 
 cases. 
 
 While pulmonary tubercle was not often found, en- 
 largement of the submaxillary and cervical glands was 
 common. This enlargement of the glands was usually of a 
 discrete or shotty nature, and glandular abscesses of the 
 neck were quite infrequent. This enlargement, indeed, is a 
 part of the general hypertrophy which in rickets takes place 
 in the whole of the lymphoid tissue, lymphatic system, and 
 spleen. 
 
 A very characteristic defect, present fairly frequently, 
 was a harsh, dry condition of the skin, especially over 
 the back of the upper arm and the back of the shoulders, 
 but not infrequently extending over the whole body and 
 face. As a rule this condition was associated with coarse, 
 dry, lustreless hair, which was often scanty. All these con- 
 ditions have already been dealt with in detail in discussing 
 the changes found in the various systems in rickets. This 
 has already been fuUy dealt with in speaking of skin 
 affections in rickets. 
 
CHAPTER XXV 
 
 The Relationship of Rickets to the National Health as 
 Revealed in the Army Recruiting' Records 
 
 On November 1st, 1917, the Ministry of National Service 
 began its organised work, under the Military Service Acts, of 
 surveying the whole of the nation of military age and 
 classifpng individuals according to their physical fitness. 
 Four grades were constituted, and as a guide to the Medical 
 Boards examining recruits, these were defined as follows : — 
 
 Grade I. — ^men who attain the full normal standard of 
 health and strength, capable of enduring physical exertion 
 suitable to their age : 
 
 Grade II. — those who from various partial disabilities do 
 not reach the standard of Grade I., but who do not suffer 
 from progressive organic disease. They must have fair 
 hearing and vision, and be of moderate muscular develop- 
 ment, and ca;pable of standing a considerable degree of 
 physical exertion not involving severe strain : 
 
 Grade III. — those who present marked physical dis- 
 abilities or such evidence of past disease that they are not 
 considered fit to undergo the degree of physical exertion 
 required for the higher grades : 
 
 Grade IV. — all those who are totally and permanently 
 unfit for any form of mihtary service.* 
 
 The result of grading for the year from November 1st, 
 1917, to November 1st, 1918, gives food for serious reflection. 
 During the year 2,425,184 examinations were made of men 
 of military age. They were classified as follows : — 
 
 Grade I. 
 
 871,769 
 
 36 percent, 
 
 „ 11. .. 
 
 546,276 
 
 22-5 „ 
 
 „ III. .. 
 
 ,. 756,859 
 
 31-5 „ 
 
 .. IV. .. 
 
 250,280 
 
 10 
 
 2,425,184 100 
 
 * Ministry of National Service, 1917-1919, Report (Vol. I.) upon the 
 Physical Examination of Men of Military Age by National Service Medical 
 Boards from November ist, 1917, to October 31st, 1918. 
 
 371 
 
372 Rickets 
 
 That is to say that of every nine men of military age in Great 
 Britain, on the average three were perfectly fit and healthy ; 
 two were upon a definitely infirm plane of health and strength 
 whether from some disabihty or some failure in development ; 
 three were incapable of undergoing more than a very moderate 
 degree of physical exertion and could almost, in view of their 
 age, be described with justice as physical wrecks ; and the 
 remaining man was a chronic invalid with a precarious hold 
 upon life. Full consideration, it is stated in the report, was 
 given to the fact that this was the fourth year of the war, and 
 that already many calls had been made on the manhood of 
 the nation, and also to the fact that the figures represent 
 examinations of men who were examined twice, and who 
 appear as two individuals. But in spite of these facts the 
 investigating committee considered that the above figures 
 fairly represented the health and physique of the general 
 community at this time. 
 
 Such a statement requires the most careful examination. 
 Unfortimately the report does not state on what grounds it 
 was held that these important facts did not affect the results 
 obtained. Of the great value of the figures and the charts 
 obtained as the result of the examination by the National 
 Service boards there can be no question, but the inference 
 drawn from these figures that they form a true estimate of the 
 state of the national health will not bear critical examination. 
 
 Much harm has been done in past years by the publication 
 of alarmist reports as to the health of the nation. These 
 reports have mostly been intended to awaken the country., 
 but have signally failed to carry conviction because it is 
 apparent to the common sense of the people that these state- 
 ments are exaggerated. In school reports high percentages 
 of the children are marked as defective. It is self-evident 
 to the community that if these defective children were taken 
 to their own medical man the parents would be informed 
 that no fear as to the child's health need be entertained, but 
 that some minor defect, such as one or two carious teeth, or 
 some impairment in the vision, or possibly otorrhoea, required 
 attention. 
 
Relationship to National Health 373 
 
 The dangers of such conditions, if neglected, might with 
 advantage be pointed out, and ought to be pointed out, but 
 to mark such children as defective and to draw conclusions 
 by massing such defects together and representing them in 
 percentage results is not only misleading, but has a tendency 
 to defeat its own object. 
 
 The National Service Report makes statements of such a 
 serious nature as to the health of the nation that it is very 
 necessary to enquire into the grounds on which these con- 
 clusions have been come to. It is difficult to believe that 
 the fact that the Ministry only took up its work in the fourth 
 year of the war did not afEect the results obtained. And yet 
 it is stated that while full consideration was given to this 
 fact, the conclusion was come to that it did not materially 
 afEect the result. Certainly in the treatment of the sick and 
 wounded from the V9.rious battle fronts the general expe- 
 rience was that it made a very material difference whether 
 the patient belonged to the original army or to the voluntary 
 recruits on the one hand, or to the defective class who were 
 recruited late in the war, on the other. The men of the old 
 army and the volunteers of the first two years of the war 
 were a class by themselves and had a stamina and a power 
 of resistance to wounds and disease which were of the 
 greatest value in their treatment, factors which were notably 
 absent in the recruit who was accepted late in the war. 
 Again, the fact that a man examined twice or three times 
 was counted as a fresh individual each time is a matter of 
 importance. Many were examined two or more times, and 
 in the majority of cases these were defective men whose 
 enlistment into the service was postponed on that account. 
 Obviously it is of great importance to know the number of 
 men who were so re-examined. 
 
 The fact that in less than 4 per cent, only the decision of 
 the Board was not upheld on appeal, the category being 
 lowered, is thought to be evidence of the accuracy of the 
 Board's work. This is open to the obvious objection that 
 an examination which only classes one man in three as 
 Grade I. does not leave much ground for appeal. The 
 
374 Rickets 
 
 leniency of the examination is also borne out by the fact that 
 in many cases men of low category arriving in Egypt, for 
 instance, were immediately reclassified and placed in 
 Grade I. 
 
 The following are the figures of the full strength in the 
 army and navy as supplied to me by the War Office and the 
 Admiralty up to November 1st, 1917, the date on which the 
 Ministry of National Service took over the recruiting 
 administration. The total number recruited by the War 
 Office from England, Wales, Scotland and Ireland, between 
 the dates August 4th, 1914, and October 31st, 1917, inclusive, 
 was 4,421,694. The approximate strength of the personnel 
 of the navy on November 1st, 1917, was as follows : — 
 
 1. Serving afloat and in naval establishments 327,635 
 
 2. Serving in the Royal Naval Air Service ... 45,133 
 
 3. Serving ashore 41,345 
 
 Total na.va.1 personnel 414,113 
 
 This gives a total of 4,835,807 recruited at home who were 
 already serving on the personnel of the army and navy on 
 November 1st, 1917. These were not all fit men, but the fit 
 men of the nation of miUtary age were certainly included in 
 this nmnber. 
 
 In England and Scotland on this date 11'5 per cent, of 
 the total population was represented by enlistments, and 
 practically one-quarter of the estimated male population was 
 already serving with the army and the navy. It must be 
 remembered that these represented the best element ©f the 
 nation. Large as the numbers were with which the Ministry 
 of National Service dealt, it is reasonable to suppose that 
 the abstraction of such large niunbers of fit men from the 
 male population must have materially affected the results of 
 the examination. 
 
 For these and other reasons, the figures given by the 
 report cannot be accepted as a true estimate of the health of 
 the nation. With this proviso, however, the study of the 
 report is of the greatest value as giving a rough estimate of 
 
Relationship to National Health 37 S 
 
 the existence of an enormous number of disabilities, and a 
 degree of impairment in the national standard of health 
 which had never before been realised. 
 
 Sir Arthur Keith suggested the following standard as one 
 which a fit population might reasonably be expected to 
 
 80%-- 
 
 Keiths Standard 
 
 
 yn"/ 
 
 
 
 I 
 
 \ 
 
 ^n V 
 
 z 
 
 '- 
 
 tU/o — 
 
 
 : 
 
 T/l V 
 
 
 \ 
 
 
 
 : 
 
 40 % 
 
 
 : 
 
 
 : 
 
 E 
 
 ■3/1 V 
 
 \ 
 
 
 
 z 
 
 yn °/ 
 
 
 o 
 
 - CM 
 
 
 
 - 
 
 
 10 % — 
 
 : 
 
 E 
 
 u 
 
 t; 
 
 • 
 
 1 
 
 / 
 
 
 Grade- 
 
 12 3 4- 
 
 attain. A standard which expects to find seventy men who 
 have attained the full normal development of health and 
 strength, and are capable of enduring physical exertion 
 suitable to their age, among every hundred men of mihtary 
 age can hardly be regarded as unduly exacting. 
 
 Below are three graphs taken from the Ministry of National 
 
376 
 
 Rickets 
 
 Service Report which may be usefully contrasted with Keith's 
 standard. These show the actual results obtained by the 
 National Service boards as the result of their examinations. 
 The graph for Great Britain shows the average for the whole 
 country while that for the London and south-eastern region 
 is the lowest result obtained, and that for Wales the highest. 
 
 48 
 
 44 
 
 42 
 
 40 
 
 33 
 
 36 
 
 34 
 
 32 
 
 30 
 
 28 
 
 26 
 
 24 
 
 22 
 
 20 
 
 16 
 
 16 
 
 14 
 
 12 
 
 10 
 
 8 
 
 6 
 
 •4 
 
 2 
 
 O 
 
 GRBAT 
 BRITAIN 
 
 K) 
 
 10 
 
 = n. 
 
 iv:::- 
 
 1 
 
 Z..— 
 
 t 
 
 0^ a 
 
 1 I 2 I 3 1^ 
 
 ^5W\LE5 
 
 -^ 
 
 =4 - i — o — 
 
 % 
 
 t 
 
 5 a « 
 
 O '0 n 
 
 t 
 
 ' \^\^\^ 
 
 No. OF Exams. 2.425. ia-4- | | 17^1 E>3I 
 
 LONDON 0- 
 SOUTHEAST 
 
 -tN 
 
 >0 
 
 --I 
 
 \r, -//■ 
 
 
 
 
 I 2 3 '^ 
 
 ^4 37:400 
 
 It will be seen that all these graphs fall lamentably below the 
 very modest standard suggested. 
 
 Comparing the graphs of the general average for Great 
 Britain with Keith's standard, the results may be sum- 
 marised by saying that in round numbers the physical 
 census showed a shortage of 825,000 Grade I. men, an excess 
 of 61,000 Grade II. men, and the alarming excess of no less 
 than 575,000 Grade III. men, and 190,000 Grade IV. men. 
 
Relationship to National Health 377 
 
 In the following tables the results may be put into figures 
 as follows : Normally any 1,000 young men collected from 
 a population of good health and physique should approxi- 
 mately be divided as follows : — 
 
 Grade I. 
 „ II. 
 „ HI. 
 ., IV. 
 
 700 
 
 200 
 
 75 
 
 25 
 
 that is 10 per cent, of unfit men should be expected. A 
 typical recruiting survey from an industrial town yields the 
 following disastrous results : — 
 
 Grade I. 
 „ II. 
 „ III. 
 „ IV. 
 
 190 
 270 
 410 
 130 
 
 As the committee remarks, this is a serious conclusion which 
 calls for the closest scrutiny.* In considering the healthiness 
 or unhealthiness of certain occupations it must be remembered 
 that there is a constant tendency for the population to grade 
 itself. Attention has already been drawn, in speaking of the 
 industrial population of London, to the steady flux which 
 is constantly going on in the labour market. The environ- 
 ment is such that a steady deterioration occurs in the value 
 of industrial labour which is constantly being made good by 
 the introduction of fresh blood from the country and the 
 provinces. But the position remains serious, for the tendency 
 is to the formation of a large class of inferior labour, notably 
 in the East End of London, which is unable to find a proper 
 wage for its support and readily lends itself to casual and 
 sweated labour. Miners and workers in metals can hardly 
 be said to follow occupations the environment of which is 
 conducive to the preservation of good health, but they are 
 occupations which demand a large output of energy and can 
 only be followed by the healthiest and most muscular section 
 of the community. The labour in these occupations is well 
 paid and attracts the virile portion of the population. Thus 
 
 • Loc. cit., p. 12. 
 
378 
 
 Rickets 
 
 in the western valleys and the eastern portion of Carmarthen 
 the percentage of Grade I. miners reaches a higher point than 
 in any part of Wales ; these miners are usually the sons of 
 farmers who remain on the land and send their sons to the 
 
 SHEFFIELD. 
 
 Crade 
 /nde^e of 
 f/tnejs 
 
 collieries. Therefore the type of man who becomes a miner 
 is good ; he is born and bred on the land in healthy sur- 
 roundings, totally different from those obtaining during the 
 childhood of most of our industrial population. This 
 tendency of the population to grade itself is strikingly 
 exemplified in the case of Leeds and Sheffield, two great 
 
Relationship to National Health 379 
 
 industrial centres lying within thirty miles of each other, and 
 both drawing their labour from a common source. The 
 superiority of physique of the Sheffield worker is well brought 
 out in the accompanying graphs, the result of grading for army 
 purposes during the months of March, May and June, 1918. 
 
 LEEDS. 
 
 60%_ 
 
 5-0% ^^ 
 
 40%:. |_- 
 
 (jRADB 
 Index of 
 F/tfiess 
 
 In Sheffield the industrial population is almost entirely 
 employed in the iron and steel industries — a class of labour 
 which requires men of good physique and wherein there is 
 but little opening for the female worker. In Leeds the chief 
 industry is woollen and cloth manufacture. Artificial silk 
 is also extensively made, and the leather trade is the largest 
 
38o Rickets 
 
 in England. Women are employed in large numbers in the 
 factories. 
 
 Following the law of supply and demand, there is a natural 
 tendency for the available labour to separate itself and to 
 take up the occupation for which it is best fitted physically 
 and temperamentally. The result of this natural cleavage 
 is, that while both towns faU markedly below Keith's stan- 
 dard, Sheffield in the above tables was able to supply 55 per 
 cent. Grade I. men to the army, while Leeds could only yield 
 17'5 per cent. Great caution must be observed in estimating 
 the effect of industrial conditions on adult labour. Thus it 
 might easily be argued that there must be something in the 
 industry of Leeds inimical to the welfare of the worker as 
 compared with the iron and steel industries of Sheffield. If 
 the health of the two towns is viewed from another stand- 
 point a different result is obtained. An excellent criterion 
 of the health conditions of a community is to be found in the 
 incidence of child mortahty. The infant in Sheffield would 
 seem to have many advantages as compared with the child 
 in Leeds. Two important factors are in its favour, namely, 
 the better physique and the greater virility of the father and 
 the fact that the employment of female labour is not common, 
 whereas in Leeds the physique of the parents is poor and 
 female labour is very commonly employed. The result is 
 quite different from what might be expected, for taking the 
 total death-rate from aU causes at ages 0-5 years per 1,000 
 births the figures are : — 
 
 Sheffield 209 
 
 Leeds 202* 
 
 The death-rate for both towns is very excessive and is some- 
 what greater in Sheffield than in Leeds. Differences in 
 feeding will not account for this for the advantages are still 
 with the Sheffield infant. The explanation lies in the fact 
 that in both towns the children are reared under home condi- 
 tions entirely inimical to their proper growth and develop- 
 
 » " Report on Child Mortality at Ages 0-5 in England and Wales," 
 Forty-Fifth Annual Report, Local Government Board, 19 16. 
 
Relationship to National Health 381 
 
 ment. These deaths take place before pulmonary tubercu- 
 losis plays any large part in increasing the mortality. It is 
 significant that in both towns rickets is very prevalent.* 
 The evil environment tells in two ways — ^by keeping up a high 
 mortahty among the children in the poor neighbourhoods 
 and, what is more important, by producing a greater degree 
 of ill-health amongst those who survive, so that the whole 
 development of the child is backward and defective, resulting 
 in weakly adults who formed Grades III. and IV. of the popu- 
 lation during the late war. 
 
 Much has been done to improve the conditions under 
 which the industrial labourer works. The building of 
 hygienic factories, the better ventilation of mines, the 
 regulation of the hours of labour, and the control of child and 
 of female labour, are all matters of importance and are 
 capable of control by legislation. The grosser evils inimical 
 to the health of the labourer in the factory and workshop 
 have now been largely done away with. 
 
 But the depreciation of the health of the nation with 
 which we are now deahng is not the result of the environ- 
 mental conditions of the industry affecting either the child 
 or the adult worker. It is the environment of the young 
 infant during its first years of hfe which is the important 
 factor, and in rickets this is the aU-important factor which 
 is at fault, and which leads to the wide diffusion of the 
 disease through a large section of the community. The 
 ever-increasing tendency of the population to centralise into 
 large industrial areas, and the evils associated with crowded 
 communities hving under slum conditions, strike at the very 
 foundations of the health of the nation, for they produce 
 their maximum effect on the young infant inducing not only 
 a high mortaUty but leading to iU-health and perverted and 
 stunted growth in the survivors. 
 
 Summarising the results of recruiting in Sheffield and 
 Leeds in particular, and speaking generally of the Yorkshire 
 
 * " Geographical Distribution of Rickets, etc.," Reports of the 
 Collective Investigation Committee of the British Medical Association, 
 January, 1889. 
 
382 Rickets 
 
 and East Midland region, the Commissioner of Medical 
 Services gives six causes for the variation in the results of ^ 
 grading in the various areas.* The sixth and most important 
 cause of variation he believes is due to the conditions under 
 which the people live either at their work or at their homes. 
 " This last cause has in my opinion," he states, " most far- 
 reaching effects on the standard of health of' the nation ; for 
 it is in their homes that the young (up to fourteen years) 
 spend their lives when environment has the most marked 
 effect on the physical and mental development of the 
 individual, and my contention is that if an analysis were 
 made of the children bom in the slum districts and who 
 eventually grow up Grade I., the result would be so appalling 
 that no Government would have the slightest difficulty in 
 passing any measure which would remedy this evil. Until 
 we tackle this problem thoroughly and are prepared to spend 
 a large sum of money in improving the surroundings of the 
 young, no other remedies will raise the index of fitness to 
 anything like what should be a normaL level, and in fact 
 would be almost useless." 
 
 The Commissioner of Medical Services for the eastern 
 region is in the happy positionof being able to state, referring 
 to recruiting in Northampton, that there are no slums in 
 Northampton and that the houses are mostly modem and are 
 built of brick, f It is interesting to note that these improved 
 conditions are immediately reflected in the infant death- 
 rate, which the Local Govemment Board's report on child 
 mortaUty for 1916 shows is 146 per 1,000 for children of 
 ages from 0-5 years, contrasted with 209 in Sheffield, and 
 202 in Leeds. 
 
 During the active recmiting in the spring of 1918 the 
 rettuns in grading from certain of the medical boards in the 
 north-western region showed such wide variations that an 
 enquiry was made as to the cause of these differences. It 
 was found that the explanation of the apparently anomalous 
 results lay in the fact that some boards were dealing whoUy 
 
 • Loc. cit., p. io8. 
 t Loc. cit., p. 117. 
 
Relationship to National Health 383 
 
 with miners, while others dealt with cotton operatives or, 
 as the report phrases it, that the boards were dealing with 
 different human material. The conclusion is come to that 
 the differences in physique between the two classes represent 
 the effects of their respective occupations and conditions of 
 life, and that in the case of the cotton operatives, work in 
 the moist and over-heated atmosphere of the mills, when 
 extended over a long period, has a profound effect upon their 
 health. This is only part of the truth. There is probably 
 in all occupations a natural tendency for the worker to follow 
 the employment for which he is most fitted, and while to say 
 that a man is a worker in steel because he is healthy, and a 
 tailor is a tailor because he is unhealthy, is a crude statement 
 of the case, it is undoubtedly true that in such an instance 
 as that of Sheffield and Leeds, where the labour is drawn 
 largely from a common source, the fit men tend to follow the 
 heavier and betterr-paid trades, while the weaker portion of 
 the population tends to follow the occupations connected 
 with soft goods in Leeds. 
 
 Some trades seem to have more continuity than others. 
 In the case of the coal miner the occupation is hereditary, more 
 perhaps than in other trades. To-day the mortality from 
 phthisis is actually less among coal miners than it is among 
 the general population, but when the heavy mortaUty from 
 this disease among miners which existed some forty or fifty 
 years ago is considered, it raises the question how far this 
 improved result has been obtained by the eUmination of the 
 weaker section of the mining community in the past. In any 
 case this improved condition in the health of the individual 
 miner is not reflected in the health of the progeny, for, as 
 has been shown, the areas of the greatest prevalence of 
 rickets practically coincide with the distribution of coal 
 mining and industrial regions. 
 
 Unlike the coal miner, the occupation of the industrial 
 labourer in London tends to be a very fleeting one, which is 
 reflected in the rapid flow and exchange which takes place 
 in its population. Not only is there but little continuity of 
 labour from father to son but the same individual frequently 
 
384 Rickets 
 
 changes his occupation according to the exigencies of trade. 
 Many factors control the choice of a trade. Racial charac- 
 teristics have an important influence. In the East End of 
 London the foreign population, which is largely Jewish, 
 follows such trades as tailoring and the fur trades, while dress- 
 making and work in cigarette factories give emplojnnent to 
 large numbers of the female portion of the community. 
 Even as a school child the Jewish boy is not expert at hand- 
 work such as carpentry, and in later life it is seldom that he 
 takes up one of the heavier trades. The female portion of 
 the population is domesticated in a high degree, but it is 
 nevertheless exceedingly rare for the Jewish girl to enter 
 domestic service. 
 
 But the important point is that no matter what occupa- 
 tion is followed, immediately an area becomes an important 
 industrial centre, the population tends to herd together in 
 slums, living under housing conditions which depreciate the 
 health of the adult, and which seriously interfere with the 
 growth of the young infant and with the standard of fitness 
 of the nation. 
 
 Ef&cient drainage of streets and houses has banished 
 many of the filth diseases, such as typhoid and typhus 
 fever, and has greatly improved the general health condi- 
 tions. But the great problems of overcrowding and defective 
 housing, instead of being solved have grown more trouble- 
 some and more complex with the great growth in population. 
 In nearly every large town there is a considerable area where 
 the streets are narrow and squalid and devoid of sunlight, 
 where the houses are badly built, still frequently standing 
 back to back and incapable of being properly ventilated. 
 In the squalid and overcrowded rooms of these houses it is 
 impossible for the adult to retain his health and vigour, and 
 yet it is in these surroundings that the growing infant is 
 expected to lay the foundation of a healthy and vigorous 
 manhood or womanhood. 
 
 The north-eastern district of London, which has already 
 been dealt with in some detail as regards environment 
 (Fig. 9) and conditions of feeding, was specially marked 
 
Relationship to National Health 385 
 
 out in the recruiting campaign, with certain slight modifica- 
 tions, as a black list area by the Ministry of National Service, 
 with a view to finding out what effect overcrowding and bad 
 hygienic conditions had on the community. From a study 
 of one thousand children taken at random from this area 
 some little time before the war it was found, as already 
 pointed out, that 80 per cent, showed definite signs of having 
 suffered more or less severely from rickets, and the conclu- 
 sion was come to that practically the whole of the infant 
 population living in the slums of this area had to fight their 
 way through a rickety phase during the first two years of 
 life.* The examination of the recruits by the National 
 Service Medical Boards gives the results of the examination 
 of the adult of the same area at a time when an attempt was 
 being made to call up every individual who was fit for any 
 form of military service. The two following graphs are 
 compiled from the examination of recruits during the period 
 January to October, 1918. They are of interest as forming 
 a comparison in relation to the health of a purely city 
 population as distinct from a population largely rural and 
 country town. The south-eastern region comprised Surrey, 
 Sussex, Kent and Hampshire. 
 
 It will be noted that both charts are far below Keith's 
 standard, but that the south-eastern region shows a very 
 distinctly higher percentage of Grades I. and II. men, while 
 the percentage of Grades III. and IV. is distinctly lower. 
 The figures for the London region include the black list area. 
 During the period under consideration, January to October, 
 1918, 8,244 examinations were made in this area. If the 
 ineffectives as comprised in Grades III. and IV. in this area 
 alone be compared with the figures for the whole of London, 
 including this area, the following result is obtained : — 
 
 
 Grade III. 
 
 Grade IV. 
 
 
 Per cent. 
 
 Per cent. Per cent. 
 
 Black List area 
 
 ... 42-4 
 
 20-85 = 63-25 
 
 London region 
 
 ... 36-5 
 
 12 = 48-5 
 
 * " On the Incidence of Rickets in School Children,'' by J. Lawson 
 Dick, School Hygiene, May, 1916. 
 
 c c 
 
386 
 
 Rickets 
 
 That is 63-25 per cent, of men examined in the black list 
 area were placed in Grades III. and IV., as compared with 
 48-5 per cent, for all London. Naturally, if the figures from 
 this very defective area were taken out of the consolidated 
 
 LONDON REGION SOUTH-EASTERN REGION 
 
 4-0 7. 
 
 35% — 
 
 30% 
 
 25% 
 
 20% 
 
 15 % 
 
 10 % --- 
 
 5% 
 
 Grades 
 
 L 
 
 -A 
 
 
 % 
 
 — J/ 
 
 Z 1 
 
 i:r_ 
 
 r--- 
 
 I 
 
 \ 
 
 1 
 
 !:-, 
 
 chart for the London region the contrast would be still 
 more marked. In other words, the appalling result is 
 obtained that well over five thousand men out of 8,244 
 examined in the black list area were suffering from dis- 
 abilities which only allowed them to be placed in Grades III. 
 and IV. when their fitness for military service was considered. 
 
Relationship to National Health 387 
 
 Three series of observations, then, have been made in this 
 north-eastern sector of London, viz. : (1) a systematic 
 examination of the children immediately prior to the war, 
 which showed that 80 per cent, suffered from rickets or 
 had passed through a rachitic phase ; (2) a special examina- 
 tion of recruits during the late war, 1918, which showed that 
 63-25 per cent, of the male adult population of miUtary age 
 were practically useless from a military point of view, even 
 when a very low standard of fitness was required ; (3) a 
 special study of the environment surrounding the population, 
 in which the chief factors were defective housing with lack 
 of sunlight and fresh air, associated with the breathing 
 of vitiated air, and the want of exercise, all conditions 
 which bear especially on the infant and young child during 
 the first two years of hfe. It is not held that every failure 
 in adult life is due to rickets, but it is maintained that these 
 later disabiHties in the adult have their origin in the first and 
 second years of life, and that the most common and the most 
 far-reaching factor affecting the health of the infant at this 
 early period is rickets. 
 
 The following figures are of interest as showing the 
 cause of rejection of recruits in London in the early days of 
 the war from August to December, 1914. Of the primary 
 causes of rejection it was found that there were : — 
 
 under height standard 3-28 per cent. 
 
 under chest measurement 34-98 „ 
 
 congenital and acquired deformities ... 1-72 
 
 disease of ear and deafness 1-77 
 
 defective teeth 6-35 
 
 48-10 
 
 These disabilities, totalling 48-10 per cent, of the primary 
 causes of rejection of recruits, are nearly all due to faulty 
 growth and development, and are most frequently associated 
 with rickets, and are indeed usually its direct result. 
 
 In Liverpool, during the period November 1st, 1917, to 
 May 31st, 1918, an analysis of the grading of 12,699 recruits 
 
388 Rickets 
 
 of all ages/frorri' under eighteen years and eight months to 
 forty years and over, gives the following results : — 
 
 Grade I. 
 
 • •• • • • 
 
 ... 3,335 
 
 „ II. 
 
 ... ■•• 
 
 ... 2,381 
 
 „ III. 
 
 * ■■ >■ • 
 
 ... 4,116 
 
 „ IV. 
 
 ... ... 
 
 ... 1,392 
 
 Examinatioi 
 
 IS deferred 
 
 ... 1,475 
 
 12,699 
 
 That is, taking Grades I. and II. as efficient and Grades III. 
 and IV. as inefficient, it is found there is only a difference of 
 208 in favour of the first group : — 
 
 total number of Grades I. and II. recruits = 5,716 
 total nunlber of Grades III. and IV. recruits = 5,508 
 
 Difference = 208 
 
 In an analysis of the cause of rejection of 2,894 Liverpool 
 men from November 1st, 1917, to July 31st, 1918, it was 
 found the following disabilities occurred in these propor- 
 tions : — 
 
 physical defects 20-6 per cent. 
 
 poor physique and debility ... 8-5 „ 
 deafness and otitis media ... 4 „ 
 
 33-1 
 
 In grading large numbers of men, several methods might 
 be employed for finding out their index of fitness, each of 
 which would give equally useful results when taken over 
 large numbers. Thus, men might be graded : — 
 
 (1) by height and weight alone : 
 
 (2) by estimating the exercise tolerance or the reaction of 
 
 the body to exercise and noting whether the symptoms 
 of fatigue or distress were in excess of what would be 
 produced in a normal person of the same age. This is 
 the test the application of which revealed the existence 
 of a large class of men who, without any actual organic 
 disease, were suffering from constitutional weakness, 
 and who broke down at an early date in the war, 
 frequently being classified and sent home as cases of 
 
Relationship to National Health 389 
 
 disordered action of the heart. To this class belonged 
 many undersized men, often with flat or elongated 
 chests, with a history of debility in early childhood, who 
 had suffered from the evil effects of faulty environment 
 from their earUest infancy. In the main these are 
 the representatives in the adult, of the class who in 
 early childhood had suffered from rickets, and who had 
 made an incomplete recovery. In civil life they formed 
 the least effective portion of the population although 
 they were, as a rule, able to earn a living. When, 
 however, the unaccustomed strain of army training 
 was applied to them they speedily broke down : 
 (3) the third method of examination, and the one which was 
 actually employed, was a careful medical examination 
 of the various systems of the body and a study of the 
 history and the personal statement of each individual. 
 
 Each of these methods of examination would in all 
 probability give very similar results, and each would be 
 equally accurate when taken over large numbers. But the 
 risk of hardship in individual cases would be very great if 
 either of the first two methods of examination were exclu- 
 sively employed, and for practical purposes the third method 
 is the only one available, when the intention is to call up men 
 for active service. The third method of examination should, 
 of course, include the first and second to make the report 
 complete. 
 
 Judging from the standard of height and weight alone, 
 some interesting figures are given for the West Midland 
 region, comprising Staffordshire, Warwickshire, Worcester- 
 shire, Herefordshire and Shropshire. If five of the larger 
 industrial centres in the region are taken — Birmingham, 
 Burslem, Coventry, Walsall and Wolverhampton — and an 
 average is made for these five centres, it is found that the 
 following results are obtained as regards height and weight : — 
 
 height at 18 years is | inch below average of general population. 
 25 „ li 
 ,, 30 ,, 2 „ „ „ 
 
 ,, 4" ft " »> »> >» 
 
 weight at 18 years is 8f lbs below average of general population. 
 25 „ 12i „ 
 
 „ 30 „ 221 
 ,. 40 „ 23 
 
39° Rickets 
 
 These results show that the growth of these recruits was 
 not only retarded, but that the fuU measure of growth 
 required to bring them up to the standard of the general 
 population was never attained. Rickets is pecuharly a 
 condition which retards growth, and nowhere does healthy 
 environment tell more directly than in growth and stature 
 both as regards height and weight. 
 
 In applying standards' of height and weight the difficulty 
 arises that there is no accepted standard of physique. In 
 the case of school children the ubiquity of the conditions 
 which react harmfully on the child makes one content with 
 not only a much lower general standard of physical growth, 
 but also with a lower standard of mental development than 
 might legitimately be expected if the environment of the 
 child were such as to allow of its full mental and physical 
 development. Speaking of the disparity in development met 
 with in different social grades of school children. Dr. Kerr 
 very rightly remarks * : " As a nation we should not accept 
 quietly the difference in physique between primary and 
 secondary schools. We must make all our children pass into 
 the one national standard of physique, and no longer regard 
 as inevitable the inferior physique of artisans, and superior of 
 professional classes, knowing that the difference is largely 
 due to social failure and is an index of national inefficiency." 
 
 Similarly with recruits there is evidence to show that a 
 combination of height, 5 feet 6 inches, weight, 130 lbs., chest 
 girth, 34 inches, will be found to be approximately the average 
 of the Grade I. men of military age. As the National 
 Service Report points out, it is impossible to regard these 
 standards as satisfactory or to rest content with the economic 
 and social conditions which are responsible for such a result.f 
 
 It is a matter worthy of note that nearly aU the medical 
 officers reporting on the results of recruiting throughout the 
 country point out the disastrous effects of defective housing 
 and slum areas on the physique of the recruits coming before 
 
 * " standard Measurements for School Children," by James Kerr, 
 M.A., M.D., School Hygiene, April, 1918. 
 t Loc. cit., p. 23. 
 
Relationship to National Health 391 
 
 them. Speaking of the West Midland region, it is remarked 
 that the tendency of industrial life is to lower physical 
 fitness ; men are middle-aged at thirty and old men at forty. 
 " The worst housing," it is stated, " is in the city of Birming- 
 ham and some of the large towns, although in rural districts 
 there is also much to complain of. In Birmingham there 
 are many highly congested areas with considerable slum 
 property and a large number of back-to-back houses. At 
 the date of the Poor Law Report these were estimated at 
 forty thousand. In some densely populated wards of the 
 city there is a high infantile mortaUty, which is indicative 
 of the general conditions which exist there."* 
 
 Speaking of Glasgow, the Commissioner for Scotland, as 
 the result of his experience of the examination of recruits, 
 states : — 
 
 " The physical characteristics of the male population, on 
 the whole, are not good, the stature being on the small side, 
 and there being an unduly high percentage of physical 
 malformations. 
 
 " The industrial classes are housed chiefly in flats, and 
 overcrowding is common. Such conditions necessarily lead 
 to physical deterioration of the inhabitants. The east, 
 north-east and south-west portions of the city are to a 
 considerable extent slums, and consist almost entirely of 
 flats of houses of a relatively small number of rooms, which are 
 hadly ventilated, badly lit, and insanitary. 
 
 " As one would expect from its size and importance as an 
 industrial centre, the atmosphere of Glasgow is unduly 
 smoky and polluted, and there is in the area more than the 
 average rainfall. These facts, together with the very high 
 buildings and the many relatively narrow streets, account 
 for the lack of sunshine in the quarters occupied by the 
 working people. In such areas there is a notorious lack of 
 suitable air spaces and pla57ing grounds for the young. 
 
 " Furthermore, the health-giving recreations of the 
 industrial classes occupying these areas are almost nil, their 
 spare time being taken up in parading the city streets, 
 * Loc. cit., p. 72. 
 
392 Rickets 
 
 attending picture-houses, and watching certain games instead 
 of taking part in them. 
 
 " Such conditions do not encourage the maintenance of 
 good physique or satisfactory health in the present inhabi- 
 tants, nor give promise of the production of better physique 
 and vitahty in the next generation."* 
 
 It is important to bear in mind that there is no evidence 
 of true racial degeneration. On the contrary, allowing for 
 racial differences, there has been a marked increase in 
 stature, both in height and weight, of the inhabitants of 
 England as compared with prehistoric man in Great Britain, 
 or with the early Briton of the Roman period, or even with 
 the Englishman of mediaeval times. This is amply borne 
 out by examination of the bones from ancient burial grounds 
 and comparison with average skeletons of to-day. The 
 great improvement in food supply, in quality, quantity and 
 variety, and the greater security that there will be a suffi- 
 ciency for each day, and not a time of plenty and a time of 
 comparative famine, are probably the main factors bringing 
 about this enhanced stature. But, apart from this improve- 
 ment in food, the envirorunent has become more harmful, 
 and diseases such as rickets, have arisen which were 
 unknown when, though the feeding was precarious, life was 
 untrammelled by the conditions which now beset modem 
 civiUsation. As history goes the growth of towns is an 
 incident of modem life, but, though recent, the conditions 
 associated with industrial communities have proved inimical 
 in a high degree to the welfare of the race. From being rural 
 dwellers employed in agriculture the population has become 
 a nation of cotton spinners, miners, and workers in steel, with 
 an environment which has been peculiarly dysgenic in that 
 it has acted most harmfully on the young infant. 
 
 As the war progressed, it became increasingly necessary 
 to employ all available man power, and if a recruit could 
 handle a spade or mount guard it was held that, though not 
 himself able to stand in the fighting line, he still had some 
 function in the army, and could at least take over work 
 
 * Loc. cit., p. 128. 
 
Relationship to National Health 393 
 
 which would release more fit men for the trenches. As an 
 aftermath of the war the country has now been faced with a 
 heavy drain on its resources in compensating many of these 
 later recruits for the aggravation of disabilities which existed 
 long prior to the war. 
 
 The question as to whether or no a discharged soldier 
 is, or is not, entitled to pension is often a difficult one to 
 decide, but, strangely enough, the difficulty does not 
 arise with the man who has seen active service in France, 
 or who has acquired infection in Salonica or Mesopotamia, 
 but arises rather with the man who was never considered 
 fit for service in a fighting unit, and who was attached to 
 a labour corps, frequently being engaged in camp duty at 
 home or in some such occupation as loading and unloading 
 transports at the base. Large numbers of these men joined 
 up with disabilities of long standing which had possibly 
 existed since early childhood. Such cases merit every 
 consideration, for usually they have been handicapped from 
 their earliest start in life, and it is often a, problem which 
 requires great judgment to decide how far these conditions 
 have been affected by military service. 
 
 Conditions such as deafness and discharging ears are 
 exceedingly common, and, as stated, have usually existed 
 since early childhood. The association of rickets with 
 enlargement of the tonsils and adenoids is a very direct 
 one, and mouth-breathing and infection of the middle 
 ears form, as has been shown, a common sequence. These 
 men present a characteristic appearance. The lower jaw 
 drops, and the mouth is open, giving a vacant dull expression 
 to the face. Often there is marked bossing of the skull or a 
 heavy overhanging forehead. On examination the man is 
 found to be a mouth breather, and the nose is badly developed 
 and is not used for breathing purposes ; deflection of the nasal 
 septum is common, the palate is arched and high, the teeth 
 are carious and irregular, and hypoplasia is common. The 
 face is long, thin and lantern-jawed. The tonsils are probably 
 enlarged and may be septic, and adenoids are, or have been, 
 present. The chest is badly developed, and the breathing 
 
394 Rickets 
 
 capacity is deficient. Frequently the muscular power is 
 feeble, though in many cases this has developed to a wonderful 
 extent, and there is considerable physical strength. Inquiry 
 into the early life reveals that such a man has been back- 
 ward at school ; the despair of his teachers, he has only left 
 school on account of age, never having passed the fourth or 
 fifth standards. When he leaves school he obtains employ- 
 ment as a van-boy or as an errand-boy, and later on he drifts 
 into casual labour. In after-life he marries, but he has little 
 ambition, and lacks the capacity to create a comfortable 
 home around him. His wages are small because he is of 
 but little value in the labour market. He probably lives 
 with his wife and three or four children in two rooms in a 
 slum area. The mother is badly nourished, and the children 
 are poorly fed, and it is little wonder if his offspring reproduce 
 the same characteristics and develop along much the same 
 lines as the parent. 
 
 It is frequently asked what can be expected from the child 
 of such a parent, forgetting that there is not necessarily any 
 inherent degeneracy in the individual, but that he is the 
 product of a vicious circle of environment. He resembles a 
 mentally deficient case, and is frequently, when a schoolboy, 
 referred by his teacher for examination on this ground. He 
 is not, however, a case of true mental deficiency, but is simply 
 an example of obstructed and thwarted development, pro- 
 duced in response to a perverted environment operative 
 since birth. If the children of such a parent are removed in 
 early infancy into airy svurroundings and are properly clothed 
 and well fed, experience shows that they develop along 
 normal hues and tend to become bright and intelligent and 
 as physically sound as the average. The influence of 
 heredity will be discussed later, but in the meantime it 
 cannot be too strongly insisted upon that it is the persistence 
 of the evils of the environment which produces the same type 
 generation after generation in the slum dweller, and not 
 inherited disabilities from degenerate parents. It is vfith 
 this class that the greatest difficulty will be experienced in 
 helping them to find their place in the labour world after 
 
Relationship to National Health 395 
 
 the war. They require much patience and consideration. 
 Teaching them how to fit themselves into the general scheme 
 of labour is much more likely to benefit them than any dole 
 in the form of pension. Above all, the children should be 
 protected as far as possible, and at as early a date as possible, 
 even at the risk of much sacrifice, from the inimical influences 
 which have operated so disastrously on the parents. 
 
 All reports on the state of the pubhc health which have 
 been pubUshed during the last decade have shown a steady 
 improvement in the health of the community. These 
 favourable reports have been chiefly based on diminished 
 mortality, both infantile and adult, and a lessened incidence 
 of certain diseases. 
 
 Caution must, however, be exercised in drawing deduc- 
 tions from mortality tables as to the state of the general 
 health. So much is this the case that there is very little reason 
 to believe that the general health of the community, as 
 measured by the capacity of the individual for work and 
 for the enjoyment of the amenities of life, is better to-day 
 than it was say three centuries ago, and that notwithstand- 
 ing the fact that plague, typhus and typhoid fevers, small- 
 pox, and other allied states, have for all practical purposes 
 been abolished. 
 
 It is true that the conditions which lead to a high infant 
 mortality must also tend to produce disease in many who 
 survive, but this by no means implies that a diminished 
 infant mortality is necessarily followed by a lessened amount 
 of disease in those who survive. 
 
 But little notice is taken in health statistics of the 
 standard of health. It is recognised by all that there are 
 certain broad class distinctions, and that the health of the 
 children of the better class of the community is superior to 
 that of the poor and of the industrial class. To be efficient 
 the conduct of public health must concern itself with the 
 attempt to raise the general health of the whole community to 
 the level of what can now be attained by only the favoured 
 few. Even a cursory consideration of the state of retarded 
 mental and physical growth and the general poor level of 
 
396 Rickets 
 
 health seen in the industrial areas of large towns should be a 
 sufficient safeguard against any undue elation on the score 
 of past achievements. 
 
 Observation of such communities shows defective growth, 
 as indicated by coarse features and a large square head, 
 often with overhanging eyebrows. The stature is apt to be 
 stunted, or the individual may be tall and weedy with a flat 
 chest and stooping shoulders. Mental development is often 
 very backward, and the irritable nervous system is peculiarly 
 liable to give rise to convulsive attacks. Anaemia is common, 
 and the complexion is sallow and muddy. Enlargement 
 of the tonsils and adenoid vegetations are frequent, and are 
 apt to be associated with mouth-breathing, discharging ears 
 and deafness^ or chronic catarrhal non-suppurative otitis 
 media. The teeth are irregular and defective, and decay 
 early. There is great muscular debility. This wide pre- 
 valence of ill-health is the large factor in producing the 
 inefficient adult. 
 
 It cannot be too clearly realised that much of the ill- 
 health of the community is the direct result of life in industrial 
 areas in great towns under modern conditions, and that it is 
 in reality but the result of the normal response of the 
 individual to a vicious environment ; in other words, these 
 changes are of an adaptive nature, the rachitic process 
 being one of nature's chief methods in bringing this adapta- 
 tion about. 
 
 There are then great numbers of diseased states, and 
 conditions of impaired health, and want of physical and 
 nervous energy, which fail to find their place in any health 
 tables. And yet it is to these conditions that the inefficiency 
 of the nation is primarily due. 
 
 Rickets is one of the chief agents concerned in the produc- 
 tion of these impaired states. A hopeful feature is that 
 these conditions are capable of great amelioration, and have 
 indeed already been much improved by the intelligence of 
 an enlightened motherhood, which has been quick to seize 
 on some of the broad essentials which' have been proved 
 efficacious in the bringing up of the infant and yoimg child. 
 
CHAPTER XXVI 
 The ^tiolog-y of Rickets 
 
 It is one of the great qualities of the mind of John Hunter 
 that, while he studied inductively and based his work on 
 experiment and observation, he was still able to preserve the 
 magnificent detachment which belongs to the deductive 
 mind and, looking beyond mere detail, to formulate great 
 generalisations capable of the widest application. 
 
 Hunter propounded the theory that disease was but the 
 physiological response of an organism to an environment 
 which demanded alteration of development or modification 
 of function or structure to meet conditions to which the 
 healthy organism could not normally respond. In other 
 words, he believed that there was no hard and fast line of 
 demarcation between health and disease or between physio- 
 logical and pathological processes. Each alike was the 
 effort of the organism to respond to the actual conditions 
 which surround it. It is a notable fact that many diseases 
 are a result of the infraction of the simplest laws of health 
 and a neglect of the most obvious niles of right living. 
 
 Alteration in environment may be of two kinds. First, 
 there may be an actual alteration in the external surround- 
 ings, such as change of diet or of climate, or an alteration in 
 the habits of the race to which the organism must adapt 
 itself. Or, secondly, there may be a relative change of 
 environment due to an alteration in structure and function 
 of the organism itself. Thus a hereditary disease, such as 
 congenital syphilis, profoundly alters the relationship of the 
 individual to its surroundings, leading to widespread changes 
 which have, as already noted, a peculiar resemblance to 
 those associated with rickets. One important difference, 
 however, is that while the adaptive efforts of the victim of 
 
 397 
 
398 Rickets 
 
 syphilis are frequently unsuccessful, so that death, either 
 ante-natal or soon after birth, is exceedingly common, in 
 rickets the disease in itself does not as a rule end fatally, but 
 results in recovery more or less complete. Possibly the 
 difference is that in syphilis the child itself is diseased and is 
 combating a comparatively normal environment, whereas 
 in rickets the child is normal except for the effort it is com- 
 pelled to make to suit itself to a vicious environment. In 
 the rachitic child the cause in any individual case is capable 
 of being easily removed, and the child tends to return to the 
 normal. 
 
 Rickets is a morbid process which will be better under- 
 stood if it is considered as the sum of the results achieved by 
 the organism in attempting to adapt itself to altered environ- 
 ment. The parent is exposed to extreme alterations of sur- 
 roundings to which the adult organism is capable of making 
 a ready response. The infant in utero is screened from the 
 varying conditions which surround the parent, so that, 
 broadly speaking, it seems to make little difference whether 
 the new-bom infant comes from the dweller in the slums or 
 is the child of the wealthy. Both alike seem to start with 
 equal chances of healthy growth. A few months later it 
 would seem as if the weakly, rickety infant were the natural 
 product of the badly developed, overworked, and, it may be, 
 underfed parent, but, as a matter of fact, it is found that if 
 the child is taken from its unhealthy environment and 
 placed in wholesome surroundings it immediately responds 
 to the altered conditions and tends to become a healthy 
 normal individual. Nothing is more important in rickets 
 than this constant tendency to spontaneous recovery. In 
 other words, it is not necessarily an inherited tendency which 
 makes the child of the slums resemble its weakly, degenerate 
 parents, but is more commonly the fact that both parent and 
 child are bom and brought up under similar adverse condi- 
 tions, inimical to all healthy growth and maintenance. 
 
 Of late years the great contention as to the aetiology of 
 rickets has lain between two factors, deficiency of food and 
 faulty environment. Rickets is a disease of nutrition, and 
 
The Etiology of Rickets 399 
 
 it is natural in the first instance to consider the question of 
 food supply. This has given rise to several crude theories 
 which are readily proved untenable. 
 
 Most of the earlier theories supposed that some disturb- 
 ance of the calcium intake was responsible for the production 
 of the disease, which might be produced in various ways. 
 
 Lactic Acid Theory. — ^This theory maintained that lactic 
 acid was generated in excess by the fermentation of starchy 
 foods imperfectly digested. By its absorption into the 
 circulation the acid was held to unite with the lime of the 
 bones, forming a soluble salt which was removed from the 
 system. This hypothesis, like many others, is founded upon 
 a supposition that the morbid changes in the bones comprise 
 the whole pathology of the disease. It affords no explana- 
 tion of the morbid processes which affect the muscles, 
 tendons, mucous membranes and the special organs. Heitz- 
 man held that lactic acid produced an irritating effect on the 
 ossifjHLng tissues and stimulated growth, while the material 
 necessary to complete growth was wanting. Lactic acid 
 is said to have been found in the urine and in the tissues of 
 rickety animals, and Heitzman claimed that he had pro- 
 duced the disease in animals by its administration. This 
 increased formation of lactic acid has not been confirmed,* 
 and while acid food may produce a disease in which the 
 epiphyses and the costo-chondral junctions are enlarged and 
 in which the bone is easily broken, the results are comparable 
 to those found as the result of feeding on a calcium-poor diet, 
 and are due to the same cause. The lactic acid theory is 
 open to objection on chemical grounds, for it obviously could 
 not exist in the blood in a free state, but would be neutralised 
 by soda or potash. Again, if it were present in the blood, 
 lactic acid, being more feeble chemically than phosphoric 
 acid, would not replace it in phosphate of lime. Many 
 children, too, become rickety without any evidence of 
 fermentation dyspepsia and on malted foods and condensed 
 milk which they digest perfectly. 
 
 * " Systen? 9i. Medicine," Allbut and Rollestbn, London, 1907, Vol. III. 
 p. 84," 
 
400 Rickets 
 
 Calcium-poor Foods. — Frequent experiments have been 
 ^performed on animals with diets deficient in calcium, and 
 very varying results have been obtained. Usually animals 
 fed on such a diet or on an acid food, which comes into the 
 same class, develop disease of the bone, which in gross 
 appearance resembles rickets. Great care has, however, to 
 be exercised in the interpretation of such experiments. 
 Dogs under experiment are especially liable to the develop- 
 ment of bone changes, and such detached laboratory experi- 
 ments as a rule make no pretence to align themselves with 
 clinical experience. In the case of animals fed on calcium- 
 poor diets, Miwa and Stoeltzner * found there were certain 
 differences between this artificial disease of the bone and 
 true rachitis as described by Pommer f in 1885. Pommer 
 defined for the first time the essential nature of the bony 
 changes which occurred in rickets. These were the formation 
 of osteoid tissue, increased and irregular cartilage growth, 
 associated with delay in calcification and delay in ossifica- 
 tion. The framework laid down was largely composed of 
 non-calcified osteoid tissue. 
 
 Miwa and Stoeltzner found that there was but slight 
 disturbance in the endochondral ossification and a very 
 considerable osteo-porosis. Stoeltzner, therefore, named the 
 condition pseudo-rachitic osteo-porosis. This pseudo- 
 rachitic bone possesses a marked affinity for calcium salts, 
 and takes them up as soon as they are suppUed. 
 
 These results were confirmed by Getting { and Schmorl.§ 
 Admitting that changes in the bones resembling those of 
 rickets can be produced experimentally by the exhibition of a 
 calcium-free diet, there is abundant evidence to show that 
 
 * Miwa and Stoeltzner, " Ueber die bei Jungen Hunden durch kalkenne 
 Fiitterang entstehende Knochenerkrankung," Beitr. z. path. Anat. «. 
 (dig. Path.. 1898, XXIV., 578. 
 
 t Pommer, " Untersuchungen fiber Osteomalacie und Rachitis," Leipzig, 
 1885. 
 
 J Getting, " Ueber die bei jungen Tieren durch kalkenne Emahrung 
 and Oxakaurefutterung entstehenden Knochenveranderungen," Virchow's 
 Arch. f. path. Anat., 1909, CXCVII. 
 
 § Schmorl, " Die pathologische Anatomie der rachitischen Knochen- 
 krankung mit besonderer Beruchsichtigung ihrer IJistoIogie und Patho- 
 genese," Ergeb. d. inn. Med. u. Kinderh,, 1909, IV., 403. 
 
The iEtiology of Rickets 401 
 
 this is not the common cause of rickets in children. In the 
 first place, rickets is exceedingly common in the limestone 
 districts, where the ordinary drinking water is heavily charged 
 with lime.* Many children who develop the disease have 
 had lime water regularly in their food. Again, the very foods 
 upon which children are supposed to become rickety, such as 
 farinaceous foods, are rich in lime and in phosphoric acid, 
 and cow's milk is richer in these than is human milk. Not 
 only does the abundant supply of calcium salts not prevent 
 the development of rickets, but the disease is usually deve- 
 loped while abundance of these is being supplied. Neither 
 excess of carbohydrates nor deficiency of calcium will in 
 itself produce rickets, and it has frequently been shown, 
 that when the conditions of the child's Ufe are altered, there 
 is rapid improvement on precisely the same diet as that 
 which was supposed to have caused the disease. In some 
 recently pubhshed experimental studies by Leonard Findlay, 
 D. Noel Paton and J. S. Sharpe,t the work of Stoeltzner has 
 received confirmation. These authors come to the con- 
 clusion that changes in the bones simulating somewhat those 
 in rickets can be caused by feeding dogs on a calcium-low 
 diet, but that the condition is of the nature of osteo-porosis 
 and not true rickets. As a result of their observations they 
 find that no support can be given to the view that rickets is 
 due to a deficient supply of calcium to the bone ; the dis- 
 turbance in the calcium metaboHsm is probably not the 
 primary factor in the disease. While the lime theory has 
 been largely discredited, other more important deficiencies 
 have been blamed for the production of rickets. 
 
 Deficiency ofProteids and of Fats. — It is somewhat strange 
 that attention has for many years been directed to the 
 shortage of fats, and that deficiency of proteids has been com- 
 paratively Mttle dealt with. Now in the children of the poor 
 there can be but little doubt that insufiiciency of proteid 
 
 * " A Discussion on Rickets," W. B. Cheadle, British Medical Journal, 
 1 888, Vol. n., p. 1 146. 
 
 f "Studies in tjie Metabolism of Rickets," by Leonard Findlay, 
 D. Noel Paton, and J. S. Sharpe. The Quarterly Journal of Medicine, 
 Oxford, Vol. XIV., No. 56, July, 1921. 
 
402 Rickets 
 
 supply is the outstanding failure in their diet and is prob- 
 ably a large factor leading to imperfect development and 
 impaired growth. The human body is chiefly composed 
 of albuminous or nitrogenous substances, and in the meta- 
 bolism of these bodies the source for most of the functions 
 of the body is found. The albuminates or proteids of the 
 food have three main functions. In the first place, they are 
 the chief agents utilised in the repair and development of 
 the nitrogenous organised tissues ; secondly, they stimulate 
 functional activity and promote oxidation and metabolism ; 
 thirdly, they are capable of being split up and of contributing 
 to the formation of fat and to the development of muscular 
 and nervous energy as well as to the production of heat. 
 
 Very noteworthy is the remarkable effect meat extracts 
 have on the general nutrition. It has repeatedly been proved 
 experimentally that the addition of beef extracts in small 
 quantities to the diet of wasting animals improves the 
 nutrition of the animal out of all proportion to the volume 
 of the intake of the extract. Clinically the same is found in 
 the feeding of infants and children. In other words, the 
 process of assimilation is stimulated, and the general meta- 
 bolism is improved. Raw meat juice and scraped meat are 
 most useful additions to the diet of the rachitic child, as, 
 indeed, they are in most wasting diseases of children. 
 
 A moderately healthy child may be reared with the use of 
 little or no meat, but the best results are not obtained by 
 such a diet. When the diet is so restricted, the child will 
 not attain the same height and weight as a child fed on a 
 diet in which meat is an important constituent, nor will it 
 have the same physique and mental energy, while it tends to 
 be much less resistant to infection. In the feeding of children 
 aU eccentricities of diet should be carefully avoided. A diet, 
 to be perfect, should be well balanced, and this is best attained 
 by throwing the net as widely as possible and utilising all 
 the various articles of food consistent with a simple and 
 wholesome fare. It is easy to exaggerate the degree to 
 which the children of the poor suffer from insufficient diet. 
 l t ry go to the other extreme, and say that rickets is due to 
 
The Etiology of Rickets 403 
 
 an over-abundant supply of food and the failure of the 
 organism to deal with an excessive intake, more especially 
 of carbohydrates. No one, however, who examines carefully 
 a thousand children from slum areas, would maintain that 
 excess of diet, whether well balanced or no, is a factor 
 which is commonly operative. Many of them are obviously 
 underfed, but the percentage is not so great as is usually 
 supposed. Among the children of the East End^of London 
 the nutrition is on the whole very fair, and in certain schools, 
 as already noted, in 80 per cent, the nutrition was either 
 good or very good. Rickets is equally common among well- 
 fed and badly fed children, but in the former it tends to run 
 a modified course. The point has before been insisted upon 
 that with the most perfect breast feeding, if the child is 
 exposed to certain conditions, it will inevitably develop 
 rickets. 
 
 It must be remembered that rickets appears at a time 
 when the child is normally at the breast and is independent 
 of the general table. The percentage of breast-fed babies 
 among the poorer classes is very high, approximating, as has 
 been seen, to 80 per cent., and yet in certain areas of all large 
 industrial towns practically all the children show signs of 
 rickets of a more or less severe form. The question naturally 
 arises as to whether or no the quality of the mother's milk 
 is at fault in these cases. In the majority, the nutrition 
 and state of the mother's health is on the whole good. A 
 careful examination by means of test feeds where the child 
 is weighed immediately before and after being suckled shows 
 as a rule that the intake is sufficient. It is not often that 
 breast feeding has to be given up on this account. 
 
 Indeed, failure of the milk supply is more likely to occur 
 among well-to-do mothers of the middle and upper classes. 
 Among the poor the child is more often weaned because it is 
 obviously not thriving at the breast, and that in spite of the 
 fact that the mother herself is in good health, and the supply 
 is not insufficient. 
 
 The deficiency of fats has now for many years been 
 considered the chief factor in the production of rickets. This 
 
404 Rickets 
 
 has largely been based on the value of fats in the treatment 
 of rickets. One of the great purposes served by fat in the 
 food is to diminish albuminous metabolism. 
 
 Proteids and fats are to a certain extent opposed to one 
 another, in so far as the former increase waste and promote 
 oxidation, while the latter have the power of diminishing 
 these processes, and this they do by affecting the metabolic 
 activity of the cells of the tissues themselves.* Fat, there- 
 fore, economises the albuminous elements of the food and 
 checks tissue waste, while by its decomposition it 37ields 
 muscular force and heat. 
 
 Rickets always markedly affects the tissue proteids, and 
 as a result the muscle fibre throughout the body tends to 
 become wasted, soft and flabby. If the disease is at all 
 marked, the child lacks energy and avoids the active move- 
 ment which the normal child rejoices in. 
 
 Very commonly in rickets the child tends to become thin, 
 and the subcutaneous fat wastes. The fat disappears 
 rapidly, and at an early stage, from the yellow marrow of 
 the shaft of the bones, and is replaced by a proliferation of 
 the medullary cells. But this wasting of the fatty consti- 
 tuents of the body is by no means a necessary part of the 
 rachitic process. There is a large and well-recognised class 
 of children which suffers from " fat " rickets. Frequently 
 in these cases there has been difficulty with the feeding. 
 Breast feeding may have been abandoned because the child 
 was not thriving, and after many experiments condensed milk 
 may have been found to suit the child. Condensed milk is 
 often useful in tiding a child over a temporary difficulty. 
 The sweetened variety commonly used contains 13 per cent, 
 of fat, that is to say all the original fat of the milk, besides 
 considerable quantities of added sugar. The milk is given so 
 dilute that the curd which is formed is very Ught, and the milk 
 is easy of digestion. The child appears to thrive and often has 
 a false appearance of health because it lays on a rapid deposit 
 of fat, and a stolid, heavy child results, with flabby muscles, 
 in whom the disease is not suspected till it is found that by 
 
 * " Food in Health and Disease," by I. Burney Yeo, London, 1893. 
 
The iEtiology of Rickets 405 
 
 the twelfth month the child has not cut any teeth, or that 
 by the end of two years it has made no attempt to talk or 
 to walk. The rickets is usually attributed to the use of the 
 condensed milk without any very valid reason. There is no 
 evidence of this, for the food is exceedingly well digested, nor 
 is there any want of fat in the ordinary brands used, for they 
 contain all the original fat of the milk. The truth is that 
 the milk has no power to produce the disease, nor is it able 
 to prevent its occurrence if the infant is exposed to the 
 ordinary conditions which produce rickets. Malt and cod 
 liver oil and fat emulsions are frequently given to these 
 children in excess, and at the same time they are kept 
 indoors and are deprived of exercise and fresh air. They 
 become heavy and stolid ; a want of colour is noted in the 
 face, and the mucous membranes are pallid. The muscles 
 are soft and flabby, and the ligaments lax and weak, 
 and the child generally is lethargic and dull. Thus, while 
 emaciation is often present in rickets, it is by no means 
 invariably so. 
 
 The Vitamin Theory and Experimental Rickets in Ani- 
 mals. — ^The development of the vitamin hypothesis of late 
 years has given rise to the theory that rickets is due to an 
 absence of fat-soluble A or of some factor which has a similar 
 distribution. In speaking of food in relation to the geo- 
 graphical distribution of rickets, the subject of deficiency 
 diseases has already been referred to. It is now fairly 
 generally accepted that beri-beri is a condition due to the 
 absence of an accessory food factor or so-called vitamin, the 
 anti-neuritic factor which is probably identical with water- 
 soluble B. Similarly scurvy and Barlow's disease in children 
 are now considered as definitely due to the absence of the 
 anti-scorbutic factor from the food. By analogy it has 
 been suggested that rickets is another such disease and is 
 due to thje absence of an accessory food factor associated 
 with fats. 
 
 In 1910 Schaumann suggested that rickets was due to the 
 lack of a specific food factor, and somewhat later Funk 
 included it among the avitaminosen. 
 
4o6 Rickets 
 
 Recently Dr. and Mrs. Mellanby * have carried out some 
 experimental work on the aetiology of rickets, and have 
 supported the view that the disease is due to the absence of 
 fat-soluble A or an associated factor. As a result of 
 experiments on dogs, these observers maintained that 
 animals fed on diets deficient in the supply of suitable fats, 
 developed extensive and well-marked disease of the bones 
 and teeth, while diets containing abundance of the so-called 
 anti-rachitic factor, such as is present in cod-liver oil, effec- 
 tually prevented the disease. The efficiency of the various 
 oils was found to vary greatly, vegetable oils being generally 
 less active than animal fats, while among the vegetable oils 
 themselves great differences were found in the quantity of 
 the anti-rachitic factor. One pecuhar result found was that 
 lard contained no anti-rachitic factor. CHnically bacon fat 
 is a most excellent way of administering fat to poorly 
 nourished children, and it is usually well digested. There 
 is no question of the extensive disease of the skeleton 
 and teeth produced in these animals. Indeed, the whole 
 growth of the animal seemed to end in a complete debacle, 
 so that of the two hundred animals experimented upon 
 many died, while those which survived developed, in the 
 course of a few weeks or months, extensive softening of the 
 bones associated with bending and deformity. The tem- 
 porary teeth were frequently mere shells of enamel imper- 
 fectly calcified with some defective dentine and a large and 
 expanded pulp cavity. The whole condition was of a degree 
 of intensity the like of which is never found in children. It 
 may be argued that the rapid development of the puppy, as 
 compared with the slow growth of the child, would naturally 
 lead to an acute process. This is true to a hmited extent, but 
 it also opens up the avenue to many other complications. 
 Dr. Mellanby himself states that the rachitic condition need 
 not be at all advanced before the animal's whole behaviour is 
 transformed. It becomes lethargic, and is far more liable to 
 
 * " An Experimental Investigation on Rickets," by Ed. Mellanby, 
 Lancet, March isth, 1919 ; " An Experimental Study of the Iniluence of 
 Diet in Teeth Formation," by May Mellanby, Lancet, December 17th, 1918. 
 
The Etiology of Rickets 407 
 
 be affected by distemper and broncho-pneumonia, and is very 
 susceptible to mange. Nor do the results as propounded by 
 Dr. Mellanby warrant the assumption that rickets is due to 
 the absence of fat-soluble A or a definite factor associated 
 with it. It was found that meat itself had a powerful action 
 in the prevention of rickets. Dr. Mellanby states, " The 
 action of meat is undoubtedly inhibitory in nature, and when 
 fifty grams of meat are given will almost prevent rickets in a 
 growing puppy. Meat has a stimulating action on the growth 
 of puppies far beyond its fat-soluble A content, so also it 
 appears now that the anti-rachitic action of meat is in a greater 
 measure than any fat-soluble A it is reputed to contain." 
 
 Recently Professor Noel Paton has published some 
 experimental results which directly contradict the con- 
 clusions arrived at by Dr. and Mrs. Mellanby.* It was found 
 that in young dogs confined to the laboratory under ordinary 
 conditions a liberal allowance of fat, even up to fourteen 
 grams per kilogram of body weight, neither prevented the 
 onset of rickets nor cured it when present. On the other 
 hand, pups kept in the open air, even on an intake of less than 
 one gram of fat, might escape the development of rickets. 
 
 A very interesting observation is made as to the necessity 
 of observing strict cleanliness where it is desired to prevent 
 rickets. Three litters of pups were placed on varjdng diets, 
 but each diet was so arranged that it increased proportion- 
 ately to the increase of the animal in weight, and care was 
 observed that the energy intake in each case should be kept 
 ample throughout the period of growth. 
 
 One series was placed on fresh whole milk and bread, 
 another on dried whole milk and bread, a third on dried 
 separated milk and bread, and in a fourth lard was the only 
 fat used, a fat stated by the Medical Research Committee 
 to be deficient in the so-called anti-rachitic factor. 
 
 AU of these animals were kept in the laboratory, but 
 scruptilous care as to cleanliness was observed throughout 
 
 * " The Etiology of Rickets : an Experimental Investigation," by 
 D. Noel Paton, M.D., F.R.S., and A. Watson, British Medical Journal, 
 April 23rd, 1921. 
 
4o8 Rickets 
 
 the experiment. The result was that all the pups, with one 
 exception, remained free from rickets, although those upon 
 the separated milk and bread had only from 0-3 to '6 gram 
 of milk fat per kilogram of body weight each day. This 
 observation as to the necessity of observing strict cleanUness 
 is borne out by experience in sporting kennels. It is a matter 
 of interest in relation to Kassowitz's belief that the con- 
 tinuous inspiration by the young infant of exhalations from 
 soiled clothing was a fertile source of rickets. In these 
 experiments then it was found that under ordinary con- 
 ditions all animals confined to the laboratory tended to 
 become rachitic, but when scrupulous cleanliness was 
 observed the disease was prevented. In the open it was 
 found that it was difficult to produce rickets. In none did 
 the presence of fat prevent the onset of the disease when the 
 other conditions were favourable to its production, nor did 
 its absence produce the disease when the animals were 
 allowed to run free in the open. 
 
 Two other facts are emphasised in Professor Noel Paton's 
 results: firstly, that a diet of low energy value, however 
 plentifully supplied, quite apart from the presence of any 
 hypothetical anti-rachitic factor, may render the animal 
 more liable to be attacked by rickets. This does not imply 
 that it is caused by such a diet. On the contrary, if the animal 
 is placed on a high energy intake while it is kept in the 
 laboratory under ordinary conditions, rickets results. The 
 second point is that the supply of fat in the form of lard is 
 quite efficient for the maintenance of normal health and 
 growth. This is an important matter, which agrees with all 
 clinical experience. 
 
 The whole question of experimental rickets is a (Mfficult 
 one. Dogs are known to be notoriously prone to rickets. 
 In artificially bred dogs, such as the bull-dog, it is exceedingly 
 difficult to prevent rickets. No matter what food is given 
 to a bull-dog pup, if the animal is placed on a hard stone 
 floor, it will inevitably develop severe rickets. With 
 sporting dogs the hygiene of the kennel is the first essential 
 if the health of the dog is to be maintained. Fresh air. 
 
The Etiology ot Rickets 409 
 
 sunlight, proper exercise, and scrupulous cleanliness are 
 found necessary. Bland-Sutton's early observations on lion 
 cubs at the Zoological Gardens in London, whereby the 
 addition of fats and crushed bones to the diet of the cubs 
 allowed some of them to be reared, have gained wide credence 
 for the view that fats prevent rickets. But this knowledge 
 has by no means abolished rickets from the Zoological 
 Gardens. Sir John Bland-Sutton states that systematic 
 inquiry which he has conducted into the diseases of animals 
 d5dng in the Zoological Gardens, has established the fact 
 that rickets is a very common disease, and that half the 
 monkeys and lemurs brought to this country die rickety. 
 He gives the following extensive list of animals he has found 
 suffering from this disease : — 
 
 among the carnivora. — Lions, tigers, hyaenas, bears of all 
 
 kinds, domestic cats, dogs, foxes, racoons and seals ; 
 among ruminants. — Deer, sheep and goats ; 
 among rodents. — ^Beavers, porcupines, rabbits and coypu rats ; 
 among marsupials. — Kangaroos, phalangers and opossums ; 
 among birds. — Emus, ostriches, rheas and pigeons. 
 
 That rickets is exceedingly common in the young of 
 animals born in captivity is undoubtedly true, but there is 
 a large margin of error, if every animal djdng in captivity 
 and exhibiting bony changes associated with softening and 
 bending of the long bones, is to be considered rachitic. 
 
 I have recently had the opportunity of examining the 
 skeleton of a chimpanzee which died at the Zoological 
 Gardens with extensive disease of the skeleton. The 
 animal was eighteen years of age when it died, and had been 
 in captivity for six years. It was ill for three or four years. 
 All the bones were very light. The head of the humerus on 
 each side was much flattened, and was depressed, resembling 
 the condition that in the hip joint is called coxa vara. There 
 was extensive osteo-porosis and much bending of the bone. 
 Similarly the tibia was markedly distorted in its upper 
 third, and the bone was very light and porous. The femora 
 were light, but were not notably deformed. No attempt at 
 consolidation or repair had taken place in the long bones. 
 
410 Rickets 
 
 The bones of the skull, especially in the frontal region, were 
 greatly thickened, and consolidation had taken place to a 
 considerable extent, for the texture of the bone was compact, 
 and the skull was heavy. But the most marked changes were 
 in the bones of the face, especially of the superior maxillae, 
 which were enormously enlarged and thickened, resembling 
 very closely the appearance found in leontiasis ossea. 
 
 This enlargement of the bones of the face is a fairly 
 common feature in so-called experimental rickets. Such a 
 massive overgrowth of the superior maxilla never occurs in 
 the rachitic state in children, although, as has been already 
 noted, a slight degree of thickening of the bone sufficient to 
 produce a shadow on transillumination is not so very 
 uncommon. Characteristic changes occur in the jaws of the 
 child, but they are never of the extreme kind so often found 
 in experimental rickets and in animals in confinement. It 
 will be noted that the disease attacked this animal after it 
 had reached the adult stage, and consequently the structure 
 of the teeth was unaffected. From the history and from the 
 nature of the bony changes, I have no hesitation in stating 
 that the condition was not one of rickets. The term 
 "rickets" is loosely appUed to all softening of the bones 
 which occurs in animals in confinement and in the laboratory, 
 but the probability is that many of them, as in the case 
 described, have a pathogenesis quite different from that 
 which occurs in true rickets. 
 
 The vitamin theory is wholly inadequate as an explana- 
 tion of the strong tendency which the young of all animals 
 kept in captivity show to the development of spontaneous 
 rickets. In the wild state these animals never develop the 
 disease. Contrast the life of the lion cub or of the young of 
 the tiger in its wild state with what appertains in confine- 
 ment. In its wild state soon after birth the animal plays 
 in the sun. It ranges over all sorts of ground, now on stone, 
 now on sand, or again in mud or shallow water. Every en- 
 couragement is given to the development of all its physical 
 energies. Its food, as with all beasts of prey, must be subject 
 to severe variations, but rickets never results. In captivity 
 
The Etiology of Rickets 411 
 
 the young animal is confined in a small space on a hard 
 cement floor. The food is served in abundance and regularly. 
 The metabolism of such an animal is enormously rapid, and 
 it seems more reasonable to attribute, the defective growth 
 which occurs to the altered conditions as regards fresh air 
 and sunlight and exercise, and the loss of the varying 
 environment of the young animal in its wild state, rather 
 than to the food factor which is all in favour of the animal 
 kept in captivity. 
 
 While this spontaneous disease in the young animal is 
 probably a true rachitic process, there is a very large doubt 
 whether or no the type of bone disease produced experi- 
 mentally is true rickets. The results of experiments on 
 animals are exceedingly conflicting. 
 
 Experimental work in the production of rickets has been 
 carried out by many observers. In 1838 Jules Guerin shut 
 up two dogs in confinement and fed them on bread and meat, 
 and at the same time allowed some control dogs to run in a 
 park while fed on the same diet. At the end of three months 
 both series of animals had developed diarrhoea and suffered 
 from rickets. As a result, Guerin maintained that defective 
 alimentation and premature weaning were the essential 
 causes of rickets. 
 
 In 1864 and 1874 Leon Tripier sought to confirm these 
 results, but failed and came to the conclusion that neither 
 defective alimentation nor premature weaning had anything 
 to do with rickets. 
 
 Troitzky * in 1896 fed dogs on a potato- broth and gave 
 daily laxatives and found that in three months the animals 
 presented the signs of the disease in a rachitic rosary, bending 
 of the long bones, dental caries and wasting. Microscopically, 
 however, the bony changes did not conform to those found 
 in true rickets. 
 
 L. Spilhnan experimented on lambs, cats, chickens, 
 rabbits and a young fox, submitting them to varying condi- 
 tions of bad hygiene, defective alimentation and premature 
 weaning. As a result, he found that all these conditions 
 
 * Troitzky, Soci6t6 des ra6decius Russes, Congr6s de Kiew, 1896. 
 
412 Rickets 
 
 produced digestive troubles, diarrhoea, arrest of growth and 
 wasting. Only rarely did he find osseous lesions, and when 
 they were present they did not present the appearance of 
 rickets microscopically.* 
 
 Most observers are now agreed that there are wide 
 differences between so-called experimental rickets and the 
 human form of the disease. That a true rachitic process 
 does occur spontaneously in young animals as the result of 
 confinement is probably true, but that there are other forms 
 of bone disease to which animals in captivity are liable 
 seems almost certain. 
 
 In captivity, it is quite clear that it is not the food which 
 is at fault. It is a matter of common observation that the 
 young of all species delight to skip and jump and frolic in 
 the open, and that free and unrestrained movements are 
 necessary for the maintenance of health and the process of 
 growth. Stock breeders, especially of the heavier varieties 
 of stock, are well aware that unless the young are allowed 
 their liberty soon after birth they do not thrive, the joints 
 become thickened and the legs are clumsy and heavy. 
 
 On the other hand, bulldogs, some years ago, were fre- 
 quently kept chained up so as to produce the outward bend 
 of the legs considered desirable, for breeders knew that free 
 exercise in the open tended to produce straight limbs. 
 Rickets most frequently attacks the heavier or lymphatic 
 type of dog, such as the Great Dane, St. Bernard, wolf- 
 hound, bloodhound and foxhound. The difficulty of keep- 
 ing kennels of sporting dogs free from rickets, even when 
 the feeding is excellent, has already been referred to. 
 
 In many ways, experimental rickets differs from true 
 rickets and resembles osteo-malacia. The experimental 
 disease, like osteo-malacia, often tends to assume an epidemic 
 form, and frequently spoils whole series of experiments. It 
 affects the adult animal as well as the young. Growth is 
 more rapid in the young of animals than in man, and there- 
 fore the experimentally-produced disease is much more 
 acute and frequently tends to produce a complete break- 
 
 * Marfan, loc. cit., p. 494. 
 
The etiology of Rickets 413 
 
 down of the metabolism and a widespread infection ending 
 rapidly in death. In man, rickets is essentially slow and 
 chronic and constantly tends towards spontaneous recovery. 
 In the experimental condition the absolute and relative 
 calcium content in both the bones and in the soft parts 
 of the body is greatly reduced. This condition is also found 
 in osteo-malacia. In true rickets, while the calcium con- 
 tent of the bones is smaller, that of the soft parts is either 
 greater, or, at all events, not less than normal. There seem, 
 then, to be many varieties of disease in which changes occur 
 at the growing ends of the long bones and also in the mem- 
 brane bones. 
 
 That the young of wild animals are free from rickets in 
 their natural state and that they are subject to rickets in 
 confinement seems to be undoubtedly true. Changes re- 
 sembling rickets are present in animals kept on a calcium- 
 free diet, but the histological appearances show consider- 
 able variation from what are found in the true disease ; in 
 the experimental condition the osteoid tissue seems hungry 
 for calcium and takes it up readily when offered, with the 
 production of normal bone. In true rickets there is a failure 
 of calcification even although there is abundance of calcium 
 in the blood. 
 
 Scurvy, as has been shown, produces changes at the ends 
 of the long bones resembling rickets. 
 
 Acute infections are very apt to mask the rachitic state 
 in experimental rickets and a complete breakdown of the 
 whole development of the animal is produced. Such a con- 
 dition has little in common with true rickets, which typically 
 leads to a simple delay in development with increased 
 preparation for the normal process but inadequate per- 
 formance on the lines laid down by Pommer. (See p. 400.) 
 
 In the adult animal bony changes which occur in con- 
 finement have probably nothing in common with true 
 rickets, and suggest rather some profound toxaemia follow- 
 ing an infective condition. 
 
 Findlay, in an important article on the aetiology of 
 rickets, lays great stress on lack of exercise as a factor in 
 
414 Rickets 
 
 the production of experimental rickets.* Dogs deprived of 
 exercise developed the disease while those which had light 
 and fresh air and freedom of movement escaped. Experi- 
 mental animals, he noted, often developed rickets simply 
 through being caged. Other animals fed by Findlay on 
 foods usually blamed for the production of rickets died from 
 marasmus but did not develop rickets. This agrees with 
 the clinical observation that children suffering from maras- 
 mus do not develop rickets. Findlay further points out that 
 during the spring the dispensaries are full of rachitic chil- 
 dren as the result of the winter confinement. 
 
 Hess and Unger, who have carried out much important 
 investigation on the accessory food factors, at first considered 
 that among the negro women in New York, whose breast-fed 
 children are practically always rachitic, the diet was often 
 deficient in fat. In his recent work on scurvy, Hess, who 
 has carried out much pioneer work in deficiency diseases, has 
 abandoned this view, and, commenting on Dr. Mellanby's 
 work, states " our experience is that rickets develops in 
 infants even when the diet contains adequate fat soluble 
 vitamines." t 
 
 • " The iEtiology of Rickets," by Leonard Findlay, British Medical 
 Journal, 1908, Vol. II., p. 13. 
 
 ■f " Scurvy, Past and Present," by Alfred F. Hess, M.D., Philadelphia 
 and London, 1920. 
 
CHAPTER XXVII 
 The ^tiolog-y of Rickets {continued) 
 
 The Mtiology of Rickets considered in relation to the Geogra- 
 phical Distribution. — It has been shown that rickets prevails 
 in a well-defined strip running across Europe and North 
 America between the latitudes 40° and 60° North, that is, 
 a line running approximately through Rome on the south 
 and the north of Scotland on the north. Outside this zone 
 in the rest of the northern hemisphere, and in the whole of 
 the southern hemisphere including this corresponding zone, 
 the disease is almost negligible except, as has been shown, 
 in the case of Australia. 
 
 The characteristics of this area have already been dis- 
 cussed. It is wet and damp and is exposed to long, cold 
 winters on the one hand, but, on the other hand, it is the 
 wealthiest section of the globe, and into this zone are poured 
 aU the foodstuffs of the earth in abundance. The food of 
 the people is richer and more varied and more uniformly 
 distributed than in any other part of the globe. Yet, with 
 these advantages, Hess states, and his statement is sup- 
 ported by many observers, that within the temperate zone 
 the majority of infants suffer from rickets to some degree. 
 
 Breast feeding is stiU the general rule, especially among 
 the poorer sections of the community, where rickets is most 
 rife. Difl&culty in suckling is much more common among 
 the upper classes, where rickets is less frequent and slighter 
 in degree when it does occior. 
 
 In England, Scotland and Ireland it has been shown that 
 the prevalence of rickets follows the coal mining and indus- 
 trial areas. And yet the families of the miners are pros- 
 perous and live well on a wholesome and varied diet. The 
 wife does not, as a rule, require to go out to work, and the 
 
 415 
 
\i6 Rickets 
 
 fathers, from the recruiting point of view, gave the largest 
 proportion of fit men to the army dm-ing the late war. And 
 yet it is in these areas that the disease is most prevalent. 
 
 It has already been noted that these same areas of 
 greatest prevalence of rickets, which correspond with the 
 coal fields, are also the areas which suffer from the highest 
 child mortaUty. It is impossible to ascribe these results to 
 deficient and defective feeding, for these families Uve exceed- 
 ingly well. It is little to be wondered at that, in order to 
 keep up the efficiency of the labour supply in the mining 
 districts, it is necessary that it should constantly replenish 
 itself from the country and from the famiUes of the farmers. 
 
 In the west and south-west of Ireland, where poverty 
 has prevailed for generations and the people Uve largely on 
 starchy foods, rickets is, nevertheless, conspicuously absent. 
 
 In South Africa the climate up-country is as healthy as 
 can be found anywhere in the world, but it is trjHlng to the 
 nursing mother on account of the great heat and the 
 continued droughts which sap the energies of the white 
 population. Dairy produce is scarce, and the fare is both 
 scanty and coarse, consisting chiefly of bread, meat, and 
 cofEee. Milk and eggs and green vegetables are scarce. 
 The child has frequently to be weaned prematurely, and the 
 difficulties of feeding are often great. The addition of 
 starchy foods to the diet at an early date in addition to the 
 breast feeding is exceedingly common. Diarrhoea and 
 dysentery, often of an intractable kind, are frequently 
 present. Yet in these children rickets never develops. 
 
 The natives are composed of many races. The so-caUed 
 Hottentot population of Cape Colony, who form the domestic 
 servant class, the Kaffirs and the Zulus of Natal practically 
 never show signs of rickets. The servant class, who have an 
 admixtm-e of white blood, live on much the same class of 
 food as the white population, but they live mostly trader 
 native conditions in the locations outside the towns. The 
 Kaffirs are large meat-eaters, but they also live on coarse 
 grains, such as Indian com, and sour or fermented milk is 
 freely used when it can be obtained. 
 
The -Etiology of Rickets 417 
 
 In America these same races suffer excessively from 
 rickets, so that nearly all observers agree that it is practically 
 imiversal among negro infants. The type of disease is often 
 very severe. 
 
 Professor A. E. Jenks, the American anthropologist, 
 estimates that one in ten of the population of the United 
 States is negro. He believes that two movements are taking 
 place — one of segregation in the Southern States and in 
 some of the larger cities, while in the north there is a tendency 
 to amalgamation of white and black, especially with some 
 of the more recent European immigrants, among whom the 
 distinction between black and white is not as strictly drawn 
 as it is in the Southern States of America, or in a country 
 like South Africa, where the line of demarcation is very 
 rigid. The study of the physical, mental and moral 
 characters of these people of mixed ancestry is obviously 
 a matter of much importance in considering the develop- 
 ment of the population as a whole. 
 
 America is not a country where even the poor feed badly, 
 nor can it be said that the native women are worn down by 
 excessive toil. Some cause quite other than the food factor 
 is at work. In Jamaica, as has already been detailed, only 
 2 per cent, of the population is white, and the children are 
 often weaned early and are usually fed from an early date 
 on starchy pap, and yet rickets is practically absent. The 
 food conditions here are such as are usually blamed for the 
 production of the disease in Europe. 
 
 The Italians in London are a thrifty people who cook 
 well and live on a fare more substantial and varied than that 
 on which they subsist in Italy, and yet in London the infants 
 suffer markedly from rickets, and that in spite of the fact 
 that the great majority are breast fed. 
 
 The Jews in the East End of London hve on excellent 
 food into which oil enters very largely. The health of the 
 mothers is very good and, as has already been shown, over 
 80 per cent, breast feed their infants. Yet in spite of these 
 facts, rickets — contrary to what is usually believed — is 
 exceedingly common among the Jews, just as common, in 
 
 E E 
 
41 8 Rickets 
 
 fact, as among the non- Jewish population, but the type of 
 disease is less severe. 
 
 Among the great rice-eating populations of China and 
 India, and the East generally, the population lives on a diet 
 of low nutrient value, the proteid and fat content being 
 conspicuously low. The diet is monotonous, and even this 
 simple fare is by no means constantly ensured, for they live 
 at all times on the border line of want. Early admixture of 
 starchy pap Avith the breast feeding is constantly employed. 
 Prolonged lactation is the rule — indeed, every known 
 dietetic error in the rearing of the infant to which rickets is 
 attributed in England is exceedingly prevalent all over the 
 East, and yet the children do not develop rickets. Probably 
 if BengaU children living in Calcutta under conditions of 
 European housing were systematically examined slight 
 degrees of rickets would be found to be present in some 
 cases. I have had no personal opportunity of making such 
 observations, but creche workers inform me that in Bengal 
 cases where the child is not thriving and the wrists are sUghtly 
 swollen are not very uncommon. That does not alter the 
 fact that, taken over India generally, those hving under 
 native conditions are entirely free from the disease. 
 
 All over India child mortality is high and gastro- 
 intestinal infections are exceedingly common and difficult 
 to combat, but rickets does not supervene. Marasmus and 
 widespread and devastating famines are common and yet 
 the disease remains absent. Obviously over a large portion 
 of the globe's surface, food conditions and errors and defects 
 in diet have no influence whatever in the production of 
 rickets. 
 
 During the war over a prolonged period there was a 
 great shortage of food, and substitutes and preserved foods 
 were used to make up the scanty ration. Probably the 
 deficiency was felt more keenly in London than an5rwhere 
 else. The supply of meat and dairy produce, and especially 
 of fat, was very restricted. The results, however, were quite 
 different from what might have been expected under such 
 circumstances. The general nutrition of school children 
 
The iEtiology of Rickets 419 
 
 both in London and elsewhere was very good, and was, 
 indeed, beheved by many medical officers to be better than 
 before the war. There was certainly no formidable out- 
 break of rickets either in infant welfare clinics or in school 
 cUnics, beyond what occurred in ordinary normal times of 
 prosperity. Several factors probably contributed to this 
 result. The head of the family was in the army, but the 
 mother was allowed a substantial sum for maintenance. 
 There was a more equable distribution of foodstuffs through- 
 out all classes of the community owing to the rigid system 
 of rationing. 
 
 In spite, however, of the fact that the nutrition was 
 well maintained, there was a large rise in the incidence of 
 tuberculosis, mainly affecting women and children. 
 
 The Mtiology of Rickets considered in relation to the Histori- 
 cal Evidence. — Glisson, as has been shown, beheved that the 
 essential cause of rickets was to be found in an abundance of 
 rich foods and excess of luxury operating in both the parents 
 and through the parents on the child, and over-nutrition and 
 undue pampering of the child itself. It must be remembered 
 that in Glisson's time rickets, as is often the case with a 
 comparatively new disease, seems to have been of a severe 
 type, and was by no means confined mainly to the poor as it 
 is to-day. Indeed, Glisson's behef , and the general impression 
 of the lay public, was that it affected mainly the children of 
 luxurious homes. 
 
 It is evident that in many ways the children of 
 the wealthy in these ruder times had to struggle through 
 a phase of their existence handicapped by adverse 
 features which did not affect the children of the poor. It 
 must be remembered that child mortahty was very heavy. 
 Recurring plagues, smallpox, and other epidemic and endemic 
 diseases, created an impression on the public mind which led 
 to excessive precautionary measures which defeated their 
 own end. Sanitary science was tmknown, and diseases were 
 attributed to some dread miasmatic contagion from which 
 dehcate young life must be protected at all costs. These 
 diseases, it was held, were carried through the air, especially 
 
420 Rickets 
 
 the night air, and it was therefore deemed necessary that 
 young infant life should be effectually protected from the 
 ingress of fresh air into the nursery. Artificial feeding and 
 milk substitutes did not exist. In wealthy families the child 
 was breast fed either by the mother or by a wet nurse. The 
 resources of the nursery extended no further. The child was 
 shut up in a room which as far as possible was sealed so as to 
 exclude ventilation. Cradles were solid structures, and clothes 
 were heaped on the unfortunate infant while the child was 
 placed near a great fire. In the winter time such a child would 
 hardly be allowed out of the room. Indeed, we have hardly 
 left the old superstition as to the danger of fresh air behind 
 us to-day, especially in the country and among the poorer 
 classes of the community. Certainly up to mid- Victorian 
 times bedsteads with heavy hangings which were carefully 
 drawn at night were in common use. Long sand cushions 
 were placed on the ledges of the windows and at the doors to 
 prevent the ingress of draughts, and are still in use in 
 many homes throughout the country. It is but little to be 
 wondered at that many children, as John Evelyn suggests 
 in the case of his own son, succumbed to the very excess of 
 care devoted to them by the anxious parent and nurse. 
 
 Glisson instances the following factors operating in the 
 parents as agents predisposing to the production of the 
 disease : — 
 
 (1) the soft and loose and effeminate constitution of either 
 
 or both parents ; 
 
 (2) an over-moist and over -full diet ; 
 
 (3) a delicate kind of life abandoned to ease and voluptuous- 
 
 ness, slothful and rarely accustomed to labour, danger 
 and care. 
 
 Speaking of the increase of rickets in the south-western 
 counties of England, as compared with the rest of England, 
 he specifically states, in a passage already noted, that the 
 essential cause is the affluence of all good things in these 
 counties, " for this part of the kingdom is much the more 
 fruitful, rich and flourishing and abounding with all manner 
 of allurements to pleasure." 
 
The Etiology of Rickets 421 
 
 The poor led a healthier, if rougher, existence, and in the 
 homes of the labourer there was but little comfort to conduce 
 to long hours spent luxuriously indoors. Labour was mostly 
 employed in the fields, and the life of the whole family, 
 parents and children alike, was spent much in the open. 
 The influences spoken of by Ghsson are the same which 
 induce rickets to-day, but with the essential difference that 
 these conditions, such as confinement in badly ventilated 
 and overcrowded rooms, lack of exercise, lack of sunshine 
 and lack of the opportunities of cleanhness, are to-day con- 
 centrated in the homes of the poor in our slum areas. It 
 may again be reiterated that in a chmate such as ours the 
 conditions of the slum may be reproduced in the most 
 beneficent surroundings. The occurrence of defective and 
 impaired growth in the midst of beautiful country, aboimding 
 in rich dairy produce, is as striking to-day as in Glisson's 
 time, although the deviation from the normal is not so wide. 
 Even to-day, as has already been noted, in the south-western 
 counties of England, evidence can be found of the disease in 
 the home of the better-class farmer, as well as in the cottage 
 of the farm labourer — a somewhat striking fact, fpr rickets 
 is a disease which presents class distinctions and tends to 
 bear chiefly on the lower grades of society. During our 
 prolonged and inclement winters, damp and cheerless 
 dwellings between the hills and ignorance of the first prin- 
 ciples of healthy hving can reproduce, even in such unlikely 
 surroundings, the vicious environment of the slum. Whole- 
 some food is necessary, and of all food none is so conducive 
 to the well-being of the infant as the breast milk of a 
 healthy mother. Equally essential is a bright and healthy 
 environment with ample fresh air and opportunity for 
 exercise. The environmental factor is the one which con- 
 stantly fails in rickets, and is the sole agent without which 
 the disease cannot be reproduced. The food factor is much 
 less likely to fail, and if it does even to the extent of 
 producing marasmus and acute wasting, it never in itself 
 produces rickets. 
 
 The record for the study of rickets in the world's history 
 
422 Rickets 
 
 is a long one, for wherever there is a skull or a skeleton there 
 is a document which can be scanned for evidence of the 
 disease. In Neolithic remains and those of the Bronze Age, 
 down through the Ancient British period to the Roman 
 occupation of England, and from thence to the Anglo-Saxon 
 period, and up to mediaeval times, there is a striking and 
 complete absence of the disease. This is the more note- 
 worthy, for there is no lack of evidence of the existence of 
 marked bone disease even in remote times. Osteo-arthritis 
 of a severe type is especially common. The further one gets 
 back to crude and remote periods, the greater is the evidence 
 of a harsh and severe struggle for existence. The growth of 
 the people is stunted and the incidence of the stress falls 
 chiefly on the women, who are affected out of all proportion 
 to the men. 
 
 It would seem as if these conditions must have borne 
 most hardly on the offspring of such a people, but the few 
 facts there are, such as those detailed in speaking of the 
 remains of the Upper Nile (see p. 316), seem to show that the 
 iniant to a large extent escaped, and that the stress told on 
 the adult, leading to stunted growth and an early invasion 
 by disease and shortened expectation of life. 
 
 Taking the variability of such a factor as height in the 
 present population, the tendency has been to regard it as 
 almost entirely the result of heredity. This result has been 
 arrived at by measuring the variations in the heights of the 
 parents and comparing these with variations in the heights 
 of the offspring, and also by measuilng the amount of varia- 
 tion between brothers and sisters. 
 
 But caution must be observed in ascribing what occurs 
 in the parent and child alike, even over large numbers, as 
 necessarily being due to heredity. The evidence of history 
 would seem to show that, apart from racial differences, where 
 certain conditions such as defective feeding are universal 
 over a large population, the result as regards growth in 
 weight and stature will not be so good as if food were 
 abundant and of good quality. Still more important, I 
 believe, is the effect of environment. In new countries the 
 
The iEtiology of Rickets 423 
 
 population derived from European stocks tends to increase 
 in stature generally, a fact which was apparent in the 
 colonial troops recruited in the late war, as compared with 
 those recruited from the industrial centres of our great 
 towns. 
 
 The important function of heredity is not to produce 
 variation but to stabihse the type and produce a healthy 
 average. But to do this to the best advantage nature 
 demands favourable conditions, especially of feeding and 
 environment. 
 
 The effect of placing the bulk of the community under 
 conditions of town and slum dwelhngs introduces factors 
 which, owing to the universality of their operation, are 
 exceedingly difficult to distinguish from hereditary influences 
 when brought to bear upon a whole community over pro- 
 longed periods. 
 
 In speaking of the skeletal remains of the ancient 
 inhabitants of Egj^pt and of Coptic peoples, it was stated 
 that the evidence seemed to show that the incidence of 
 disease in the young infant and child mortality were prob- 
 ably much less than they are to-day. The conspicuous 
 absence of the study of children's disease from the writings 
 of the ancient classic writers has already been commented 
 on. Hippocrates and Galen were no mean observers. In 
 these early civilisations the probability is, that diseases of 
 the adult, in the form of defective ehmination, were more 
 prominent than errors of growth in the young infant. 
 
 In the Royal College of Surgeons there is arranged in 
 series a large number of skulls from Neolithic times up to 
 the present day. Through the various periods the skulls 
 show wide racial differences, but, whatever the period and 
 no matter how varied the shape of the head up to a com- 
 paratively recent date, say, the close of the sixteenth cen- 
 tury, the jaws and teeth, the best records of the rachitic 
 state, show the same conformation. The vault of the palate 
 is depressed and wide, and not high and vaidted as it tends 
 to be in the modem skull. The alveolar borders are wide- 
 spread and the teeth are nearly all present. There is but 
 
424 Rickets 
 
 little liability to decay, notwithstanding the roughest usage, 
 and hypoplasia is conspicuously absent. The large collec- 
 tions of bones in EngHsh crypts up to and beyond Reforma- 
 tion times are remarkably free from rickets, while syphilis, 
 tubercular disease and osteo-arthritis, are often well 
 marked. 
 
 The modern type of skull does not, indeed, become 
 common till the beginning of the eighteenth century, since 
 when marked and" rapid change has occurred in the skull 
 corresponding with the growth of towns and the develop- 
 ment of modern industrial centres. 
 
 I would class the modern English skull as dating from 
 the beginning of the eighteenth century, and the variations 
 which have occurred are, I believe, the result of altered 
 environment acting continuously and widely over a great 
 and increasing population. There are undoubtedly many 
 other factors to be considered, such as the employment of 
 women and children under deplorable conditions in factories, 
 which had a great influence on the health of the community. 
 The evil results of work in the factories, especially in the 
 case of expectant mothers, must have had deleterious effects 
 on the offspring, though it is possible to exaggerate these. 
 The conditions of women's labour have, however, been very 
 much ameliorated for several generations, but rickets 
 remains as common a disease as ever, though the degree of 
 severity is undoubtedly mitigated. Child labour had most 
 pernicious results in thwarting and retarding the develop- 
 ment of the young child, but these were not the conditions 
 which produced rickets, for the disease arose as the result of 
 evil environment, bearing on the young child from soon after 
 birth up to the end of the second year. 
 
 What, then, is the nature of the environment which 
 produces rickets ? It is that associated with the over- 
 crowding of immense populations into slum areas, accom- 
 panjdng the development of industrial conditions in large 
 towns and cities. It impUes several factors : — (i) absence 
 of sunlight ; (2) deprivation of fresh air, and of the means 
 of proper oxygenation of the blood and removal of 
 
The ^Etiology of Rickets 425 
 
 carbonic acid, required for the metabolism of the healthy 
 infant ; (3) deprivation of the means of exercise which is so 
 essential a stimulus to the proper regulation of the process 
 of growth ; (4) the breathing of an atmosphere polluted 
 by overcrowding in confined and badly-ventilated rooms ; 
 (5) the want of the opportunity for proper cleanliness. 
 
 The transformation of the people of England from a 
 sparse rural population to an enormous densely-packed 
 industrial one has taken place within the short period of 
 three hundred years- Nature has had to deal with a pro- 
 blem which menaced the very life and continuity of the race 
 within the northern temperate zone. 
 
 Picture a child born in a small damp basement room in 
 Hoxton or Shoreditch. There is a family of four or five, 
 perhaps more, in one, two or three rooms. All the house- 
 hold operations, such as cooking and washing, have to be 
 carried out in these living rooms. There is no bath. Ven- 
 tilation is as restricted as possible during a large portion of 
 the year. During the day there is no fresh air and at night 
 the conditions are worse, for the child in slum populations 
 almost invariably sleeps with the mother. The separate cot 
 for the infant is a desirable reform which the infant welfare 
 worker knows is one of the most difficult to carry out. 
 
 These are not occassional conditions, nor are they the 
 environment of a century ago, but, as has been shown in the 
 case of the north-east sector of London alone, which includes 
 a population of a little over 900,000 people, are the ordinary 
 conditions in which 314,000 of these people live to-day. 
 Careful examination shows that overcrowding and confine- 
 ment in small rooms are the essential factors wherever rickets 
 is prevalent. Whether in England, or Europe, or America, 
 the greatest prevalence of rickets is associated with the 
 greatest density of population. 
 
 The metabolism of the young infant is exceedingly rapid, 
 and growth takes place out of all proportion to the mere 
 food intake. After the first few months the expenditure of 
 energy in the form of actual exercise is very great. The 
 child is seldom still ; it loves to exercise its muscles in short 
 
426 Rickets 
 
 jerky movements. From an early period it carries on a 
 continuous babble when awake, and cries lustily to indicate 
 its needs. To carry on this active metabolism, and these 
 expressions of its vitality, a rapid respiratory interchange 
 must take place. To a large extent the young infant feeds 
 upon air. That this is actually possible is seen in the hiber- 
 nating animal, which not only lives upon air but may 
 actually gain weight without any fresh intake of food 
 whatever. It is a matter of everyday experience that a 
 change to fresh air and fresh surroundings may be produc- 
 tive of the most striking difference in the health of the young 
 child suffering from debility, producing an immediate 
 increase in growth and vitality. Without any change in 
 the diet, or even on a poorer diet, the beneficial effect pro- 
 duced by the mere change of air is often most striking. 
 
 It is generally recognised that the breathing of vitiated 
 air tends to produce ill-health and renders the body more 
 liable to infection and disease. I have been repeatedly 
 struck with this while investigating rickets in the East End 
 of London in some of the older London County Council 
 schools which have been deficient in the means of ventila- 
 tion. 
 
 In such a school, on entering a classroom, the observer 
 is conscious of an offensive smell from the vitiated air of the 
 room. The olfactory sense is extremely susceptible to varia- 
 tions in closed atmospheres, suggesting an important protec- 
 tive measure. The teachers and pupils alike show the 
 evil effects of the breathing of polluted air. Anaemia is 
 common ; the children are pale and the skin has a 
 muddy yellow tinge. Discharging ears are very frequent, 
 much more so than in other schools better situated, indi- 
 cating the presence of adenoids and naso-pharyngeal infec- 
 tions. Myopia is often exceedingly prevalent. The teachers 
 have frequently informed me that it was practically impos- 
 sible to retain the attention of the classes in the afternoon, 
 and they complained that they themselves found it exceed- 
 ingly difficult to concentrate on the work in hand. Head- 
 aches and recurring catarrhal colds are very common. To 
 
The ifEtiology of Rickets 427 
 
 add to the distress, as is usual in badly constructed buildings, 
 there is but little movement in the air and it is difficult to 
 keep the rooms cool in summer or warm in winter. The air 
 of overcrowded rooms may be vitiated in various ways, and 
 several factors have to be considered. 
 
 1. Increase of Carbon Dioxide. — The mere fact that there 
 is an increase of carbonic acid in the room does not mean that 
 there is necessarily a corresponding increase in the tension 
 of carbon dioxide in the lungs. Just as there is a heat- 
 regulating mechanism which keeps the body temperature 
 constant under varjdng conditions, so there is an adaptive 
 mechanism whereby the amount of carbonic acid in the 
 alveoli is kept fairly constant. The proportion of this gas 
 is the usual index taken to indicate the impurity of air, but 
 it is by no means a certain test, for air which, judged by the 
 amount of carbon dioxide may seem fairly pure, may be very 
 impure when judged by other standards such as the number 
 of organisms present. Experimental results seem to show 
 that large quantities of carbonic acid may be, present in the 
 air without untoward results. Thus one can breathe with 
 moderate comfort in a room the air of which will not 
 support a light. Increase of carbon dioxide tends to pro- 
 duce hyperpncea and headache, both of which may be pre- 
 vented by withdrawing this one content. 
 
 2. Diminution of Oxygen. — Experimentally this is well 
 borne, and respiration can be maintained in atmospheres 
 deprived of oxygen to an extent which is never found in 
 ordinary vitiated atmospheres. 
 
 So far as the ratio of carbonic acid gas and oxygen in the 
 atmosphere is concerned it would seem from experimental 
 observation that there is room for a wide variation without 
 harmful effect to the individual. Dr. J. S. Haldane suggests 
 that the function of the epithelial lining of the alveoli is not 
 merely that of a porous hning. Normally, he believes that 
 oxygen reaches the blood by a simple process of diffusion 
 through this membrane, but that when a special demand 
 upon oxygen is made by the economy that the living cells 
 of the epithelium actually secrete oxygen from the air and 
 
4^8 Rickets 
 
 hand it forward at enhanced pressure to the blood. This 
 property is, he believes, developed in miners, and is also 
 capable of being improved by physical training. Conversely, 
 it is reasonable to suppose that in a disease such as rickets 
 this epithelium may have the power of limiting the exchange 
 of gases and so damping down the whole process of metabo- 
 lism, which is so marked a feature of the rachitic state. 
 Interference with the special functions of cells is, as has been 
 shown, a common feature of rickets. 
 
 3. The Presence of Organic Matter in Respired Air. — ^^Once 
 again, experimental results are conflicting and inconclusive. 
 Brown Sequard and d'Arsonval found that the injection of 
 soluble organic matters exhaled from the lungs and skin into 
 the circulation caused death, as also did the constant breath- 
 ing of these products. 
 
 HaJdane and Lorrain Smith repeated these experiments 
 but were unable to confirm these findings.* They came to 
 the conclusion that the immediate dangers from breathing a 
 highly vitiated air arose entirely from excess of carbon 
 dioxide and deficiency of oxygen and not from any special 
 poison. Subsequent to these experiments, Dr. Sigmund 
 Merkel I published results again confirming the work of 
 Brown Sequard. Four air-tight glass vessels were connected 
 by means of glass tubes, a mouse being placed in each vessel. 
 Between the third and fourth vessels a Geissler absorption- 
 tube containing sulphuric acid was interposed. Air was 
 drawn slowly through the vessels by an aspirator so that the 
 second mouse breathed the air from the first, the third from 
 the second and the fourth from the third. The result was 
 that the mouse in the third vessel died first, after sixteen to 
 twenty hours, while that in the fourth vessel remained alive. 
 Merkel concluded that, as the fourth mouse remained alive, 
 the death of the third cannot have been due to an excess of 
 carbonic acid, or to a deficiency of oxygen, but must have 
 been caused by the presence of some volatile substance 
 
 * " The Physiological Effects of Air Vitiated by Respiration," by John 
 Haldane and J. Lorrain Smith, Journal of Pathology and Bacteriology, 1893, 
 Vol. I., pp. 168 and 318. 
 
 t Archiv. fur Hygiene, 1892, Vol. XV., p. i. 
 
The ^Etiology of Rickets 429 
 
 which is absorbed or destroyed by the sulphuric acid. Again, 
 Haldane and Lorrain Smith were unable to confirm these 
 results. 
 
 The air of overcrowded rooms contains an increase in 
 the number of micro-organisms. Apart from the chemical 
 composition, the physical properties of the air, such as 
 temperature, humidity and movement, are all potent factors 
 in the maintenance of health. A continuous warm, moist 
 atmosphere is most depressing to all the functions of the body. 
 This is usually combined, under conditions of overcrowding, 
 with stagnation of the air. As a result the general meta- 
 bolism of the body is diminished and the appetite is poor. 
 The tone of the muscles is impaired, and there is a lack of 
 nervous and muscular energy. Free stimulation of the skin 
 by a moving and constantly varying atmosphere, such as is 
 met with in the open, is most wholesome in its effect on the 
 general metabolism. Even the adult when confined indoors 
 soon shows the effect of the loss of such stimulation and tends 
 to lack energy and to become sallow and pale. It can be 
 readily understood that a warm, moist and motionless 
 atmosphere such as the child of the slum dweller lives in for 
 weeks and for months together must have a most depressing 
 effect. 
 
 There can be no doubt that the breathing of impure air 
 is very unwholesome. Experiments are unsatisfactory in 
 that they do not reproduce the conditions under which such 
 air usually acts. In experiments, an adult presumably in 
 good health remains in a chamber for a few hours. The 
 young infant, on the other hand, remains day after day and 
 week after week in an atmosphere contaminated by young 
 and old, while disease and dirt also add their impurities. 
 Kassowitz, indeed, believed that the breathing of ammoniacal 
 exhalations owing to insufficient cleanliness was a common 
 cause of rickets. Whether or no there is an actual toxin in 
 respired air, it is at present impossible to say, but clinical 
 evidence certainly seems to support the experimentalists 
 who find such products are present. That there are certain 
 organic impurities in respired air seems certain from the 
 
43° Rickets 
 
 sense of smell, and also that they have a deleterious effect 
 even though they may be minute in quantity. The long- 
 continued action of such substances may induce through the 
 central nervous system alterations in respiration, circulation 
 and nutrition, which are inconsistent with the maintenance 
 of good health. If the air is stagnant and still, the moisture- 
 laden emanations from the body are imprisoned and 
 entangled by the clothing, and a humid layer of foul air 
 hinders further evaporation.* 
 
 Consider the position of a young infant exposed during 
 the first few months of its life to the deleterious influence of 
 such an atmosphere ; even in a modified degree, such as may 
 occur in the " stuffy " room of the better-class house, the 
 effects are most harmful. The rapid exchange of gases in 
 the act of respiration is interfered with. There is a sUght 
 increased tension of carbon dioxide in the alveoli, and this 
 gas is not eflftciently removed from the blood. Hyperpnoea 
 results and heavy sweats are induced owing to the effort of 
 nature to relieve the system of the excess of carbonic acid. 
 The supply of oxygen is interfered with, and the damp, 
 moist, frequently overheated air acts as a further depressing 
 agent. As already stated, whether or no there is a definite 
 organic toxin in respired air is still in dispute, but there 
 can be no doubt of the extremely unwholesome results of 
 breathing such air, which in many well-known and extreme 
 cases has ended in death. It is obvious that a robust child 
 full of life and vitality could not long survive under such 
 conditions and still retain its full vigour. Nature, according 
 to John Hunter's axiom, meets the altered conditions by a 
 process of conservation and holding up of the entire meta- 
 bolism of the child. In the rickety infant the metabolic 
 processes are at a low ebb. There is an absence of energetic 
 movement. Respiration is hurried but it is shallow, and 
 the quantity of air taken into the chest is the smallest 
 amount that the organism finds essential for carrying on its 
 work. 
 
 The enlarged and tender epiphyses at the ends of the 
 * Parkes and Kenwood, " Hygiene and Public Health," London, 1917. 
 
The iEtiology of Rickets 431 
 
 softened long bones further restrict the child's desire for 
 movement. The very great muscular debility is in con- 
 formity with the general plan of producing an organism 
 capable of living in an environment where a healthy vigorous 
 child could not long maintain its existence. Nature, ever 
 mindful of the continuity of the race, is often heedless as to 
 whether or no her process of natural selection is beneficial 
 to the individual ; if a feebler type is necessary for the 
 perpetuation of the race owing to overcrowding in great 
 towns and widespread unhygienic conditions, the type of 
 individual fitted to live under these conditions will 
 undoubtedly be produced. Such is the rachitic infant. 
 Heredity even may step in, for it would seem to be the case 
 that when conditions threaten the actual life of the germ, 
 an adaptive change may readily occur in the germ plasm 
 itself, and Glisson's idea, which accords with common 
 experience, that weak, debilitated parents tend to produce a 
 debiUtated progeny may easily be true. But that does not 
 imply that rickets is hereditary. 
 
 All these conclusions w^ould appear to point to inimical 
 influences acting through the air, whether it be the result 
 of the overcrowding of the poor, or over-care and coddling 
 of the rich in close stuffy rooms. The healthy child dehghts 
 in free movement which entails vigorous action of the respira- 
 tory and circulatory functions to carry on the rapid oxida- 
 tion and removal of effete products necessary for this 
 abundant expenditure of energy and the processes of growth. 
 In the rachitic child all these processes are " damped down " 
 as it were. The child is silent and moves but little. The 
 processes of growth are delayed and the formation of osteoid 
 tissue and irregular calcification of the cartilage indicate 
 that provision is being made for growth of the bone, but that 
 the process of building up, which should take place, is being 
 held up because of a failure in the economy of the child. 
 Few things are more striking than the way nature again 
 resumes her work immediately environmental conditions 
 improve. 
 
 Why is it that a child suffers from rickets only during 
 
432 Rickets 
 
 the first two or three years of Hfe ? The disease, of course, 
 may occur at any time up till complete ossification takes 
 place at the ends of the long bones and, as has been stated, 
 true cases of late rickets occur at adolescence which may be 
 either a recrudescence or a new outbreak of the disease. 
 Such cases are, however, by no means common. Rickets 
 is usually recognised cUnically between the ages of six months 
 and eighteen months, though in the routine examination of 
 an infant welfare centre the physician will often be able to 
 pick out cases even before the sixth month. The reason 
 why the disease is confined to the first two years of the child's 
 life is because the full force of the vicious environment is 
 brought to bear on the child at this period. The infant is 
 entirely dependent on the mother for exercise and fresh air. 
 In the winter in England during the short days the busy 
 mother of a family in a poor home has but Uttle time to 
 devote to taking her baby out in the open air. She is 
 content if the child lies quiet while she carries on her house- 
 hold duties. At night the windows are closed for the sake 
 of warmth and the child sleeps with the mother, so that all 
 the evil conditions of the day are present in an exaggerated 
 form at night. Even in a good class home it is exceedingly 
 difficult during the inclement winter months for the mother 
 or nurse to give the child sufficient outdoor exercise, and care 
 must be taken to utilise every half hour of sunshine or fine 
 weather that is available. 
 
 Why does a child begin to throw off the disease about 
 the third or fourth year ? There has been no improvement 
 in the diet. Indeed, as the child grows older, it is not, as a 
 rule, so favoured as the young infant for whom the best and 
 most wholesome part of the diet is usually reserved. Never- 
 theless, these children almost invariably improve at this 
 age, and the common statement of the mother is, that all her 
 children pass through the same delicate stage, but that they 
 all get stronger by the age of seven, and long experience has 
 taught her not to worry. There is a good deal of truth in 
 what these mothers say. Immediately the rickety child 
 struggles to its feet about the age of two or three years and 
 
The iEtiology of Rickets 433 
 
 begins to lead a separate existence, and especially when it is 
 allowed the relative freedom of the streets, it begins to 
 improve rapidly. This delayed development of the rickety 
 child both in physical and mental growth, and the compara- 
 tively rapid improvement which occurs from the age of five 
 to seven years is well known to teachers in primary schools. 
 
 The Part played by Sunshine in the Prevention of Rickets. 
 — It is well known that rickets especially favours damp and 
 cold cUmates where the skies are grey and sunless, and 
 where a curtain of smoke hangs over great cities, screening 
 away a large proportion of what little sunshine there is. No 
 plants will grow in these areas, and special provision must 
 be made if trees are to survive. That sunshine has a very 
 direct action on the economy is certain. The feeling of 
 elation and bien-etre felt in bright weather is an indication 
 of its effect on the adult metabolism, and it can readily be 
 understood that it is Ukely to be an important factor in the 
 healthy development of the child. The young infant can 
 no more flourish than the tree or flower if it be entirely 
 deprived of sunlight. It is well known that the rays at 
 the violet end of the spectrum — the actinic rays — are 
 chemically active. They hasten the hatching of frogs' eggs, 
 for instance, and they kill many bacteria, including the 
 tubercle bacillus. They produce heliotropism in plants. 
 The rays in the middle portion of the spectrum are less active 
 chemically, but they stimulate the growth of plants while the 
 red rays have heating properties.* 
 
 It is difficult to say precisely in what manner sunlight 
 plays its part in the prevention of rickets, but that that 
 part is a large one is very certain. A study of the geo- 
 graphical distribution of the disease, even with our present 
 imperfect knowledge, establishes the fact that where bril- 
 liant sunshine is constant, as in Egypt, India, China, South 
 Africa, and New Zealand, rickets, for all practical purposes, 
 does not exist. Now it is well known that in the teeming 
 populations of the Far East overcrowding and insanitary 
 conditions are apt to be very prevalent. The hut of the 
 • " Air and Health," by R. C. Macfie, London, 1909, p. 104. 
 
 F F 
 
434 Rickets 
 
 native, judged from the European standpoint, lends but 
 poor accommodation to its many occupants, but this is not 
 the type of overcrowding which causes rickets. The young 
 of animals in their burrows lie curled up with the mother 
 under conditions which may be held to resemble the sur- 
 roundings of the slum dweller, but the disease never deve- 
 lops. The reason is that the life of the wild animal and the 
 life of the native are largely regulated by the sun. The 
 native infant, as soon as the sun is up, is allowed to play 
 outside the hut or habitation, and continues to be bathed 
 in sunshine till the time of rest at sunset. Under such cir- 
 cumstances rickets does not develop. It is possible that 
 with the development of European conditions in the East a 
 sUght tendency to the disease may develop, but it is likely 
 to be of a modified type. In Australia, under conditions 
 which are not conducive to rickets, slighter forms of the 
 disease have appeared as the larger towns have grown in 
 size and density. 
 
 Such theories as to the aetiology of rickets have long been 
 known, and it is noteworthy that practically every writer 
 who accepts the dietetic theory of the origin of the disease 
 hastens to state that the breathing of vitiated air, lack of 
 sunshine, and lack of exercise, are powerful contributory 
 factors. Even those who support the view that it is a 
 deficiency disease, that is, that it is due to the absence of 
 an accessory food factor or vitamin, hold that defective 
 hygienic conditions are contributory. Why this should be, 
 if the vitamin theory be true, it is difficult to say. Other 
 deficiency diseases are clearly due to the absence of a factor 
 necessary for the maintenance of health, and occur what- 
 ever the surrounding conditions may be. Beri-beri has an 
 enormously wide distribution over the East in all sorts of 
 varying conditions, while scurvy and Barlow's disease may, 
 and frequently do, occur in good homes, where all the con- 
 ditions are entirely favourable except for the absence of the 
 anti-scorbutic factor from the diet. Defective and deficient 
 feeding of infants, and ignorance of the elementary prin- 
 ciples of dietetics, are found all the world over. They are 
 
The etiology of Rickets 435 
 
 more prevalent in the East than in the highly civilised and 
 wealthy populations of Europe and America. Nevertheless, 
 rickets as a disease is practically confined to the northern 
 temperate zone between well defined limits, and under cer- 
 tain definite conditions only found in this zone. 
 
 In 1906 Von Hansemann * published his well-known 
 domestication theory of the origin of rickets, and, though 
 the aetiology of the disease cannot so far, according to this 
 theory, be pinned down to any one factor as the actual excit- 
 ing cause, it fits in with all clinical experience. The vita- 
 min theory is a tempting and facile explanation which is 
 contradicted by the study of the geographical distribution 
 and of the history of the disease, as well as by the clinical 
 evidence. 
 
 It is interesting to note that in the enquiry by the 
 National Health Insurance Medical Research Committee 
 into the causes of high rates of infant mortality. Dr. Brend f 
 comes to the following conclusions : — 
 
 (!) that excess of infant mortality has very little relation to 
 
 pre-natal conditions ; 
 (2) that the excess is due to some factor or factors in industrial 
 
 towns, the centres of large cities, and mining areas, of 
 
 which possibly the most important is a polluted state of 
 
 the atmosphere. 
 
 * " Uber die Rachitis als Volkskrankheit," Berlin, Miii. Woch., 
 November gth, 1906. 
 
 t " The Mortalities of Birth, Infancy and Childhood," Special Report 
 Series, No. 10, published by His Majesty's Stationery Office, London, 
 1918, 
 
CHAPTER XXVIII 
 
 The etiology of Rickets (continued) 
 
 Rickets and the Endocrine Glands. — The rachitic state is 
 associated with the breathing of a vitiated air at a time 
 when fresh air and the free interchange of carbon dioxide 
 and oxygen are most essential to the young infant. There 
 is an inhibition of all free movement and the child is deprived 
 of the stimulating effect of daylight and of the sun's rays. 
 Many diseases are associated with similar conditions. 
 Typhus fever, though due to a micro-organism, is neverthe- 
 less a disease associated with overcrowding and insanitary 
 conditions. Free ventilation in sunny wards contributes 
 to its cure and effectually prevents its spread. 
 
 Cretinism is a disease with a distribution not uhUke that of 
 rickets, and is associated with sunless valleys and dwellings. 
 Formerly many cases of sporadic cretinism were attributed 
 to foetal rickets. In its early manifestations it exhibits many 
 of the signs and symptoms of rickets in an exaggerated form. 
 
 Tuberculosis is notably associated with similar condi- 
 tions, as also are various forms of anaemia and general 
 impairment of health. 
 
 In the rachitic state, nature produces the lymphatic 
 child with quick, shallow breathing, holding in strict reserve 
 all its activities, so that no undue demands are made on the 
 respiratory exchange and the breathing of vitiated air is 
 made as limited as possible. 
 
 In the present state of our knowledge of the function of 
 the endocrine glands it is undesirable to dogmatise as to the 
 special part each plays in the economy of the body. Their 
 secretions are so widely operative in growth and metabolism 
 generally, and are so linked up with each other, that there is 
 a danger of fitting their function to suit any theory which 
 requires support. 
 
 436 
 
The iEtiology of Rickets 437 
 
 At the same time certain broad facts seem quite definitely 
 decided. That the thyroid gland and the pituitary body, for 
 example, both stimulate growth is now well established. 
 This is shown, in the one case, by the action of the thyroid 
 gland in cretinism, and in the other, by the enlargement of 
 the bones of the face and jaw, and of the hands and feef as 
 the result of disease of the hypophysis cerebri. 
 
 Growth may be considered from two points of view, viz., 
 firstly, foetal growth, in which is epitomised the whole evolu- 
 tion of the species, and secondly, the development of the 
 somatic or physical characters of the individual. Both these 
 modes of growth are largely the result of the combined action 
 and interaction of the endocrine glands. 
 
 It is accepted that man is the highest evolved animal. He 
 is also the most highly speciaUsed of all the primates, but 
 that is not eqiaivalent to saying that he is the farthest 
 removed from the parent stock. Indeed, the contrary is the 
 case, for man has persisted, as it were, along a certain 
 definite line, and retains many fcEtal characteristics which 
 are lost in the anthropoid apes. In other words, the anthro- 
 poid ape is travelling along a line away from the original 
 stock and is forsaking the human type. 
 
 For instance, the hand and especially the foot in man 
 retain more of the foetal type than in the other primates. 
 In the anthropoid ape the hand and still more notably the 
 foot are modified so as to depart widely from the foetal type. 
 This change is produced by the action of the glands of 
 internal secretion, and probably the gland chiefly responsible 
 for this special change is the pituitary. This is suggested 
 by the fact that in acromegaly the hands and feet of man 
 tend to assimie ape-like characteristics, and to depart from 
 the foetal type. Again, the small development of the bones 
 of the face and of the jaws in man is a persistence of the foetal 
 type, while the prognathous development is a pithecoid 
 departure from the foetal type due to the action of the 
 pituitary gland. In acromegaly there is a marked tendency 
 to the development of this characteristic in man. 
 
 Up to a point, man and the other primates have deve- 
 
438 Rickets 
 
 loped along certain lines together, and the extent and direc- 
 tion of the growth has been largely moulded and determined 
 by the action of the endocrine glands. At various times, 
 however, certain departures from the parent stem occur. In 
 the anthropoid ape, for example, the action of the endocrine 
 glands is so modified as to produce an evolution along lines 
 which lead away from the human type, which remains 
 simpler and more true to the foetal form of development. In 
 diseased conditions involving the glands of internal secretion 
 in man the t5^e of growth is apt to assume an anthropoid 
 character. 
 
 That is to say that in man, in the growth of the hands and 
 feet and in the tendency to prognathism already instanced, 
 there is normally a repression of the function of the pituitary 
 gland, which repression may, however, be removed as the 
 result of disease. Prof. Bolk, of Amsterdam, states that he 
 knows of no new developmental somatic characters in man, 
 unless it be in the muscles of the face and the intrinsic 
 muscles of the larynx, and that all the other distinctive 
 human characters are the result of the suppression of the 
 action of the endocrine glands and the perpetuation of the 
 foetal type. 
 
 It is well known that in apes the sutures of the skull 
 close early, and that the development of the young is hurried 
 forward so that maturity is rapidly reached. 
 
 In man, on the other hand, the closing of the cranial 
 sutures is considerably delayed, and the foetal or child-like 
 stage is greatly prolonged. In the anthropoid ape the 
 secretion of the internal glands hurries forward these pro- 
 cesses, but in man the action of the glands is retarded. 
 
 In the new-bom infant there is an enormous internal 
 impulse to growth. So great is the energy that a brake is 
 required, and this is probably found in the thymus gland, 
 which attains its maximum function in the first few years of 
 life. The thymus is held to be intimately associated with the 
 process of bone formation, though this has not been definitely 
 proved and the evidence is still somewhat conflicting. 
 
 The thjnroid apparatus is certainly concerned in the process 
 
The Etiology of Rickets 439 
 
 of ossification, the parathyroids especially having a controlhng 
 influence on the calcium metabohsm. That these two 
 glands, the thymus and the thyroid, are active during the 
 early life of the infant is beyond doubt, and that they have a 
 direct influence on the pathogenesis of rickets seems very 
 probable. The thyroid is an accelerator of growth and is 
 katabohc in its action, the thymus, on the other hand, is 
 conservative in its action and is anabolic. 
 
 The thyroid system, then, consists of the thyroid gland 
 and the parathyroids, and the morbid conditions associated 
 with this system may be divided into hypothyroidism 
 and hyperthyroidism. 
 
 Various diseases are commonly associated with these 
 two morbid states, though no hard and fast line can be drawn 
 between them. Thus, to the hypothjnroid state belong such 
 conditions as the benign hypothyroidism of Hertoghe, myx- 
 oedema, cretinism, various spasmodic affections such as 
 tetany and paralysis agitans, and rickets itself. To hyper- 
 thyroidism belong goitre and Graves' disease. 
 
 All clinical experience shows that for the proper func- 
 tioning of the thyroid apparatus, especially in the young, a 
 free life much in the open is essential. Deficient ventilation 
 and the breathing of an unwholesome atmosphere, want of 
 sunUght, and want of exercise, in other words an absence of 
 all the healthy impulses to growth, are the essential factors 
 producing the rachitic state, through the endocrine system. 
 
 The question naturally arises as to whether or no there 
 is an actual toxaemia in rickets, and if so what is its nature 
 and source. The presence of some organic impurity in the 
 respired air suggests itself clinically as a probable factor, 
 but it is unsupported by experimental evidence. But 
 experimental results as regards questions of general hygiene 
 and the function of respiration are notably inconclusive. It 
 is practically impossible to reproduce in the laboratory the 
 conditions which surround the young infant in the slums 
 during our long and dreary winters. Much more trustworthy 
 evidence is to be obtained by watching great natural exiperi- 
 ments, such as the effect of the transplanting of southern and 
 
440 Rickets 
 
 native races into the midst of civilised communities within the 
 temperate zone, whether in Europe or America ; or the con- 
 verse may be watched in the transformation which occurs in 
 the slum dweller when transferred to the freer life of the 
 colonies. Reference has already been made to the great natural 
 experiment among the Jews in the East End of London, where 
 excellent conditions of feeding are associated with very defec- 
 tive conditions as regards environment and general hygiene. 
 
 Another possible source of toxaemia which suggests itself 
 is bacterial infection, which will be dealt with more fully 
 later. Infections of many kinds are common in rickets, 
 especially those of a catarrhal nature affecting the mucous 
 surfaces. It is a possibility, however, to be kept in mind 
 that in rickets and in such conditions as endemic goitre the 
 action of varied organisms may be part of nature's process 
 of adaptation and not the assault of a pathogenic germ such 
 as occurs when the body is invaded by the bacillus of typhoid 
 fever or the pneimiococcus. It is certain that this aspect of 
 the production of diseased conditions has not received the 
 attention it deserves, notwithstanding that the theory of 
 artificial immunisation is based on such an assumption. 
 
 The th5n3ius and the lymphatic structures generally, being 
 essentially conservative structures, are unduly developed 
 wherever control or slowing of metabolism is required. 
 Lymphatism tends to lead to an increased deposit of fat 
 such as is seen in fat rickets. It is markedly associated with 
 hibernation where a holding up of all the vital processes is 
 very essential. Contrary to what was generally supposed, 
 Hammar, of Upsall, showed that the th3niius increased in size 
 up to the age of puberty, diminishing between the ages of 
 fifteen to twenty-five years till at the latter age it corre- 
 sponded with the size at birth. At birth the thymus weighs 
 five grams, at puberty twenty-five grams, and from fifteen 
 to twenty-five years it shrinks in size till at twenty-five years 
 it again weighs five grams.* In rickets depraved action of 
 the thymus, thyroid, and parathyroid glands leads to still 
 
 * " Internal Secretions and Principles of Medicine," by Charles E. de 
 M. Sajons.lSth Edition, Vol. I., Philadelphia, 1918, p. 280. 
 
The iEtiology of Rickets 4+1 
 
 further delay in the closing of the cranial sutures and to an 
 undue lengthening of the foetal or child-hke stage. Not only 
 are the bony sutures of the cranial vault late in closing but 
 the eruption of the teeth is notably delayed, and the faculty 
 of speech and the general mental development are also 
 retarded. Two facts, then, seem to stand out clearly — that 
 there is an overgrowth of the whole lymphatic system, 
 including the thymus, in rickets, while at the same time there 
 is defective action of the thyroid apparatus. Now the 
 thyroid opposes the thymus, in that it is the great accelerator 
 of metabohsm, and is probably the great controlling influence 
 presiding over all the other glands of the endocrine system. 
 All observers from the time of GUsson onwards are agreed 
 that clinically the thymus and the general lymphatic system 
 are enlarged in rickets. 
 
 The question of a possible antagonism between rickets 
 and tubercle has aheady been referred to. The absence of 
 pulmonary tubercle from infants and young children is very 
 striking. It is very rare to find evidence of tuberculosis of 
 the lungs in school children even when the conditions as 
 regards general nutrition and environment are at their 
 worst. In adults in these same areas the incidence of tubercle 
 is very great and the death rate is high. A priori one would 
 expect it to be very prevalent in the young infant. Evidence 
 of invasion by the tubercle bacillus is not so uncommon in 
 rickets as was formerly supposed. It has already been shown 
 that tubercle in the child chiefly affects the l3miphatic glands, 
 the growing ends of the long bones, and the joints, the very 
 sites where active changes are proceeding in rickets. If the 
 defence of the lymphatic glands break down, a general 
 form of acute miliary tubercle not infrequently supervenes, 
 rapidly carrying off the child. Moderate degrees of enlarge- 
 ment of the mesenteric glands are not uncommonly found 
 accidentally in later life where the tubercle bacillus has 
 attacked the gland, but has not been able to spread beyond 
 it, and it is very probable that the lymphatic hyperplasia of 
 rickets materially contributes to this defensive mechanism. 
 It is another instance of the adaptive power of nature, for 
 
4+2 Rickets 
 
 exposed as these children are, in an intensive form as it were, 
 to the conditions producing tuberculosis, unless some effectual 
 barrier were raised to protect the body from general invasion 
 the disease would menace the continuity of the race in those 
 locaHties where rickets prevailed. The development of the 
 lymphatic state is one of the methods which nature employs 
 to cope with the danger. The enlarged and hypertrophied 
 lymphatic glands form an effective organic filter protecting 
 the body from the invasion of the tubercle bacillus. 
 
 The action of the thyroid, the great accelerator gland of 
 the body, is markedly depressed. Hertoghe pointed out that 
 in the minor degrees of defective action of the thyroid — the 
 state of hj^pothyroidism — there is a very characteristic train 
 of symptoms. He showed that the thyroid governed the 
 building up of the cells and regulated the destruction of the 
 protein molecule ; impaired action led to defective growth 
 in the young child, and to the accumulation of imperfectly 
 katabolised material in the adult. To this state of thyroid 
 insufficiency he attributed such signs as relaxation of the 
 articular hgaments, especially those of the knee, ankle 
 and vertebrae. Eneuresis, a common sign in rickets, he 
 attributed to the same cause. 
 
 The thyroid has important functions at most of the critical 
 periods of life and is exceedingly susceptible to environ- 
 mental conditions. Amenorrhoea is a common sign of 
 hjTpothyroidism. It is a matter of concern to mothers 
 and teachers alike that long periods of amenorrhoea are 
 exceedingly apt to occur when girls are sent to boarding 
 school. The food may be excellent, and the general hygiene 
 of the school may be beyond reproach ; the condition is not 
 at all amenable to tonics, and as a rule after a varpng period 
 passes off spontaneously. The cause of the trouble is the 
 over-careful regulation of the schoolgirl's routine. Her life 
 of complete freedom at home is limited to one of carefully 
 regulated exercise in the form of walks and modified games. 
 The young growing organism demands less restraint and a 
 wide range of freedom as regards outdoor exercise. There is 
 much to be said for the modern development of free exercise 
 
The -(Etiology of Rickets 443 
 
 in the open, and the engaging in games which were formerly 
 deemed unsuited to developing womanhood. 
 
 When a vicious environment produces its evil influence 
 on the thyroid in the first years of life it can readily be 
 understood that its effects wiU be even more serious. The 
 parody of growth which occurs when the action of the thyroid 
 is suppressed, producing cretinism in the young infant, is well 
 known. When the eificiency of the gland is interfered with in 
 cold, damp, and sunless localities, and in overcrowded slum 
 areas, the effects, though modified, are far-reaching and are 
 responsible for many of the characteristic signs of rickets. 
 
 There is, then, recognisable in rickets a certain type of 
 child, which may be fat and well nourished, though the 
 muscular tone and development are defective, often markedly 
 so. The conditions associated with the rachitic state are 
 strongly suggestive of hypothyroidism.* These may be 
 detailed as follows : (i) coarseness of features and pale 
 pasty complexion ; (2) tendency to adenoids and catarrhal 
 conditions associated with general l3miphatic enlargement ; 
 (3) nocturnal incontinence pecuMarly amenable to treatment 
 by thyroid extract ; (4) tendency to laryngismus stridulus 
 and general convulsions so often associated with defective 
 calcium metaboHsm ; (5) pronounced harshness of the skin ; 
 (6) coarse scanty hair, without lustre ; (7) backwardness of 
 speech and slow general mental development ; (8) softness 
 and enlargement of the long bones at their epiphysial ends 
 and thickening of the membranous bone of the shaft of the 
 long bones, and of the fiat bones of the skull ; (9) hypoplasia 
 and other defects of the enamel, with marked tendency to 
 caries. 
 
 The degree to which these cases respond to thyroid treat- 
 ment cannot be accepted as a true index of the extent of the 
 thyroid deficiency. Personally, I have had some success 
 with the treatment of cases of backward physical develop- 
 ment and sluggish mentality, and also in the treatment of 
 some special ss^mptoms such as nocturnal eneuresis ; but in 
 
 * " On Some Signs and Symptoms of Hypothyroidism in School 
 Children," by J. Lawson Dick, Lancet, September 5th, 1914. 
 
444 Rickets 
 
 my experience adenoid vegetations and enlargement of the 
 tonsUs have been but little, if at all, affected by the adminis- 
 tration of th3n:oid extract. The ductless glands act very 
 directly the one upon the other, and it is the sum of their 
 combined energies which determines the line of growth. 
 
 When the whole process of growth is perverted owing to 
 the want of harmony in the action of the various glands 
 which are normally responsible for this process, and when 
 this lack of harmony is due to a profoundly altered environ- 
 ment, it seems idle to expect much help from so crude a 
 therapeutic measure as the administration of a gland 
 extract. 
 
 The co-existence of m5rxcedema and rickets is not very 
 uncommon, and Marfan has witnessed it on several 
 occasions.* 
 
 In 1900, Stoeltzner | advanced the view that rickets was 
 due to a defect in the supra-renal glands, but this has not 
 been confirmed and has foimd but few adherents. • 
 
 Lately it has been suggested that the absence of a 
 vitamin or accessory food factor from the diet is the agent 
 which produces the variation in the action of the endocrine 
 glands in rickets. It has been shown that there is nothing 
 to support, and much evidence to contradict, such a theory 
 of the production of the rachitic state. 
 
 The Infective Theory of Rickets. — The resemblance of 
 rickets to other diseases of bacterial origin has naturally 
 given rise to the theory that a specific micro-organism 
 may be the actual agent producing this disease. The very 
 notable resemblance to syphilis would seem to lend support 
 to such a view. 
 
 The theory that rickets is not a true or distinct entity 
 in itself, but may be an end result of many different kinds 
 of infection has already been commented on, in speaking of 
 the history of the disease. Antoine Portal, in 1797, first 
 elaborated this theory and spoke of venereal, scrofulous, 
 
 * Marian, loc. cit., p. 446. 
 
 ■f " Ueber Behandlung der Rachitis mit Nebennierensubstanz," von 
 Dr. Wilhelm Stoeltzner, Jahrbuch filt Kinderheilkunde, Vol. I., pp. 73 and 
 199. 
 
The etiology of Rickets 445 
 
 scorbutic and other varieties of rickets. Parrot followed 
 with a modification of this view, namely, that rickets was 
 always the sequel of a syphilitic infection. These theories 
 have been in the main discarded, though even so distin- 
 guished an observer as Prof. Marfan, of Paris, still holds a 
 modified form of this view. Thus he maintains that syphilis, 
 tuberculosis, prolonged broncho-pneumonia, staphylococcal 
 infections of the skin and diverse other infections and chronic 
 intoxications may end in the production of rickets. 
 
 It is impossible to accept such a view. Rickets, as 
 described by Glisson, is a true and separate entity dependent 
 on a certain pernicious environment without which the 
 disease cannot be produced. True it frequently accom- 
 panies congenital syphihs and may be modified by it, but it 
 remains a distinct disease with a different pathology and an 
 entirely different outlook as regards prognosis. 
 
 Many experiments have been made with the object of 
 establishing the bacterial origin of rickets. Morpurgo * 
 claimed to have produced rachitic lesions in young rats by 
 means of the artificial infection of the animal with a gram- 
 positive diplococcus. Pappenheimer f brought about simi- 
 lar lesions in rats by the injection of a suspension of bone 
 marrow from a rachitic animal. It must be remembered 
 that the mere finding of bacteria in rickets does not consti- 
 tute proof that these cause the disease. It has repeatedly 
 been shown that to a marked extent rickets depresses the 
 resistance of the body and predisposes very notably to 
 the invasion of the organism by bacteria. 
 
 Endemic goitre is an interesting condition which has 
 many points in common with rickets. Geographically, it has 
 a rough resemblance to rickets in its distribution, being most 
 prevalent in the temperate zone, though it is als® found in 
 regions of great cold and great heat. It is associated with 
 clefts and valleys in mountainous districts, and is also preva- 
 
 * Morpurgo, B., " Ueber eiae infectiose Form der Knockenbruchigkeit 
 bei weissen Ratten," Verhandl. d. detitsch. patholog. Gesellsch., 19D0, III., 
 40. 
 
 •f Pappenheimer, A., " Further Experiments upon the Extirpation of 
 the Thymus in Rats," Jour. Exper, Med., 1914, XX., 477. 
 
446 Rickets 
 
 lent in the damp plains of Lombardy, Piedmont, and Alsace ; 
 the courses of rivers and canals and marshy tracts seem to 
 favour its appearance. It is markedly connected with 
 defective air space, want of sunlight and bad hygienic con- 
 ditions. All races of men suffer, and it seems to affect new- 
 comers to an endemic area with unusual severity. The type 
 of individual produced is the lymphatic type. Endemic 
 goitre is very widely spread among animals whose habits 
 have been modified by the vicinity of man, such as mviles, 
 oxen, horses, dogs, cats, goats, pigs, sheep, white rats, white 
 mice, and in fowls and pigeons. 
 
 In two important points endemic goitre differs from 
 rickets. It shows a seasonal variation, but unlike the 
 rachitic process it tends to appear in March, April, May and 
 June in the form of summer goitre. 
 
 It also differs from rickets in being more common in rural 
 districts than in towns. 
 
 McCarrison * believes that endemic goitre is due to the 
 presence in the alimentary tract of certain undetermined 
 anaerobic bacteria whose toxic products reach the blood- 
 stream and induce in the thyroid gland hs^ertrophic, hyper- 
 plastic and degenerative changes. 
 
 Endemic goitre resembles rickets in that it suggests an 
 attempt on the part of nature to adapt the individual to 
 inimical surroundings. Both conditions are apt to be 
 associated with the presence of micro-organisms, and it is 
 possible that, even in rickets, the signs and symptoms of the 
 disease may be foimd to be in part produced by the action of 
 toxins of bacterial origin. Of this, however, there is no 
 certain evidence up to the present time. 
 
 But, as already shown, that would not necessarily alter 
 the fact that the essential cause of rickets was to be found 
 in unhygienic conditions siuTounding the young infant at a 
 time when it is most dependent on a healthy environment. 
 Indeed, it would rather suggest, as already noted, that the 
 economy made use of the action of friendly bacteria in pro- 
 
 * " Endemic Goitre," by Robert McCarrison, Practitioner, Vol. 
 XCIV.. 1915. 
 
The ^Etiology of Rickets 447 
 
 ducing the modifications necessary to adapt itself to vicious 
 surroundings. 
 
 It has been shown that the meconium of infants who have 
 not breathed is entirely free from bacteria, but that micro- 
 organisms appear within a few hours after birth. On a pure 
 milk diet two species predominate, viz., the bacillus coli and 
 the bacterium lactis, and appear to act as pure saprophytes, 
 and to be related to the intestinal contents only. Under 
 certain conditions it can be readily understood that many 
 organisms may be called into action to help to adapt the 
 child to the many and varied vicissitudes of environment 
 to which it is exposed. 
 
 The bacterial origin of rickets has not been established, 
 and while its possibility cannot be denied, the probability is 
 that, if micro-organisms are found associated with rickets, 
 their action is of a secondary nature and forms part of an 
 adaptive process. 
 
 Heredity as a Factor in the Mtiology of Rickets. — ^The ques- 
 tion of foetal rickets is a subject which has been hotly dis- 
 cussed for many yeairs and which is far from settled at the 
 present time. Glisson maintained that rickets was not an 
 hereditary condition, though he believed that certain condi- 
 tions in the parents predisposed to its production. In the 
 transmission of disease from parent to child there may be an 
 alteration in three factors : — 
 
 (1) a child may inherit the anatomical and physiological 
 
 constitution of either parent, and with that a 
 special liability of failure to resist the attacks of a 
 widespread disease. An excellent example of this 
 is found in the tubercular diathesis. Since the 
 discovery of the tubercle bacillus this condition 
 has been but little noted, but the brilliant descrip- 
 tion by Sir Wm. Jenner of the tubercular diathesis 
 which has already been referred to, remains as true 
 to-day as it was in 1859 when Jenner described it : 
 
 (2) the actual bacteria may be contained in the ovum or 
 
 the spermatozoon : 
 
448 Rickets 
 
 (3) the toxins of the disease only may have affected the 
 ovum or the spermatozoon or, through the placenta, 
 the growing embryo. 
 
 It is generally held that acquired characteristics cannot 
 be inherited, but this is only partially true, and in a wider 
 sense it might be argued that all inheritance is the result of 
 the reaction of environment on the living and adaptive 
 organism. It is largely a question of time ; for if a stress 
 or strain is continued long enough it will in the end inevitably 
 produce its effect. It has already been pointed out that a 
 rite like circumcision, even when continued for centuries, 
 has no appreciable effect on the phylogeny of the race, and 
 therefore shows no tendency to produce an inherited character 
 within any period of time which we can appreciate. When, 
 however, circumstances arise like the sudden call to adapt a 
 nation consisting of a rural population living in small com- 
 munities widely distributed, to conditions such as appertain 
 to-day, when a huge population is concentrated under the 
 highly artificial conditions prevailing in industrial com- 
 munities, a serious problem arises which affects the very 
 continuance of the race so placed. Again John Hunter's 
 theory may be quoted, that disease is but the normal 
 response of an organism to an environment which demands 
 alteration of development or modification of function or 
 structure to meet conditions to which the healthy organism 
 cannot normally respond. In other words, the production 
 of the rachitic state is one of the means adopted by nature to 
 meet such a contingency, for in this way an organism is 
 produced better adapted for living in a vicious environment 
 than is a more healthy and robust individual. But such an 
 adaptation does not demand that the condition itself should 
 be inherited, for the only need is that the child should respond 
 to the environment when it is actually exposed to it, when 
 it first leads an independent existence. The great proba- 
 bility is that rickets is never inherited, but is always an 
 acquired condition. 
 
 Glisson, however, while he held that rickets was not a 
 
The ^Etiology of Rickets 449 
 
 congenital disease, maintained that certain ante-natal 
 conditions tended to favour the occurrence of the disease 
 in the offspring. 
 
 These, he believed, were mainly the conditions of life 
 found in his day among the wealthiest classes of the com- 
 munity, such as indolence and ease and over-indulgence in 
 the parents, tending to produce a weakly offspring, less 
 resistant to such a disease as rickets than a healthy child 
 would be. 
 
 The character of rickets has changed since Glisson's 
 time, and the disease, though probably more widely spread 
 to-day than it was then, is not of so severe a type and tends 
 much more to present class distinctions, and to be a disease 
 of the poor and of the slum-dweller. 
 
 Rickets in Glisson's day was comparatively a new disease, 
 and it is a common experience in the history of medicine 
 that when a population is exposed to altered conditions to 
 which they have never before been subjected, or to a new 
 infection, the disease which results is likely to be exceedingly 
 severe. This may partly explain the extreme severity of 
 the disease among the negro population in America to-day. 
 It has been formerly stated that if the child of the slum- 
 dweller were compared at birth with the child of the well-to- 
 do, there probably would be no appreciable difference found. 
 But that does not alter the fact that if ten thousand infants 
 bom in slum areas in our large towns, were compared with 
 a like number from a country district there would probably 
 be a balance in favour of the country children, not so large 
 perhaps as might be expected, but still quite definite. In 
 this sense there is probably a slight inherited predisposition 
 to rickets in the offspring of rachitic parents, and the child 
 is less resistant to the disease, but the actual condition never 
 develops before birth. In other words, evolution, as formerly 
 stated, does not necessarily mean an individual of a higher 
 type, either physically or mentally, but may mean an 
 individual better suited to his environment. 
 
 The subject of festal bone disease has been much dis- 
 cussed of late years, and many cases have been carefully 
 
45° Rickets 
 
 examined and recorded, but no scientific classification on a 
 pathological basis is yet possible. Formerly all cases of 
 foetal bone disease were classed as rachitic in origin. In a 
 general way there is a superficial resemblance in these cases, 
 even when the pathological conditions vary considerably. 
 Thus, in most the trunk of the body is normal, while the 
 extremities are short and deformed, the head large and the 
 bridge of the nose depressed. 
 
 There is a large group of heterogeneous bone diseases 
 which has in the past been greatly confused, and is even 
 now but little understood. Such are conditions due to 
 scurvy and congenital syphilis, osteogenesis imperfecta, 
 osteomalacia, achondroplasia, and the various forms of 
 bone disease classed under the heading chondrodystrophia 
 foetalis. Osteogenesis imperfecta is a disease in which the 
 primary lesion is in the foetus while the mother is healthy ; 
 osteomalacia, on the other hand, affects the mother, who, as 
 a rule, gives birth to a healthy child. Like rickets osteo- 
 malacia is a disease which suggests a failure of the endocrine 
 glands. Scurvy is now generally accepted as due to the 
 absence of an accessory food factor. Hess * strikes a note 
 of warning which is very necessary at the present time, when 
 he points out that there is a danger of grouping together 
 unexplained and little understood diseases and attributing 
 them to the overworked " vitamin " theory and classif3dng 
 them as deficiency diseases ; just as in the past there has 
 been a danger of making the endocrine glands the dumping 
 ground of any unidentified disorder. 
 
 Bone may reach its final form by two different routes — 
 firstly, by development in membrane in which spicules of 
 bone simply form in a membrane, as in the case of the flat 
 bones of the vault of the cranium ; or, secondly, by develop- 
 ment in cartilage in which the scaffolding of the future bone 
 is set up in cartilage which is removed later as the true 
 osseous tissue grows up. 
 
 Ballantyne points out that the interposition of a cartila- 
 
 • " Scurvy, Past and Present," by Alfred F. Hess. Philadelphia and 
 London, 1920. 
 
The Etiology of Rickets 451 
 
 ginous stage increases the possibility of formative failure.* 
 Thus bone formation in the cartilage at the end of the long 
 bones may come to a standstill while the membranous bone 
 continues to be formed in the shaft and achondroplasia is the 
 result.. The development of the bone suggests one line of 
 classification for foetal bone diseases, into those which affect 
 the membrane bones only, and those which affect the bones 
 developed in cartilage. Most of these diseases occur between 
 the third and sixth month of intra-uterine life. Achondro- 
 plasia or chondrodystrophy affects the endochondral ossifica- 
 tion only, never the intra-membranous bone. The flat 
 bones and the vertebrae therefore escape while the bones of 
 the extremities suffer most. The characteristic change in 
 the skull is the early ossification of the tribasilar bone formed 
 by two parts of the sphenoid and the sphenoidal process of 
 the occipital bone. These cases not infrequently survive to 
 adult life, and are quite commonly seen in London streets. 
 
 Chrondrodystrophy or achondroplasia presents patho- 
 logical appearances quite different from those which are 
 present in rickets. These differences may be tabulated 
 thus : — 
 
 Chondrodystrophy Rickets. 
 
 {A chondr aplasia) . 
 Proliferating zone in epi- Proliferating zone is much 
 
 physial line is narrower than wider than normal, 
 normal, and is ossified at an 
 earlier date. 
 
 Vascularisation not marked. Vascularisation very 
 
 marked. 
 Bones laid down in cartilage Membranous and carti- 
 
 are alone affected. laginous bones are both 
 
 affected. 
 Basilar synostosis occurs Basilar synostosis does not 
 
 early. occur early. 
 
 In achondroplasia there seems to be a simple arrest of 
 development, while in rickets, though there is a delay of 
 development there is also evidence of inflammation and a 
 sluggish reaction to an irritant. 
 
 » " Congenital Rickets," J. W. Ballantyne, British Medical Journal, 
 September 27th, 1902, p. 950- 
 
452 Rickets 
 
 Osteogenesis imperfecta (periosteal dysplasia) is an 
 example of a foetal disease affecting the membranous bones. 
 As its name implies nothing is known of its pathogenesis. 
 The condition has a rough resemblance to rickets in that the 
 bones are soft and gnaried and are very liable to fractures. 
 The vault of the skull may consist of a multitude of small 
 plates of bone. These cases have no connection whatever 
 with rickets, and indeed, as these diseases of foetal life are 
 becoming better recognised, cases of foetal rickets are being 
 reduced to vanishing point. Glisson held that rickets was 
 never inherited. Virchow believed that, if it occurred at 
 all, it must be very rare. Sir Wm. Jenner and Cheadle had 
 never seen a case of rickets at birth.* Stoeltzner, fof Berlin, 
 and Comby,J of Paris, do not believe in its occurrence. 
 
 On the other hand, Kassowitz maintains that rickets is 
 exceedingly common in new-bom infants, and Marfan also 
 beUeves in its occurrence. Cranio-tabes is a condition which 
 both these observers believe to be rachitic in origin, and 
 as this is an exceedingly common disease of the foetus and 
 of the first six months of extra-uterine life it is necessary, 
 in order to maintain this theory, to believe that rickets is 
 frequently of intra-uterine origin. As has been shown, 
 however, cranio-tabes may occur as the result of many 
 morbid states. It may arise as a result of rickets or syphilis, 
 but it is pathognomonic of neither of these diseases. In 
 many cases it seems to be a simple delay of development 
 of the bone within normal limits which rapidly corrects 
 itself. Its early occurrence before the sixth month would 
 seem to support the view that syphilis is a commoner cause 
 than rickets, for it is at this period that syphilis is especially 
 operative. After the sixth month cranio-tabes almost 
 invariably ends in spontaneous recovery, while the bony 
 changes in rickets are only becoming evident. 
 
 The absence of hypoplasia from the milk teeth when first 
 erupted is strong presumptive evidence that rickets is not 
 
 * Cheadle, British Medical Journal, November 24th, 1888. 
 f Stoeltzner, British Medical Journal, September 27tli, 1902. 
 t Comby, ibid. 
 
The Etiology of Rickets 453 
 
 a condition which affects the foetus. Defect in the laying 
 down of the enamel is exceedingly common in the second 
 dentition, dating as a rule from the first few weeks after 
 birth. Calcification of the enamel of the milk teeth begins, 
 as has been shown, about the middle of intra-uterine life. 
 By birth a considerable portion of the enamel of the crowns 
 of all the milk teeth is already calcified. If rickets were a 
 congenital defect, handed down by parents, themselves 
 affected with the disease, one would expect, with a condition 
 so exceedingly common, that the immunity conferred by the 
 mother would occasionally break down and hypoplasia of 
 the milk teeth would fairly commonly be met with. 
 
 I have looked for several years for hypoplasia of the 
 incisor teeth when first erupted in a large number of infants, 
 and I have never met with a case. After birth the milk teeth 
 suffer severely from defective lapng down of the enamel and 
 this is one of the chief causes of the widespread and early 
 decay of these teeth. It may be objected that in the 
 S3rphilitic child the milk teeth are also as a rule free from 
 defect, though it is known that the infant is infected at an 
 early period of intra-uterine life. But it must be remem- 
 bered that the notching of the central incisors of the second 
 dentition in Hutchinson's teeth is by no means common, and 
 is not so widespread a condition as rachitic hypoplasia. 
 
 Even in syphilis, however, it is interesting to note that 
 the protection afforded by the mother is very perfect, and in 
 this disease also the enamel affected is that laid down almost 
 immediately after birth. The occurrence of hypoplasia 
 suggests some interesting problems in relation to the protec- 
 tive influence conferred by the mother during intra-uterine 
 life and also during the period of suckling. 
 
 In the child with a well-marked tubercular diathesis the 
 teeth are often very perfect and neither the first nor the 
 second dentition tend to be affected. 
 
 It must be confessed that we are not yet in a position to 
 state definitely what is the exact cause of rickets, though 
 the field of enquiry can, I believe, almost certainly be 
 narrowed down to the conditions of vicious environment 
 
454 Rickets 
 
 which prevail at their worst in slum areas. These are con- 
 finement and the breathing of a vitiated atmosphere in over- 
 crowded and badly ventilated rooms, lack of sunlight and 
 loss of the opportunities for proper exercise. 
 
 The child in the deep solitude of the womb is independent 
 of these factors, but from its first entry into the world, its 
 urgent cry is for a wholesome and pure atmosphere, to enable 
 it to carry on its independent existence. True, these in- 
 fluences bear on the mother during pregnancy, but the adult 
 organism does not react in the same way to these evil condi- 
 tions as the organism of the new-bom infant does. Again, 
 the mother has a free and independent movement so that 
 their effect is considerably modified, and during intra- 
 uterine life the child lives under the protective influence of 
 the placenta. 
 
 Life under modem highly artificial conditions in a cold 
 and bleak climate such as ours endangers the normal progress 
 of the child in every direction. When these conditions are 
 very defective, as they are in the houses of a large proportion 
 of the population of all our large towns, a compromise 
 between complete efficiency and adaptation to environment 
 must be come to. Modification of growth and development, 
 largely under the control of the endocrine glands, takes place 
 which, while it tells hardly on the individual, yet adapts it 
 the better to maintain its existence under conditions which 
 render vigorous and healthy growth impossible. These are 
 the conditions invariably present where rickets is prevalent. 
 
CHAPTER XXIX 
 The Treatment of Rickets 
 
 In speaking of tlie treatment of rickets, there is not only a 
 pathology of the individual to be considered, but there is a 
 national pathology which must be treated on the broadest 
 lines. 
 
 Rickets is a national disease which adapts the population 
 to the demands of its environment. The welfare of the race 
 is safeguarded in that the largest numbers possible are fitted 
 to survive under conditions of modem civilisation which are 
 far removed from the natural state, and the well-being of 
 the individual is sacrificed to the needs of the many. 
 
 The enquiry into the aetiology of rickets is more than 
 one of academic interest. Especially is this the case in the 
 present economic state of Europe. No one doubts that it is 
 highly desirable to improve the general environment, and 
 especially to produce some amehoration of the housing con- 
 ditions of the great mass of our population. But if rickets 
 were of the nature of a true deficiency disease, and were due 
 to the absence of a specific vitamin, as has been claimed, it 
 would be wise to concentrate on suppl5dng that deficiency, 
 even at the risk of prolonging much discomfort, and limiting 
 for a further period of years the amenities of life for a great 
 mass of the population. It would be expedient to temporise 
 with such large questions as housing and to concentrate on 
 the more pressing need of adequate and proper feeding. 
 Mankind is ever on the outlook for a short cut to health, and 
 already the vitamin theory has seized on the imagination of 
 the general pubUc so that food values are discussed in terms 
 of vitamin content instead of due consideration being given 
 to a properly balanced diet derived from varied sources and 
 capable of ready digestion and assimilation. 
 
 455 
 
456 Rickets 
 
 Diet is naturally of importance in rickets as it is in any 
 other failure of metaboUsm from whatever cause, especially 
 at the active period of growth. But no dietary, as has before 
 been stated, will aboHsh rickets while the environment which 
 actually produces the disease is allowed to continue, nor, on 
 the other hand, will any defect or deficiency in the diet 
 produce the disease, if the child is brought up under con- 
 ditions where it is exposed to fresh air, and sunhght, and is 
 allowed the free use of its limbs. 
 
 Of paramount importance in this pernicious environment 
 is defective housing. It is only some eighty years ago that 
 the question of housing and sanitation was first raised. 
 Since then much has been accomplished so far as sanitation 
 is concerned. The supply of wholesome and pure water, the 
 regulation and inspection of food supphes, the proper 
 dispose of sewage, and the isolation of smallpox and typhus 
 fever, have achieved wonders. The main success has been 
 attained in abolishing infective diseases dependent on filth 
 conditions such as cholera, typhoid fever, typhus, and small- 
 pox. Against other forms of infectious disease the campaign 
 has not so far been successful. In 1917 there were in 
 England 749,604 notifications of infectious disease, including 
 measles 533,833, with a death rate of 10,538, and scarlet 
 fever and diphtheria 92,132, with a death rate of 5,242. 
 One important reason for the failure to cope with this 
 efficiently Hes in the ever-increasing growth of towns. 
 
 As regards housing, the probability is that the country is 
 in a worse position to-day than at any period in our history. 
 Fortunately, ideas of healthy living are becoming more and 
 more diffused throughout the population, and the diminishing 
 infant mortality must be largely placed to the credit of an 
 intelligent motherhood rather than to any great improvement 
 in public health administration. 
 
 Too much has been made of the incapacity of the mothers 
 of the nation. Their ignorance as regards questions of ven- 
 tilation and open air was shared by legislators who thought 
 a window-tax a statesmanlike method of raising revenue. 
 The problem of defective housing and overcrowding has been 
 
The Treatment of Rickets 457 
 
 beyond her power to deal with, and it has been beyond the 
 power of the State to suggest any practical method of pro- 
 ducing ameUoration. Spasmodic and isolated efforts have 
 been made with but Uttle result. The growth of the evil is 
 more rapid than the success achieved. Huge suburbs are 
 growing up, it is true, but these rapidly reproduce the evils of 
 the towns so that what was once fair country becomes 
 squalid and ruined. 
 
 The ideal way to deal with slum areas would be to con- 
 demn and destroy all the houses within these areas, and at 
 the same time to carry out extensive schemes of town 
 planning for the population so displaced. It is obvious that 
 in Europe where towns are the slow growth of centuries this 
 is impossible. Happily, many parts of the world are still in 
 the fortunate position of being able to carry out town plan- 
 ning on an extensive scale. In our colonies and in America, 
 wJiere it is not a question of abolishing slums but of creating 
 new townships, a statesmanlike view is required to provide 
 not only for the needs of to-day, but for the probable require- 
 ments of fifty or one hundred years hence. In England, 
 towns have grown according to the need of the moment 
 without any supervision or control. Houses and streets 
 have followed rivers and railroads and have congregated 
 round congested centres. Means of transit and ease of 
 access have been more important considerations than matters 
 of health. 
 
 A moderate estimate shows that to-day one-fourth of the 
 dwellings of this country have less than four rooms, and that 
 one-tenth part of the population lives under overcrowded 
 conditions. Houses are arranged in rows of dreary streets 
 which are often narrow and tortuous. Not only is the 
 population crowded into these mean houses, but the houses 
 themselves are packed close together so that there may be 
 thirty, forty or even fifty houses to the acre. It is evident 
 that the sweeping away of the accommodation of a tenth part 
 of the population at the present time is impracticable, if for 
 no other reason than the fact that there is no other housing 
 accommodation available for them. This difficulty has been 
 
458 Rickets 
 
 much accentuated since the war, but constitutes no new 
 
 problem. There has always been a shortage of houses 
 
 suitable for the working classes. 
 
 Under such circumstances, care must be taken not to decry 
 
 palliative measures because they offer no cure, nor on the 
 
 other hand must we rest content with these measures because 
 
 they produce a degree of temporary relief. Fairly extensive 
 
 powers have been granted to local authorities who have not 
 
 made sufficient use of them in the past. Thus they have the 
 
 right to order that houses shall be put in a reasonable state 
 
 of repair and made habitable, or if this is impossible, to order 
 
 their demolition. Even at considerable expense, the most 
 
 objectionable of these overcrowded tenements should be 
 
 closed and destroyed by municipal authorities. In 1916 the 
 
 Medical Officer of Health for Liverpool reports that the 
 
 housing committee of the Corporation of Liverpool erected 
 
 nearly three thousand dweUings on sites formerly occupied 
 
 by insanitary property. The immediate results on the 
 
 mortality were as follows : — 
 
 General death Infantile death, 
 rate per 1,000 rate per 1,000 
 of population . births. 
 
 1. Prior to demolition 40 300 
 
 2. After demolition in houses on 
 
 same site 28 167 
 
 Such is not an isolated experience but is a common resiilt in 
 all town improvements. At one sweep the Peabody Fund 
 in London has profoundly altered the health conditions of the 
 people, so that of the 22,000 persons housed under this 
 scheme, with weekly average earnings for the head of the 
 family of only 22s. 3d., the death rate is only lO-i as compared 
 with 14-3 for the whole city of London. The London County 
 Council has also carried out housing schemes which have 
 shown excellent results. Not that such schemes are alto- 
 gether healthy in their action, and may even be anti-social, 
 in so far as they tend to crowd the population into the centres 
 of the towns. These schemes, indeed, involve the writing off 
 by the public body of the difference between the commercial 
 value and the value for working-class dwellings of the site. 
 
The Treatment of Rickets 459 
 
 so that the houses are offered at terms which involve the 
 payment of a heavy subsidy from the ratepayers to their 
 tenants. No such subsidy is offered for houses in outlying 
 districts, which is the true solution. 
 
 There is a natural tendency in London for factories to 
 take the place of slum dwellings. In one or two cases it has 
 happened that the London County Council has actually 
 built schools in crowded areas where this has taken place, and 
 has had difficulty subsequently in filling these schools. This 
 displacement of slum houses by factories has been quite 
 noticeable of late years in such areas as Shoreditch, Stepney, 
 Islington, and elsewhere, and is a process which might well 
 be encouraged by lowering the heavy rates which often drive 
 manufacturers to look further afield for sites where these 
 are not so oppressive. True, this is not an ideal method, but 
 is only a palliative measure. The proper method would be 
 to transfer both the factory and the factory worker's home 
 into more congenial and wholesome surroundings in the 
 country. But as a temporary measure it has its uses, 
 especially in so far as it clears away noisome slums and 
 replaces them by well-built factories without imposing any 
 fresh burden on the ratepayer. 
 
 But while every method of diminishing the evil of slum 
 dwellings should be adopted, the larger remedies should be 
 consistently pursued. Continuity of effort is required rather 
 than the occasional and spasmodic action which has been 
 the rule in the past. 
 
 The development of the garden city has now passed 
 beyond the experimental stage, and should be encouraged in 
 every possible direction. This may be done in three ways. 
 In the first place, ample powers should be given for the 
 acquisition of land, compulsorily if necessary, at a reasonable 
 rate. Secondly, improved and cheap travelling facilities 
 should be established so that the workman can get to and 
 from his work easily and quickly and in comfort. Thirdly, 
 a well-planned scheme should be laid down which will not 
 only deal with the construction of the house and the number 
 of rooms, but will see that the streets are broad and well laid 
 
4^0 Rickets 
 
 out, allowing of free currents of air and the maximum amount 
 of sunshine. 
 
 The number of houses to the acre should be strictly 
 limited to ten, twelve, fourteen or eighteen, or some such 
 reasonable number. The reserving of suitable sites for parks 
 is a matter of great importance, especially to mothers 
 and children. Often a common garden to several houses 
 will form a large and usefid space in place of small backyards 
 which have no beauty and are of but small utility. 
 
 The development of infant welfare centres is a preventive 
 measure of the greatest value. In these centres the child is 
 seen soon after birth. The mother is encouraged to make 
 regular visits at stated intervals. A record is kept of the 
 weight and of the general progress, and the mother is urged 
 to take the child each day into the open and to make the 
 best of unpromising surroundings. Advice is given as to the 
 feeding during the first few months and later at tlie difficult 
 time of weaning. The constant supervision is of the greatest 
 benefit to the infant and in almost every case the mother is 
 anxious to co-operate with the physician in carrying out 
 general hygienic principles. 
 
 Certain very essential matters it is often very difficult to 
 achieve. The adequate ventilation of the rooms during the 
 inclement weather of a long winter is often a matter of 
 impossibility in the cold, cheerless rooms of the poor. 
 Separate sleeping accommodation for the infant is a counsel 
 of perfection which is seldom observed. There is the very 
 practical difficulty that in the chill atmosphere of the room 
 the warmth of the mother is often needed to maintain the 
 body heat of the child. The result is that the breathing of 
 an atmosphere vitiated by overcrowding in small rooms is 
 accentuated during the night. Much, however, can be 
 accomplished by the unwearjdng attention to small details. 
 The mother should be urged to use any space or yard, no 
 matter how small, provided it is in the open air, for the child 
 to sleep in during the day. If the infant is kept warm and 
 dry and is well clothed and well fed there are very few 
 days in the year in which it cannot spend a considerable 
 
The Treatment of Rickets 461 
 
 portion of the time out of doors. The importance of through 
 ventilation of the room at night should constantly be kept 
 before the mother. 
 
 No form of infant care is more valuable than that carried 
 on at- a well-conducted infant welfare centre. This work has 
 only been in existence since 1910, and the results attained 
 must not be measured by the reduction of child mortaUty 
 during that short period. The prevention of deviations from 
 the normal, with the consequent disease which such departures 
 entail, is at least as important as mere reduction of the death 
 rate, if the quality of the race is to be materially improved. 
 
 A disease such as scurvy can be prevented by compara- 
 tively simple means, and, as a matter of fact, has now been 
 well nigh abolished, except in a small number of infants who 
 are kept rigidly to certain varieties of patent food deficient 
 in anti-scorbutic properties. 
 
 No such sensational arrest of rickets is possible while the 
 conditions of overcrowding in large towns persist. But the 
 action of the community, if well informed in matters of 
 hygiene, can do much to ameliorate these conditions. No 
 factor is of greater importance than the education of the 
 motherhood of the nation, and it is in this field that the 
 greatest advance has been made within the last few years. 
 
 By the time the child has reached school age and has come 
 under the supervision of the school medical officer the nature 
 of the work has changed and the measures to be employed 
 are largely remedial. Defects following on the rachitic state 
 have now estabUshed themselves, notably enlargement of the 
 tonsils and adenoids, suppurative otitis media, carious and 
 defective teeth, and stunted growth associated with muscular 
 weakness, lax ligaments, and anaemia and debihty. 
 
 Many of the children of the poor and of the slum dweller 
 when they are first sent to school are already struggling 
 through the rachitic phase of their existence, and much can 
 now be done to help them on their way to recovery. 
 
 The site of the school should be as open and airy as 
 possible. Such spaces are, however, not easily obtainable in 
 the areas where they are most required, and the result is that 
 
462 Rickets 
 
 too often schools are situated in mean streets and are closely 
 surrounded on all sides by dwellings or are overlooked by 
 factories and warehouses. In the older type of Council 
 schools the staircases, passages and classrooms are gloomy, 
 cold, and depressing, while the playgrounds lack space and 
 are often damp and cheerless. Every effort should be made 
 to make both school and playground as light and as airy as 
 possible. Bright tiles, light walls and coloured pictures do 
 much to reUeve the dull monotony of these buildings, and 
 need not add materially to the expense. It must be remem- 
 bered, that in school there is the one opportunity of intro- 
 ducing into the lives of these children, for five or six hours 
 daily, a wholesome environment of which their life is other- 
 wise entirely deprived. 
 
 The open-air method of education has been employed by 
 the London County Council for some years, and even on the 
 very limited scale on which it has been introduced has proved 
 of great advantage to the children. Besides open-air day 
 schools, classes are held in the playgrounds, or better still, in 
 pubUc parks and open spaces, while country holidays and 
 school camps introduce a very necessary change into the 
 dull monotony of their hves. 
 
 The development of physical education is very necessary 
 if the best results are to be obtained among these children 
 whose opportunities of wholesome exercise are so extremely 
 limited. The defective rickety child lacks initiative and 
 requires to be taught how to play. Organised games no less 
 than carefully graduated gymnastics are of the greatest 
 benefit to its mental and phjreical development. 
 
 Much attention has been paid to the harmful influence 
 of active service conditions and the effect of overstrain, both 
 physical and mental, on the constitution of the recruit in the 
 late war. There is fortimately another side. In the 
 majority of the younger recruits, the benefits accruing to 
 training and life in the open, combined with an ample 
 supply of good food, produced most beneficial effects on 
 the growing youth, who had formerly dwelt in a crowded 
 city, and had been confined all day in an office or warehouse. 
 
The Treatment of Rickets 463 
 
 While there is much to be said against a conscript aimy, 
 there is little to be said against conscripting the youth of the 
 nation for health purposes. Every encouragement should 
 be given to the numerous organisations which exist for pro- 
 moting outdoor and camp life under discipline for young 
 children. This movement might well be extended on a 
 national scale. 
 
 It is along these slow and laborious lines that the preven- 
 tion and the amelioration of the disease are to be looked 
 for, and not by the successful combating of any supposed or 
 actual intestinal toxaemia, or by the addition of a missing 
 food factor to the diet. 
 
 Food in Rickets. — The statement has already been made 
 that there is no known food which will protect the infant 
 from rickets if the environment is favourable to its produc- 
 tion. Even an ample supply of breast milk from a healthy 
 mother fails to give protection. This has been noted among 
 the Jewish mothers in the East End of London. It is true 
 also of Italian children in London. Dr. Grulee, of Chicago,* 
 states that in an examination which he made of five hundred 
 negro babies in that city between the ages of six months 
 and eighteen months, all — without exception — exhibited 
 rachitic symptoms and bone changes, although many showed 
 no gastro-intestinal symptoms and were fed carefully on the 
 breast. 
 
 Hess, of New York, has also recently come to the con- 
 clusion that rickets arises in cases when the food supply is 
 adequate and the fats are abundant. 
 
 But while this is true, it must be remembered that rickets, 
 like many other morbid processes not necessarily associated 
 with deficient or defective feeding, is a disease of malnutri- 
 tion and that the food supply is a matter of great importance 
 in treating the disease. It is a disease of malnutrition in 
 the large sense in which Jenner used the term, namely, that 
 there is a faulty metabolism of the tissues which leads to the 
 production of unhealthy structure in the place of healthy. 
 
 * " Infant Feeding," by Clifford G. Grulee, Philadelphia and London, 
 1912. 
 
4^4 Rickets 
 
 The conditions which produce rickets occur most com- 
 monly among the lower class and the poorer portion of the 
 community, and for this reason they are frequently associated 
 with errors in diet. But too much has been made of the 
 imputed absence of breast feeding. The poor more than the 
 wealthier portions of the community are zealous in tr5dng to 
 suckle their children. It is more commonly the mothers 
 of the well-to-do classes who are half-hearted in their efforts 
 and who are apt to give up the attempt at the first difficulty 
 which arises. There is no question that an adequate supply 
 of milk from a healthy mother is one of the greatest safe- 
 guards of the health of the child. The mother's milk is that 
 which is best adapted to the infant's digestion, and the risk 
 of infection, notably of intestinal infection, is markedly 
 diminished. 
 
 This is due to several causes, for not only is the child 
 supplied with a food perfectly adapted to its digestion at the 
 various stages, but it is supplied with a fluid which is sterile, 
 and which confers a large share of the immunity which the 
 mother herself enjoys. The notable freedom of breast-fed 
 infants from all forms of infection has long been a matter of 
 common knowledge and of general experience. There can 
 be but little doubt that the conditions of modern civilisation 
 generally have a harmful effect on the expectant mother, 
 not only increasing the risks attendant on labour, but also 
 diminishing the prospect of a normal and healthy period of 
 lactation. In a certain number of mothers, say about 10 
 per cent., it is advisable to recognise that they are incapable 
 of nursing the child, and to place the infant at an early date 
 on artificial feeding. 
 
 When this is necessary, cow's milk is the best substitute. 
 Comparatively few children are unable to digest cow's milk, 
 but unfortunately there is one great drawback to its use, and 
 that is that it forms a most excellent culture medium for 
 the growth of bacteria. Attention to the purity and clean- 
 liness of the milk supply are matters demanding urgent 
 attention in this country. Milk of a certified grade, guaran- 
 teed to come from tuberculin tested cows, and to be of a 
 
The Treatment of Rickets 465 
 
 certain standard of cleanliness can be procured, but it is not 
 always easy to obtain, and is sold at a price which is prohibi- 
 tive to the poor. So-called nursery milk is by no means 
 rehable and frequently differs from ordinary milk only in 
 the fact that it is sold in bottles. 
 
 When the quality of the milk is in question and when the 
 faciUties for storing it are wanting, as they usually are in 
 slum areas, scalding the milk is a wise precaution. In 
 scalding, the milk is simply brought to the boiling point, 
 and is then immediately taken off the fire. The use of dried 
 milk is most useful in these cases, and experience with its 
 use in baby centres throughout the country has been most 
 favourable. The milk is sterile and can be prepared in small 
 quantities as required, matters of great consequence in the 
 dwellings of the poor, and especially important in a disease 
 such as rickets, where the child is already prone to catarrhal 
 infections. 
 
 The evaporation of the milk in the process of preparation 
 does not seem to destroy its nutritive value. Dr. C. K. 
 Millard, Medical Officer of Health for Leicester, one of the 
 pioneers in recommending the use of dried milk, informs me 
 that in that city over £10,000 worth of dried milk was 
 sold during the year 1920, and that the results as regards 
 the health and nutrition of the infant were most satisfac- 
 tory. 
 
 When milk of good quality can be procured there is an 
 advantage in the use of the natural product, but when the 
 cleanliness is doubtful or storage room is deficient, especially 
 during the summer months, the use of dried milk is to be 
 recommended. Milk after desiccation seems to be more 
 digestible than ordinary cow's milk, but if there is difficulty 
 in digesting the full-cream variety, half-cream dried milk 
 may be used as a temporary expedient. When the child is 
 incapable of digesting cow's milk, the use of ordinary 
 sweetened condensed milk is often useful as a temporary 
 expedient, but its use should not be continued. 
 
 Fat, especially in the form of cod-liver oil, has long been 
 considered useful in the treatment of rickets, and has by 
 
466 Rickets 
 
 many been considered a specific. There is no doubt of 
 its utility in properly selected cases. So firmly has the 
 belief been established for many years, that practically every 
 child who does not thrive, no matter to what class it belongs, 
 is placed straight away on one of the many forms of cod- 
 liver oil, either plain or combined with malt. 
 fif For some years, malt and cod-hver oil have been used 
 fairty freely in certain of the London County Council schools 
 with very varying results. As already noted, in children who 
 are badly nourished the most serious deficiency is in the pro- 
 teid element of the diet. It is of Uttle utility to supply cod- 
 liver oil to a child whose food supply is deficient all round in 
 the elements which go to constitute a healthy dietary. My 
 own experience has been that these children benefit much 
 more from the supply of a certain quantity of milk daily, 
 even if that be only half a pint, which is the quantity usually 
 supplied. 
 
 In baby centres the general experience with fats has been 
 that most of the varieties of fat produced the same favour- 
 able result, and the question arose how far the action of 
 the fat was a mechanical action on an irritated intestinal 
 mucosa. Clinically, the vegetable fats seemed to produce 
 equally favourable results with the animal fats. 
 
 One matter is of great importance, and that is that to get 
 the best results the fat should be in the form of a perfect 
 emulsion. Ordinary emulsification by hand with the use of 
 tragacanth is not nearly so efficacious as the very perfect 
 emulsification produced by mechanical means. The success 
 of many of the patent emulsions is probably due to the very 
 perfect sub-division of the fat globules, which remain dis- 
 tinct and do not tend to run together. Emulsions of 
 petroletim have practically no direct nutritive value, but have 
 been found of great value from their local lubricant action, 
 combined probably with a certain inhibitory influence on 
 bacterial activity. 
 
 Clinically, bacon fat has been found one of the most 
 efficient modes of administering fats in an easily digestible 
 form to infants, and it is impossible to agree with laboratory 
 
The Treatment of Rickets 467 
 
 experiments which seem to suggest that it is of little or no 
 nutritive value. 
 
 Yolk of egg is a useful addition to the diet of the healthy 
 child and is most beneficial in rickets. From the sixth 
 month the infant may be given a few spoonfuls of the yolk 
 of a lightly boiled egg. Up to the age of two years, the child 
 should take two pints of milk within the twenty-four hours, 
 and the morning and evening meals should consist principally 
 of milk with bread and butter. 
 
 From the age of ten to eighteen months, a cup of good 
 beef-tea should be given to the child for its mid-day meal, at 
 first every other day but later each day. A little stale bread 
 or rusk may be given with the beef-tea or a mealy potato 
 well mashed with a spoon. 
 
 The preparation of good beef-tea is not always easy to 
 carry out, and a reliable meat extract is often a useful way 
 of preparing a cup of beef-tea for the mid-day meal. These 
 meat extracts are often fortified by the addition of meat 
 fibre and albumen, but cannot, even then, be regarded as 
 efficient foods in themselves, for the quantity of proteids 
 present is but small. Nevertheless, beef-tea and meat 
 extracts undoubtedly lead to a better digestion and absorp- 
 tion of the ordinary diet, so that they have both a direct 
 and an indirect nutritive value. 
 
 In the debilitated states of rickets, raw meat juice and 
 raw meat pulp are valuable adjuncts and act as stimulants, 
 easily digested and absorbed, especially when there is any 
 intestinal complication. 
 
 Meat may with advantage be given to the child from the 
 eighteenth month onwards in the form of a little finely 
 shredded or carefully pounded roast mutton. If meat be 
 excluded from the diet of the child, the best results as regards 
 growth are not obtained. The child can quite well digest 
 meat ; and indeed, in chronic diarrhoea and intractable 
 catarrhal affections of the bowels, it is a very valuable form 
 of treatment to cut off for a little all forms of milk food and 
 to keep the infant on raw meat juice, raw meat pulp, and 
 albumen water. 
 
468 Rickets 
 
 While the adult may with advantage cut down meat to a 
 very small proportion when there is a failure of elimination, 
 the young organism is dependent on a relatively large pro- 
 teid supply if efl&cient growth and development are to be 
 maintained. 
 
 Poverty and want of food are not by any means the most 
 common causes of under-feeding in children. In slum areas 
 and among rachitic children deficiency of the proteid and 
 fat elements is the commonest error. The child is given 
 portions of what the rest of the family eat, and if a child be 
 allowed other foods it readily loses the desire for milk, and 
 can only be made to take it with difficulty. The need for 
 supplying the proteid deficiency has been emphasised, for 
 in most works on rickets the administration of a suitable 
 fat is usually spoken of as if it were the one specific method 
 of treatment. 
 
 During the first year the infant thrives on milk and milk 
 foods, and it is a common error to continue this diet without 
 change during the second year. The child fed on a milk diet 
 entirely has not the energy nor the power of resisting disease 
 possessed by the child who receives a more varied diet. 
 
 I have not been impressed by excess of carbohydrates 
 in the food as a common cause of error in the infant's meta- 
 boHsm, where the other dietetic elements were supplied in 
 sufficient quantity. All over the East the early addition of 
 starchy pap food to the diet is exceedingly common, but 
 rickets never results. 
 
 Variety is to be aimed at, but that must be tempered with 
 moderation during the first two years. The pulp of a well- 
 baked apple beaten up with sugar and cream, scraped banana, 
 the inside of a grape from which the pips and skins have been 
 removed, or one or two teaspoonfuls of orange juice are all 
 useful about eighteen months, but indigestible fruits and 
 raw apples should be avoided in young children. At the 
 third or fourth year, a raw apple may be allowed, provided 
 it is not eaten at the evening meal and is used with caution 
 in warm weather. The fibre of the apple, it is true, is useful 
 in cleansing the teeth, but it must be remembered that by 
 
The Treatment of Rickets 4^9 
 
 the third or fourth year the main part of the enamel of the 
 permanent teeth has already been laid down and the main 
 failures in the defence of the teeth have taken place long 
 before this period. In other words, no fruit diet can at this 
 late period be expected to have any action whatever on the 
 actual structure or formation of the teeth. By the third or 
 fourth year of life the teeth of the permanent set are well 
 nigh completed. 
 
CHAPTER XXX 
 
 The Treatment of.Kiekets {continued) 
 
 In the last chapter, some of the general principles applicable 
 to the treatment of rickets were enunciated. A few words 
 may, with advantage, be said as to their application to the 
 individual. 
 
 If a rachitic child does not make satisfactory progress and 
 it is difficult to find a suitable food, nothing is likely to be 
 more effective than a change of air either to the country or 
 to the seaside. Sea air, if the exposure be not too rigorous, 
 seems to be especially beneficial, and not infrequently without 
 any alteration in the diet or of the usual regimen, beyond the 
 change of air, the child begins to thrive at once. In England, 
 the more bracing climates on the east coast are to be pre- 
 ferred, such as Margate, Folkestone, Broadstairs, Lowestoft, 
 and Scarborough. A short change to such a climate often 
 proves the turning point to the rachitic child, and infants 
 who have been making no progress for months and who have 
 been placed on one food after another in the vain effort to 
 find some food which they could digest, progress and put on 
 weight immediately, and the food previously rejected is 
 easily retained and assimilated. In the case of the poor, 
 unfortunately, such a change is not easily arranged, but much 
 excellent work has already been done by voluntary agencies, 
 who lay themselves out to secure the necessary change for 
 the child of the slum dweller. 
 
 The difficulty of feeding the infant has been greatly 
 exaggerated, and defective growth is often attributed to 
 failure of the digestive powers, when the nature of the error 
 
 470 
 
The Treatment of Rickets 471 
 
 lies in a vicious environment which interferes with the 
 healthy action of every organ in the body. 
 
 Scrupulous cleanliness is of the greatest importance to 
 the rachitic child. It has already been stated that Kasso- 
 witz believed that ammoniacal decomposition of the urine, 
 where cleanliness was not observed, vitiated the atmosphere 
 which surrounded the infant and led to the development 
 of rickets. While it is unlikely that the breathing of these 
 ammoniacal vapours is in itself a cause of rickets, it cannot 
 be doubted that careful cleansing of the skin is of the greatest 
 value in the prevention of rickets. The child should have 
 a warm bath in the morning, and the whole body of the child 
 should be carefully sponged each evening. The training of the 
 infant from the first to habits of cleanliness and the frequent 
 changing of soiled clothing are of the first importance in the 
 rearing of a healthy child. The stimulation of the skin by 
 means of baths has a most beneficial effect on the general 
 metabolism of the infant. Cold douches are exceedingly 
 useful, due care being taken to avoid shock. In warm 
 weather the child may be seated in a tepid bath while 
 colder water is squeezed over the shoulders. The use of salt 
 water and of sea water affusions are simple remedies which 
 ought to be much more freely used than they are. They 
 have a most wholesome effect in toning up the system in 
 the debility of rickets. 
 
 Medicinal Treatment. — The scope for the medicinal treat- 
 ment of rickets is comparatively limited. 
 
 The administration of cod-liver oil has already been 
 dealt with, as this is more a food than a drug. As a rule, 
 the tendency is to give the oil in too large doses. For an 
 infant, it is well to begin with small doses of ten drops three 
 times a day. The combination with malt is a pleasant and 
 useful method of exhibiting the oil, especially if the plain oil 
 is not well tolerated. Emulsions are frequently more easily 
 retained and are better assimilated. 
 
 In Europe, phosphorus has been much lauded as a specific 
 in the treatment of rickets. It is usually given in doses of 
 one two-hundredth part of a grain and should be given after 
 
472 Rickets 
 
 food. Cod-liver oil is the commonest vehicle used in its 
 administration. The following are convenient formulae' for 
 its administration : — 
 
 1. Phosphorus 1 grain. 
 
 Absolute alcohol 350 minims. 
 
 Spirit of peppermint ... 10 „ 
 
 Glycerine — ^up to 2 ounces. 
 
 Six to twelve drops three times a day after food. 
 
 2. 
 
 Phosphorus 
 
 1 grain. 
 
 Almond oil 
 
 1 ounce. 
 
 Gum acacia 
 
 4 drachms. 
 
 White sugar 
 
 4 
 
 Distilled water 
 
 1| ounces. 
 
 One to two teaspoonfuls three times a day after food. 
 
 3. Phosphorus ^ grain. 
 
 Cod-liver oil Bounces. 
 
 One teaspoonful three times a day after food. 
 
 It has been suggested that deficiency of phosphorus may be 
 a cause of rickets. This is unlikely, for the disease frequently 
 develops in children who are taking a sufficiency of cow's 
 milk, which, as Bunge points out, contains six times as much 
 of this element as human milk. Nor can it be reasonably 
 maintained that the administration of this exceedingly 
 small dose of phosphorus is sufficient to lead to the normal 
 la3dng down and combination of the calcium in the various 
 centres of ossification. 
 
 Its value has been chiefly insisted on by Kassowitz, of 
 Vienna, and by Jacobi, in New York. Its use has found but 
 little favour in this country, and the probability is that the 
 usual vehicle in which it is given — cod-liver oil — ^is more 
 efficacious than the drug itself. 
 
 Iron is often of utility, especially in older children. 
 The vinum ferri may be given in doses of from twenty to 
 forty minims. The compound syrup of Hie phosphate of 
 iron in doses of from half to one teaspoonful is also a con- 
 venient preparation which is well tolerated. It is especially 
 useful in the pale, flabby, often undiily fat and lymphatic 
 type. 
 
 When the digestion is at fault a small dose of grey powder 
 
The Treatment of Rickets 473 
 
 is often efficacious, and in young infants the administration 
 of from a quarter to a half grain for three to six successive 
 nights may be employed with advantage. When the 
 motions are pale and pasty and are accompanied by mucus, 
 the use of a small dose of calomel is often helpful. A useful 
 combination is : — 
 
 Hydrargyri cum creta gr. J 
 
 Hydrargyri sub-chloridi gr. | 
 
 Sacchari lactis gr. iii 
 
 When there is much mucus in the stools, the use of small 
 doses of castor oil are very useful, and it may be employed 
 with advantage in the beginning of the treatment of diarrhoea 
 whether acute or chronic. 
 
 When the tongue is furred white or yellow, and the 
 motions are green and slimy, the following simple mixture 
 is of service : — 
 
 Gleiricini 3^ 
 
 Mucilaginis acacias ) ---»••• 
 
 o • f aa .^m 
 
 Syrupi I ^ 
 
 Aquae ad §iii 
 
 Misce. 3ii ^^^ ^^ ^i^- 
 
 When there are signs of nervous irritability such as night 
 terrors, laryngismus stridulus and the irritation associated 
 with teething, I have been impressed with the value of 
 phenacetin in quite small doses. It may be usefully com- 
 bined with grey powder as follows : — 
 
 Hydrargyri cum creta ... gr. J — gr. J 
 
 Phenacetin gr. i — gr. i 
 
 Sacchari lactis gr. iii 
 
 Fiat pulv. 
 
 When the nervous symptoms do not answer to simpler 
 treatment, bromides may be given in doses of one or two 
 grains every two or three hours in the case of an infant a 
 month or two old. When convulsions occur, the use of 
 bromides is indicated after administering a preliminary dose 
 of castor oil. The bromides should be continued for some 
 days after the convulsion and should be given three times 
 daily in diminishing doses. Chloral hydrate is useful in 
 
474 Rickets 
 
 some of the severer cases of convulsion, and may be given 
 in one to five-grain doses combined with bromides, preferably 
 by rectal injection. The use of the hot bath in convulsive 
 seizures is usually recommended and is very effectual during 
 the actual convulsion. The temperature commonly recom- 
 mended — 104° or 105° F. — is too high, a temperature of 
 95° or 96° F. being, as a rule, sufficient. While the child is 
 lying in the hot bath, cold affusion should be applied to the 
 head. If the fit be severe, the administration of chloroform 
 is exceedingly useful and may be proceeded with at once 
 without waiting for the hot bath. Small doses produce a 
 rapid result and, with the young child, can be repeated with 
 safety if required. 
 
 In laryngismus stridulus a similar line of treatment 
 should be followed. Placing the child in a hot bath and 
 sponging the chest, back and front, with cold water twice a 
 day is a useful form of treatment in these cases. 
 
 In rickets, massage of the whole body is a most valuable 
 adjunct to the treatment. This may be employed with the 
 hand alone after the bath. The friction promotes the action 
 of the skin, improves the circulation and tones up the whole 
 muscular system. It has a marked soothing effect on the 
 nervous system. 
 
 When there is difficulty in getting the child to assimilate 
 cod-liver oil by the mouth, it may very conveniently be 
 introduced into the system by friction. It is, however, an 
 unpleasant application, and friction with any simple animal 
 fat, olive oil, neat's-foot oil, or benzoated lard, is free from 
 this unpleasantness and seems to be equally efficacious. 
 These oil frictions act in three ways, viz. : — 
 
 (1) by introducing fats into the system ; 
 
 (2) by soothing the irritable nervous system ; 
 
 (3) by increasing the quantity of all the secretidhs ; the 
 
 urine becomes more abundant and the function of the 
 liver is promoted. 
 
 The persistent use of massage after the child's bath is a most 
 useful form of treatment in all cases of rickets, except in the 
 severer cases where the limbs are too tender to be manipu- 
 
The Treatment of Rickets 47s 
 
 lated. Through the cutaneous surface, both by means of 
 graduated baths and frictions, a most powerful tonic effect 
 can be produced on the whole system, which is of the greatest 
 value. The rubbing should be continued for from four to 
 six weeks and should be carried out on a systematic plan. 
 It is well to begin with the lower extremities, and at first 
 the friction should be gentle, especially if there is tenderness. 
 At first, manipulation is painful, but after a time firmer 
 pressure can be made, working from below upwards. Passive 
 movement of the aiikle, knee and hip is also useful. From 
 the lower limbs the mother should pass to the abdomen, 
 thorax, neck and upper extremities. The whole manipula- 
 tion should last about ten minutes, and can be quite well 
 carried out by the mother if the various movements, which 
 need not be of a complex nature, are explained to her. 
 
 Surgical Treatment of Rickets. — ^When a child with deformi- 
 ties of the long bones is brought for consultation, the mother 
 is usually reassured and told that in time these will pass away. 
 Now, this is true in many cases, especially if measures are taJien 
 to remedy the conditions which have produced the disease. 
 
 But it must always be borne in mind that in all large 
 cities in England, and still more on the Continent, notably 
 Vienna, Buda-Pesth, Berlin and Paris, large numbers of cases 
 present themselves with curvatures of the long bones which 
 require surgical interference. Before the war the chief work 
 of the orthopaedic surgeon lay in the correction of rachitic 
 deformities. 
 
 Indeed, contrary to what is usually supposed, bony 
 changes occurring in this disease are remarkably persistent 
 and, in many cases, may be observed in advanced life if they 
 are carefully looked for. The bending of the long bones tends 
 to disappear in the majority of cases, it is true. But the 
 changes in the skull such as the thickening of the frontal 
 bones or of the parietal bones are often exceedingly persistent 
 and remain throughout life. Deformations of the thorax 
 due to rickets, not necessarily pigeon breast, are very common 
 in the adult. Lateral deviations of the spine, flat foot and 
 knock-knee supervene at a later period and do not always 
 
476 Rickets 
 
 tend towards spontaneous cure. Most important of all, the 
 bony changes in the pelvis in women are apt to be very 
 persistent, and are likely to lead to dystocia, and to increase 
 the dangers of labour to both mother and child. Most of 
 the severe deformities demanding Caesarean section are, as 
 has been seen, due to rickets. 
 
 Tibial curves are probably the most frequent deformities 
 which have to be dealt with surgically. It must be remem- 
 bered that, while rickets is responsible for the softening of 
 the bones and the relaxation of the muscles and Ugaments 
 which support the joints, the actual bending of the bone is 
 due to mechanical causes, and means must therefore be taken 
 to obviate them. Often these children with a framework 
 defective in rigidity and resiliency, are sohd, fat, and heavy, 
 and it can readily be understood that if they are allowed to 
 stand a great deal at an early date, bowing of the tibia is very 
 Hkely to occur. 
 
 A large amount of judgment is required as to the hne of 
 treatment to be adopted. Obviously, it is desirable to keep 
 the weight off the limbs, but it is still more important that 
 the child should have ample opportunities of exercise. In 
 the ordinary outward bowing of the tibia, this can usually 
 be attained by giving daily baths, accompanied by massage 
 and passive movements of the hmbs three times a day, 
 while splints are employed in the intervals between the 
 exercises. If the child is under three years of age, and the 
 outward curve of the tibia is not very marked, a splint should 
 be applied to the innra- side of the Umb, extending from two 
 or three inches below the perinaeum to two or three inches 
 below the ankle. Straps at the top and bottom retain the 
 limb in position, while a third band at the point of greatest 
 convexity produces a continuous pressure which tends to 
 straighten the limb. The projection of the sphnt beyond 
 the ankle prevents the child getting on its feet. 
 
 At first the splint should be worn continuously night and 
 day, but as the condition improves, the child may be allowed 
 the gradual use of the limbs, the sphnts being used after a 
 time only at nights. As soon as possible, splints should be 
 
The Treatment of Rickets 477 
 
 discarded. If the child is over three years of age, the same 
 treatment should be given a fair trial for some months. 
 Similarly with anterior curves of the tibia, spHnts should be 
 given a fair trial. 
 
 If these measures are not successful, recourse must be 
 had to osteotomy. The operation is a simple one. An 
 osteotomy knife is passed on the flat through the skin over 
 the crest of the tibia and over the inner surface of the bone 
 at the most prominent part of the curve. The knife is then 
 turned at right angles so as to divide the periosteum. Along 
 the knife the blade of a fine Adams' saw is introduced, and 
 as the knife is withdrawn, the skin incision is enlarged to 
 prevent the heel of the saw abrading it. About two-thirds 
 of the thickness of the tibia is now sawn through, and the 
 fracture of the remaining third and of the fibula is completed 
 by manipulation. In more severe cases, removal of a wedge 
 of bone may be required before the deformity can be corrected. 
 Some surgeons still employ the older method of osteoclasis, or 
 fracture of the bone at the point of greatest curvature, over a 
 wedge-shaped block by means of manipulation. In this way 
 a green stick fracture is produced, a wedge-shaped gap 
 appearing at the hollow curve of the bone. In all these cases 
 the limb must be secured in the straight position by means 
 of plaster of Paris bandages, or by back and side splints. 
 
 Knock-knee, as has been shown, may occur in the very 
 young child associated with active signs of rickets, or it may 
 occur from twelve to eighteen years of age, when it is known 
 as the static variety. It is only static in the sense that it is 
 due to the operation of mechanical forces on a limb in which 
 the bones, muscles and ligaments are all weakened as the 
 result of an attack of rickets only partially recovered from. 
 Deformities occur at adolescence as the result of a dispropor- 
 tion between the weight and the rigidity of the column 
 supporting it. This disproportion may arise in two ways : — 
 
 (1) by undue increase of the weight, as when a growing child 
 
 carries heavy weights over a prolonged period. In such 
 a case even a healthy bone would give ; 
 
 (2) by weakening of the support, which is much the more 
 
478 Rickets 
 
 common cause of the disproportion. In nearly all these 
 cases belonging to the second class, the weakening of 
 the supporting column is the result of rickets in early 
 life. The rachitic process itself, in the great majority 
 of cases, has not recrudesced, for the conditions which 
 produce it are not commonly present at adolescence, 
 but the weakness of the bones has existed ever since 
 the early attack, and has now become manifest as the 
 result of the added strain. 
 
 Quite a large number of cases of knock-knee recover 
 without treatment, but this cannot be guaranteed in any 
 individual case. In the young child when the condition is 
 slight, the recumbent posture, massage, open air, and daily 
 manipulation of the limb, employing pressure so as to correct 
 the deformity, will sufi&ce to effect a cure in many cases. 
 The attitude and walk of the child in all these deformities is 
 important. In the tired subject, as previously noted, the 
 weight is taken off the muscles and the strain is thrown on 
 the ligaments, notably the internal lateral ligament of the 
 knee which is stretched and weakened, while the weight falls 
 on the inner border of the foot and the arch sinks. The 
 child tends to separate the feet in walking so as to increase 
 the base of support and points the toes markedly outwards. 
 There is no resiliency in the step. It is important to correct 
 this habit and to teach the child to walk with slightly in- 
 tumed or parallel feet. 
 
 In more severe cases Sir Robert Jones recommends the 
 Thomas' Knock-knee Brace, which is a bar of iron running 
 into the heel of the boot, placed to the outer side of the limb 
 and reaching as high as the great trochanter. A posterior 
 bar reaches well above and below the knee. The knee is 
 first bandaged to the posterior bar to keep it fully extended, 
 and afterwards to the lateral bar to correct the lateral 
 deviation. During the night, shorter splints should keep up 
 the improved position ; later, the day splints can be discarded 
 and only the night splints used. Jones makes two important 
 observations as to the mechanical treatment of knock-knee. 
 Firstly, all jointed splints for the correction of knock-knee 
 are quite useless, as the pressure strain of the splint is rapidly 
 
The Treatment of Rickets 479 
 
 lost during the act of flexion. Secondly, the test of recovery 
 and the sign that the splint may be discarded is when the 
 straightened knee fails to yield laterally on manipulation. 
 
 Any case of knock-knee may be cured in this way, but 
 naturally, when the condition occurs in later hfe, the long 
 period of treatment required militates against its use, and 
 usually some form of operative measure is required. 
 
 Some surgeons still employ forcible straightening of the" 
 knee by manipulation or by means of the osteoclast. The 
 degree of violence required to produce a fracture is often 
 very great, and osteotomy is to be preferred. Linear osteo- 
 tomy of the lower end of the femur just above the epiphyseal 
 Une, according to McEwen's method, is a safe operation, 
 and is very successful in its results. It has largely replaced 
 Ogston's operation, which had the serious objection that it 
 opened the knee joint while the internal condyle was obUquely 
 sawn through. 
 
 The treatment of flat foot is a problem which is very 
 commonly placed before the practitioner. Teaching the 
 child to walk with the toes pointed directly forwards so that 
 the inner borders of the feet are parallel is an important part 
 of the prophylaxis of flat foot. It is not expedient in the 
 young child or the young adolescent to insist straight away 
 on severe tip-toe exercises and movements which simply 
 throw an extra strain on muscles already overtaxed. Atten- 
 tion to general hygiene, change to a sea climate, salt water 
 foot baths and douches, combined with massage and move- 
 ment of the foot and ankle, are important preliminary 
 measures. At the same time, adequate periods for rest 
 should be insisted on. Many cases will be arrested and many 
 will be cured by attention to these measures alone. Care- 
 fully regulated ex:ercises may now be usefully employed, tip- 
 toe exercises for two or three minutes twice a day being sufii- 
 cient at first. The duration and the number of the exercises 
 may be gradually increased as the muscles regain strength. 
 Placing the feet close together and inverting the soles so that 
 the body weight rests on the outer border of the foot is also 
 a useful exercise. 
 
480 Rickets 
 
 The supply of a support to the arch of the foot in the form 
 of a valgus plate is frequently of value. It is sometimes 
 stated that these are harmful in that they take the work from 
 the muscles and ligaments and throw it on to an artificial 
 arch. But a well-made steel or aluminium brace, light and 
 comfortable to the foot, does not interfere with its move- 
 ments. It should be resihent as well as Ught so that there is 
 a fair amount of give and spring, combined with a continuous 
 support to the arch which allows it to retain its shape. 
 
 When the flat foot has advanced further so that the bones 
 become fixed in position and the tendons of the peronei 
 muscles and the ligaments are contracted, forcible rectifica- 
 tion of the foot under an anaesthetic is likely to be required. 
 This method of treatment is safe and effective. This 
 redressement forcee is carried out, under an anaesthetic, over 
 a wedge-shaped block, and the foot should be over-corrected 
 as far as possible while plaster bandages are applied so as to 
 retain the foot in the adducted and inverted and slightly 
 flexed position. The plaster should be allowed to dry before 
 the patient comes out of the anaesthetic, and the bandages 
 should be retained in position for one month. This method 
 of treatment is safe and effective, but it may require to be 
 repeated to obtain a good result. Very occasionally in old 
 and intractable cases operative measures, such as resection 
 of the astragalo-scaphoid joint according to Ogston's method, 
 or excision of a wedge from the head and neck of the astra- 
 galus (Stokes' operation), may be required. 
 
 The spine should be carefully observed in rickets. 
 Ks^phosis or posterior projection of the spine is not uncommon 
 in young infants as the result of muscular debility. Such 
 infants should be kept lying on a padded wicker tray which 
 can be easily carried about, and the child should be nmrsed 
 as far as possible in the reclining position. The general 
 treatment of the disease is most important in these cases, and 
 bathing and massage of the spinal muscles should be em- 
 ployed. If the child is able to sit up, a back splint of leather 
 or of malleable iron covered with leather, with axillary and 
 
The Treatment of Rickets 481 
 
 perineal straps, may be usefully employed to keep the back 
 straight. Breathing exercises are very essential, especially 
 if pigeon breast is an associated deformity. Round 
 shoulders is an exceedingly common form of kyphosis in 
 rickets, and should be treated by strengthening the enfeebled 
 muscles in the ways already indicated, and by correcting 
 the deformity by means of suitable exercises. 
 
 Scoliosis or lateral curvature of the spine is a condition 
 common in rickets from a very early period. It requires the 
 greatest care both as regards diagnosis and treatment. The 
 essence of scoliosis is that there is a rotation of the vertebrae 
 around a vertical axis, and though this is usually associated 
 with bending of the spine to one or other side, the lateral 
 deviation is by no means a necessary concomitant. 
 
 In weakly and delicate children, or after an acute illness, 
 there may be a simple lateral deviation of the spine without 
 rotation. Provided there is no structural change in the 
 bones, lateral deviation of the spine is very amenable to 
 treatment. The correction of faulty attitudes and the 
 strengthening of the muscles by appropriate exercises are of 
 the greatest importance. 
 
 The true form of scoliosis in rickets has gone a stage 
 further. It is due to a faulty position which has become 
 stabilised and has led to the rotation of the vertebrae with 
 osseous changes which do not admit of cure. 
 
 The question of retentive supports in scoliosis has been 
 very hotly contested. Where actual structural alterations 
 have occurred and a cure cannot be hoped for, the use of a 
 light form of spinal jacket is clearly indicated to prevent the 
 deformity becoming worse. A divided plaster jacket, cap- 
 able of being easily removed for the purposes of exercise and 
 education in proper breathing, is often very essential. It 
 is very necessary to recognise the cases requiring a spinal 
 support, for a policy of simply letting the patient drift will 
 almost certainly tend to an aggravated condition, incapable 
 of cure, and beyond the hope of amelioration by suitable 
 exercises. 
 
INDEX 
 
 Abdominal tension, 110-2 
 
 as an index of fitness, 1 1 1 
 Achondroplasia, 450-1 
 Acromegaly, 437 
 Adenoid facies in rickets, 183 
 
 vegetations, 158, 167, 185, 
 
 249-50, 255 
 Adolescence and rickets, 150^3, 166 
 etiology of rickets, 85, 283, 397-454 
 Africa, rickets in, 41, 69 
 Amengrrhoea, 442 
 America, rickets in, 56, 171, 221, 
 
 340, 396, 443 
 Anaemia in rickets, 244-6, 369, 405 
 Ancient medicine and rickets, 288- 
 
 300 
 Aneurism, aortic, simulated in 
 
 rickets, 161 
 Anglo-Saxon races, 329 
 Anthropology and disease, 177-8, 
 
 330 
 Antrum of Highmore, 180 
 Aprosexia and rickets, 252, 255-7 
 Arlt, Prof., 211 
 Army recruiting and rickets, 6, 385, 
 
 387 
 Artificial feeding of infants, 10, 100, 
 
 310, 404-5, 420, 464 
 Asia, rickets in, 33, 85 
 Australia, rickets in, 44, 51, 68, loi, 
 
 171, 212, 220, 340 
 
 Bacteria and rickets, 440. See 
 
 Infective theory of rickets. 
 Balfour, Wm., 162 
 Ballantyne, J. W., 450-1 
 Barlow's disease, 77, 132, 158-9, 
 
 277. 405 
 Barlow, Sir Thos., 96, 277 
 Baths in rickets, 471, 474 
 Baumel, 30-1 
 Beading of the ribs, 155-6. 274-5, 
 
 367 
 Beddows, Thomas, 306 
 Bennett, Norman G., 212, 213, 218 
 Bennett, Turner and, 319-20 
 Bills of Mortality for London, 301, 
 
 352 
 Bing, no 
 Birmingham, 389, 391 
 
 Black list area in London, 385-7 
 
 Bland-Sutton, Sir John, 409 
 
 Blood in rickets, 244-6 
 
 Boerhaave, 278, 307 
 
 Bolk, Prof., 438 
 
 Bone, cartilaginous, in rickets, 123, 
 
 128-9 
 membranous, in rickets, 117, 
 
 123-4, 130 
 Bones, ancient collections of, 331-2. 
 
 333-4 
 changes in, in rickets, Z17 et 
 seq., 132-7, 172, 246, 248, 
 250, 316-7, 443 
 chemical changes in, in rickets, 
 132-3 
 Booth, Chas., 359 
 Brachycephaly and rickets, 189 
 Breast feeding in rickets, i8, 39, 75, 
 85, 100, 310, 314, 347, 363-6, 403, 
 413, 420, 464 
 Brend, Dr., 435 
 
 Britons, Ancient, and rickets, 329 
 Bronchitis in rickets, 161 
 Broncho-pneumonia in rickets, 159 
 Browne, Sir Thos., 263-4, 278, 318 
 Brown-Sfiquard, 428 
 Bunon, Robert, 192-3 
 
 Caesarean section in rickets, 169-71 
 
 Caius, John, 266 
 
 Calcium metabolism in rickets, 191, 
 
 232-3, 237, 240, 413 
 Calcium-poor food, 400-1 
 California, rickets in, 57, 63-4, 66, 
 
 68 
 Carbohydrates, excess of, 100, 399, 
 
 401, 468 
 Carbon dioxide, increase of, 427 
 Caries of the teeth and rickets, 198, 
 
 317-20, 323, 332 
 Carpenter, George, 93-6 
 Cartesian theory, 146, 262-3 
 Castellani, 39, 73 
 
 Cataract, lamellar, and convulsions 
 in infancy, 227 
 andrickets, 211, 213-9, 228 
 Catarrhal conditions in rickets, 369 
 Causes of rickets. See etiology. 
 Celsus, 299 
 
484 
 
 Index 
 
 Change of air in rickets, 470 
 
 Chart investigation, 364 
 
 Cheadle, 452 
 
 Chicago, rickets in, 62, 65 
 
 Child labour, 12, 344, 348, 424 
 
 China, rickets in, 34-6, 418 
 
 Chondrodystrophia foetalis, 450-1 
 
 Chovstek's sign, 239 
 
 Civilisation and rickets, 15-7, 38, 
 
 278, 288, 296-7, 464 
 Clare Market, collection of bones in, 
 
 333-4 
 Clark, Alice, 339 
 Clavicle in rickets, 144 
 Cleanliness, 407, 425, 429, 471 
 CUmate and rickets, 4, 20, 85, 415-7, 
 
 421, 433-5 
 . Coalfields and rickets, 27 
 Cod-liver oil, use of, 466, 471 
 Cohn, Michael, 96 
 Collins, Edward Treacher, 212-4, 
 
 216-7 
 Colonies, rickets in the, 41 
 Colyer, Sir Frank, 193 
 Comby, 30, 97, 452 
 Congenital rickets, the question of, 
 
 88, 204, 283, 394, 436, 447, 450 
 Convulsions in infancy, 99, 191, 211, 
 
 228-31, 239, 443, 474 
 Cotton industry, 348-9, 350-1 
 Cow's milk, high mortality from use 
 
 of, 310-1 
 Coxa vara, 140-1 
 Craniotabes, 94-9, 234, 452 
 Cretinism and rickets, 33, 436 
 Cullen, 265 
 Culpeper, Nicholas, 268-9 
 
 Davis, Dr. W. H., viii., 61 
 Davis and Thumham, 329 
 Daylight saving and rickets, 304 
 Deafness in rickets, 251, 255, 393 
 De Boot, Arnold, 271-2, 279 
 Defective housing. See Housing. 
 Deformities in long bones and 
 
 rickets, 138 et seg. 
 Dentition and convulsions, 230-2 
 Denton, Dr. Wm., 312 
 De Plouquet, 305 
 De Sainte Marthe, 313 
 Development of child, stages in, 
 90-3 
 in rickets, delayed, 90, 433, 443 
 Developmental diseases, 8, 14, 190, 
 
 227, 295, 330, 387, 392-6, 412 
 Devon and Dorset, rickets in, 284 
 Diagnosis, errors in, due to rickets, 
 
 1 61-2 
 Diaphragm, action of, 113-4, ^S^. 
 
 158, 160 
 
 Diathetic conditions, 87 
 Distribution of rickets, 13, 16 et seq., 
 
 415 
 Dover, collection of bones, 333 
 Dried milk, 465 
 Dub, Bernard, 215 
 Duncan, W. H., 353-4 
 Dystocia due to rickets, 169, 174-5 
 
 Ear affections and rickets, 7, 252, 
 
 253-5, 393 
 Early EngUsh bones, collections of, 
 
 and rickets, 329 
 Eccentricity in diet, 402 
 Economic factors, 321-2, 328-9, 
 
 335, 337-51 
 Ectodermic structures in rickets, 190 
 Eczema and rickets, 208 
 Egypt, rickets in, 69, 288, 298, 316, 
 
 318-20, 423 
 Elevation and rickets, 33 
 Eliminative organs and disease, 8, 
 
 295 
 Elsasser, 94, 99, 234, 239 
 Emulsification of fats, importance 
 
 of, 466, 471 
 Enamel of teeth, 191, 197-9, 206, 
 
 227 
 Endocrine glands in rickets, 436- 
 
 444 
 
 Engels, Frederick, 356-7 
 
 Environment and rickets, 4, 9, 39, 
 75. 103. 178. 292, 303, 321, 335-6, 
 348-9, 352-70, 382-3, 390, 392, 
 394. 397-8, 421. 424-5. 43°. 432 
 
 Epilepsy and rickets, 191, 229,231-3 
 
 Europe, rickets in, 21, 30, 340 
 
 Evelyn, John, 312-4, 420 
 
 Exercise, 414, 425, 454 
 
 Experimental rickets, 180, 400, 405, 
 406-8, 410-12 
 
 Eye disease in rickets, 190, 211 et 
 seq. 
 
 Facial bones in rickets, 176, 178, 
 
 250, 410 
 Famine and rickets, 418 
 Fat-soluble A, 76, 807-1, 299, 405-6 
 Fats and rickets, 76, 82-100, 299- 
 
 300. 335. 401. 4°3-6, 465-6. 468 
 Femur in rickets, 138-40 
 Feutrie, Levacher de la, 308 
 Findlay, 106, 245. 288, 292, 401, 
 
 413-4 
 Fiorani, 140 
 
 Fitness, index of, 1 11, 388-90, 395-6 
 Flanders, rickets in, 280 
 Flat-foot. See Pes valgus. 
 Flat-pelvis. See Pelvis in rickets. 
 
Index 
 
 48s 
 
 Flemish painters and rickets, 182, 
 279 
 
 FcBtal rickets. See Congenital 
 rickets. 
 
 Foods in rickets, 9, 12, 28, 38, 71 et 
 seq., 92, 103, 188-9, 324, 335, 
 346-7, 365, 392, 398-9, 402, 410, 
 411, 415-8, 456, 467, 469 
 
 Fordyce, Dr. W., 314-5 
 
 Fractures in rickets, 130 
 
 Frohlich, 246 
 
 Funk, 405 
 
 Funnel-shaped chest, 158-60 
 
 Galen, 273, 289, 292, 310, 312, 423 
 humoral pathology of, 264-6 
 Garden cities, 459 
 Gastro-intestinal catarrh in rickets, 
 loi, 106, 232, 239-40, 274, 309, 
 
 399 
 Gee, Dr., 231 
 Genu recurvatum, 142-3 
 
 valgum, 144-8, 166, 225, 477-9 
 
 varum, 144-8 
 Girls, rickets in, 167 
 Glasgow, caries of teeth in, 320 
 
 defective housing and slums in, 
 
 391 
 Glisson, Francis, 27-8, 163, 247-8, 
 261-85, 291, 305-7, 419-21, 441. 
 
 445. 448-9, 432 
 Goitre and rickets, 39, 285, 445-6 
 Gotch, Francis, 306 
 Getting, 400 
 Gowers, 231 
 
 Graunt, Caj)t. John, 301 
 Great Britain and Ireland, rickets 
 
 in, 22-9 
 Grulee, Clifford G., 58, 60, 62 
 Gu6rin, 124 
 Guillemeau, 272-3 
 Gutter-shaped chest, 158 
 Guye, Prof., 255 
 
 Haldane, Dr. J. S.. 427-8 
 Hand in rickets, 143 
 Hanseatic towns and rickets, 280-1 
 Harrison's sulcus, 114, 158, 160 
 Health, standards of, iii, 388-90, 
 
 395 
 Heart in rickets, 156 
 Height and weight standards, 389- 
 
 go, 396, 422 
 Heitzman, 399 
 Henoch, Edmond, 221 
 Heredity and environment, 290-1, 
 
 422-3, 431, 447 
 Hertoghe, 439, 442 
 Hess, Prof. A. F., 60, 414-5, 45° 
 Hill, Sir John, 196 
 
 Hilton, 109 
 
 Hippocrates, 289-91, 312, 423 
 
 Hirsch, 31 
 
 Historical evidence of rickets, 419- 
 
 425 
 Holland, P. H., 354-5 
 Honeycombed teeth, 105 
 Horner, Johann Friedrich, 211 
 Housing, defective, 12, 335, 337, 
 351, 384, 455-8 
 schemes, 457-60 
 Humerus in rickets, 143-4 
 Humoral pathology of Galen, 264-5 
 Hunter, John, 193-5, 397, 43° 
 Hunter, Wm., 193-4 
 HutcMnson, Sir Jonathan, 108, 190, 
 
 195-6, 211-2 
 Hutchison, Robert, 155, 237 
 Hyperthyroidism, 439 
 Hypothyroidism, 439, 442-3 
 Hypoplasia of the teeth, 50, 191-2, 
 
 197-206, 211, 218-9, 228, 317, 
 
 323-4, 443, 452-3 
 Hythe collection of bones, 299, 
 
 331-2 
 
 Incidence of rickets, rate of, 104-5 
 Incontinence, nocturnal, 443 
 India, rickets in, 36, 74-5, 327, 418 
 Industrialism and rickets, 10, 12, 
 
 278, 280, 288, 322, 341-2, 344-5, 
 
 396, 415 
 Infant welfare centres, a. 4, 460 
 Infantile scurvy, 277 
 Infective theory of rickets, 440, 444 
 Intercurrent diseases in rickets, 29 
 Intermarriage, 286-7 
 Intestinal infections and rickets, 39 
 Ireland, rickets in, 26, 79, 416 
 Iron tonics in rickets, 472 
 Italians in London, 417 
 
 Jacobi, 234, 472 
 
 Jamaica, rickets in, 66-8 
 
 Japan, rickets in, 37 
 
 Jaws, changes in upper and lower, 
 
 178, 180-3, 188, 317, 321, 324 
 Jenner, Sir Wm., 87, 114, 145, 150, 
 
 156, 161, 234, 247, 452 
 Jews, rickets among the, 59, 103, 
 
 335, 363, 365-6, 417 
 Joints in rickets, 115 
 Jones, Sir Robert, 478 
 Jones, Dr. Wood, 297 
 
 Kassowitz, 99, 135, 234, 239, 408, 
 
 429, 452, 471-2 
 Keith, Sir Arthur, 91, 176-7, 182, 
 
 323, 325 
 Keith's standard, 375, 385 
 
486 Index 
 
 Koplik, 143, 239 
 Kyphosis, 165, 480 
 
 Labour, difficult, in rickets, 169, 
 
 174-5 
 Lactic acid theory, 399 
 Lane, Sir Wm. Arbuthnot, 146 
 Laryngismus stridulus, 160, 230-4, 
 
 239, 443, 474 
 Late rickets, 150-2 
 Laughton, A. M., 47 
 Lawson, Sir Arnold, 223 
 Leeds, 378-81 
 
 Lens in rickets, igo, 213, 217^ 227 
 Liver, changes in the, in rickets, 
 
 24S-9, 274 
 Liverpool Street, London, collection 
 
 of bones in, 334 
 Liverpool, slum areas in, 353-4 
 London, industries in, peculiarities 
 
 of, 358. 383-4 
 north-east sector of, 359-62 
 rickets in, 25, 58, 315, 358-70 
 Lordosis, 165 
 
 Lymphatic glands, enlargement of, 
 246, 274 
 system in rickets, 185, 238, 
 246-51. 317. 440 
 
 MacCallum, 236-7, 240 
 
 Maffei, 33 
 
 Malnutrition and rickets, 87, 100, 
 
 116 
 Malthus, II 
 
 Manchester, slum areas in, 354-7 
 Marasmus, absence of rickets in. 347 
 Marfan, 30, 69, 135, 177, 186, 245, 
 
 444-5. 452 
 Massage in rickets, 474-5, 480 
 Maxilla, inferior, 182, 183-6, 187-8, 
 
 317. 324 
 superior, 178, 180-1, 183, 188, 
 
 317. 324 
 Mayow, 27, 278, 305-7 
 McCarrison, 40, 74, 84, 446 
 McCay, D., 73-4 
 McEwen's operation for knock-knee, 
 
 479 
 Measles, m rickets, 253-4 
 rickets following, 103 
 Meat extracts, 402, 467 
 Medullary tissue in rickets, 123-4, 
 
 127 
 Melbourne, rickets in, 47 
 Mellanby, Dr. and Mrs., 406-7, 414 
 Mental development in rickets. 
 
 241-3, 251, 255, 394, 396 
 Mercury, use of, in rickets, 309, 472 
 Merei, Schoepff, 27, 31, 356 
 Merkel, Dr. Sigmund, 428 
 
 Millard, C. K., 465 
 Miners and rickets, 415-6 
 Ministry of National Service Report, 
 
 2. 371-5 
 Miwa and Stoeltzner, 400 
 Modem disease, rickets a, 9-11, 
 
 277-8, 301. 306-7, 318, 320, 
 
 324-5. 333. 424. 449 
 Montreal, rickets in, 64 
 Moodie, 319 
 
 Moore, Sir Norman, 270 
 Morocco, rickets in, 37, 69 
 Morpurgo, B., 445 
 Morse, J. L., 59, 245 
 Mouth breathing in rickets, 157-8, 
 
 183, 251, 317, 393 
 
 Muscular debility and wasting, 
 108-10, 156, 186, 224, 226, 394, 
 
 405. 431 
 Myopia and rickets, 222-6, 426 
 Myxoedema and rickets, 40, 238, 
 
 444 
 
 Nasal septum, deflection of, 184-6, 
 
 393 
 National health and rickets, 375- 
 96 
 tjrpes and rickets, 118 
 Native population of South Africa, 
 
 327 
 Negro population in America, 
 
 rickets in, 57-8, 66, 327, 340, 414 
 Neolithic infants free from rickets, 
 
 323. 325-6 
 Nervous system in rickets, 190, 
 
 227 et seq., 275 
 Newgate Street, collection of bones, 
 
 333 
 New South Wales, rickets in, 44, 49 
 New Zealand, rickets in, 52, 171 
 Northampton, 382 
 Nurses' contracture, 235 
 Nutrition and rickets, 332-3, 367 
 Nyctalopia in rickets, 220-1 
 Nystagmus in rickets, 221-2 
 
 Ogston, 151, 479 
 
 Olympian forehead in rickets, i i8-g 
 
 Organic matter in respired air, 428, 
 
 439 
 Origin of disease, 4 
 Osier, 232-3 
 Osteoclasis, 479 
 
 Osteogenesis imperfecta, 450, 452 
 Osteomalacia in rickets, 308, 450 
 Osteotomy, 477, 479 
 Oxygen, diminution of, 427 
 
 Palate, arched, in rickets, 177. 179. 
 
 184. 320-1, 393 
 
Index 
 
 487 
 
 Palm, T. A., 33 
 
 Pappenheimer, A., 445 
 
 Parathyroids, 236-7 
 
 Parrot, 94, 108, 445 
 
 Parsons, Prof. F. S., 332-3 
 
 Paston letters, 282 
 
 Paton, D. Noel, 236, 401, 407-8 
 
 Peabody dwellings in London, 458 
 
 Pearson, Prof. Karl, 334 
 
 Pelvis in rickets, l68-g, 171-3 
 
 Perspiration in rickets, 102, 115, 209 
 
 Peru, rickets in, 57 
 
 Pes valgus, 144, 149, 165, 225, 
 
 479-80 
 Petit, J. L., 307 
 Phaire, Thomas, 310 
 Phlyctenular conjunctivitis, 226 
 Phosphorus, use of, in rickets, 309, 
 
 471 
 Pigeon-breast, 157-8, 274 
 Pituitary body, 437 
 Plagiocephaly, 97-8 
 Pneumonia, 159 
 Polypnoea, 154 
 Pommer, 400 
 Population, growth of, in England, 
 
 338, 341, 448 
 Portal, Antoine, 308, 444 
 Proteids in rickete, 401-2, 404 
 Pseudo-paralysis in rickets, 1 10 
 Pseudo-rachitic osteitis, 134 
 Public Health reports and rickets, 
 
 395 
 
 Rachitic rosary, 104, 115 
 
 souffle, 92 
 Radius, deformity of, in rickets, 143 
 Record cardi 364 
 
 Reflex excitability in infant, 229-30 
 Reid, D. B., 357-8 
 Rejection of recruits, causes of, 
 
 387-8 
 Respiration in rickets, 109, 112, 
 
 154, 156-7, 159, 181-3, 250-1, 
 
 424-5. 430 
 Retzius, brown lines of, 133, 206 
 Rhodesian skull, 330 
 Ribs, beading of, 155-6, 274 
 
 softening of, 156, 168 
 Rice-eating peoples and rickets, 72, 
 
 418 
 
 Rickets, a disease of luxury and 
 
 excess, 282-3, 307, 313-5, 
 
 347, 403, 419 
 
 a modem disease, 9-1 1, 277-8, 
 
 301, 306-7, 318, 320, 324-5, 
 
 333. 424. 449 
 an adaptive process, 8, 315, 
 321-2, 394, 396, 398, 430, 
 441-2, 448 
 
 Rickets — continued. 
 
 army recruiting and, 6 
 chemical changes in, 132-4, 399 
 civilisation and, 15-7, 38, 278, 
 
 288, 296-7, 464 
 distribution of , 13, i6etseq., 415 
 ear affections in, 7, 252-5, 393, 
 
 426 
 environment and, 4, 9, 39, 75, 
 
 103, 178, 292, 303, 315, 321, 
 
 335-6, 348-9. 352-70. 382, 
 
 383. 390. 392, 394. 397-8. 421. 
 
 424-5. 430. 432 
 food in. See Food and rickets, 
 glands of internal secretion in, 
 
 436. See Endocrine glands, 
 industrialism and, 10, 12, 278, 
 
 280, 288, 322, 341-2, 344, 
 
 345. 396 
 in early Flemish art, 182, 279 
 malnutrition and, 87, 100, ii6 
 osteomalacia and, 308, 450 
 persistence of signs in, 122, 131 
 racial tendency to, 88 
 rarefying osteitis in, 130 
 scurvy and, 77-8, 13 1-2, 276-7, 
 
 309. 413. 450 
 slum areas and, 11, 103, 322, 
 
 336, 346, 352-70. 390, 394. 
 
 424-5. 454. 456 
 stages in, 105, 128 
 statistics of, 24, 30-1, 47-9,' 
 
 59-62, 90, 95, 104-5, 107, 
 
 202-3, 205-7, 218, 231, 242, 
 
 249. 256, 324, 362-70, 385 
 sjfphilis and, 93-4, 108, 119-20, 
 
 142, 190, 192, 276, 297, 309, 
 
 398, 450 
 tendency to recover, 131 
 tuberculosis and, 5, 6, 32, 89, 
 
 247, 276, 297, 309, 370, 441 
 zymotic diseases and, 252-4, 
 
 309 
 Rokitansky, 114 
 
 Roman period in England, 328-30 
 Rothwell, collection of bones in, 333 
 Rousseau, J. J., 294 
 Ruffer, Marc Armand, 318-20 
 
 Sacrum. See Pelvis and rickets. 
 Scapula in rickets, 144, 164 
 Scarlet fever and rickets, 252, 254, 
 
 274 
 Schaumann, 405 
 Schmorl, G., 104, io8, 363, 400 
 School children, inspection of, 14 
 Sclerotic, changes in, in rickets, 224, 
 
 226 
 Scolio-rachitic pelvis, 173-4 
 Scoliosis, 144, 165-6, 481 
 
488 
 
 Index 
 
 Scotland, rickets in, 25 
 
 Scurvy and rickets, 77-8, 13 1-2, 
 
 276-7, 309, 413, 450 
 Seaport towns, rickets in, 202, 286 
 Seasonal variation in rickets, 10 1 
 Sharpe, J. S., 401 
 Shaw, E. A., 256 
 Sheffield, 343, 378-81 
 Siegert, 143 
 Simulation of disease in rickets, 
 
 161-2 
 Skin disease in rickets, 190, 208-9, 
 
 227, 370, 443 
 Skull in rickets, 92, 117-8, 121, 
 
 176-8, 316-7, 321, 325, 368-9, 
 
 393. 396, 423-4 
 Slum areas and rickets, 11, 103, 322, 
 
 336. 346, 352-70. 390. 394. 
 
 424-5. 454. 456 
 Smith, Elliot, Prof., 297-8 
 Smith, Eustace, 156, 229 
 Smith, J. Lewis, 60 
 Solidism, 265 
 Somerset, 284-5 
 Soranus of Ephesus, 292-3, 311 
 South Africa, rickets in, 41, 172, 416 
 South-western counties of England, 
 
 rickets in, 27-8, 284, 420 
 Spasmus nutans in rickets, 221 
 Speech in rickets, 90 
 Spinal support, use of, 480-1 
 Spine in rickets, 163-4, 225, 369-70 
 Spleen in rickets, 246-8 
 Splints, use of, in rickets, 476, 478 
 Status l3rmphaticus, 235-6 
 Steiner, Johann, 221 
 Stilling, 222, 224 
 Stoeltzner, Wilhelm, 134, 240, 400, 
 
 401, 452 
 Stomach, dilatation of, in rickets,235 
 Summer Time Act, 304 
 Sunlight, absence of, 424, 433-4, 454 
 Sutton, Dr. Harvey, 49-50, 52 
 Sydney, rickets in, 44-6, 69 
 Syphilis and rickets, 93-4, 108, 
 
 119-20, 142, 190, 192, 276, 297, 
 
 309. 398, 450 
 
 Tansillo, Luigi, 311, 314 
 
 Teeth in rickets, 92, 177, 179, 187-8, 
 
 190 et seq., 286, 316-7, 321, 324, 
 
 332-3, 396 
 Telford, Dr. Fletcher, 54 
 Temperate zone and rickets, 20 
 Temple, Sir Wm., 340 
 Tetania strumipriva, 236 
 Tetany in rickets, 39, 228, 235, 238, 
 
 239 
 Textile industries, 345 
 Thomson, John, 222 
 
 Thorax in rickets, 114, 154 ei seq., 
 164, 167-8. 367-8 
 
 Thurnham, Davis and, 329 
 
 Thymus, enlargement of, 235, 246, 
 248, 275, 438, 440-1 
 
 Thyroid, 237-8, 437-9, 44i 
 
 Tibia in rickets, 141 
 
 Tonsils, enlarged, and adenoid vege- 
 tations, 185, 249-50, 369, 393, 
 
 396, 443 
 Town planmng, 457 
 Towns, growth of, 338, 341, 392, 
 
 423, 456-7 
 Toxaemia in rickets, 439 
 Treatment, 455-81 
 medical, 471-75 
 surgical, 475-81 
 Trousseau, 235, 239 
 Tuberculosis and rickets, 5, 6, 32, 
 
 89, 247, 276, 297, 309, 370, 441 
 Turner and Bennett, 319-20 
 
 Ulna, deformity of, in rickets, 143 
 Unger, Hess and, 414 
 
 Valgus plate, use of, 480 
 Vemey memoirs, 31 1-2 
 Victoria, rickets in, 47-9 
 Vienna, rickets in, 28, 32 
 Virchow, 104, 126, 135, 299, 452 
 Vitamins, 77, 79-80, 82-4, 299, 405, 
 
 410, 444, 454 
 Vitiated air, 425-6, 454, 460 
 Von Graefe, A., 220 
 Von Hansemann, loi, 106, 435 
 
 Walking, delayed, in rickets, 90 
 
 Walton, Isaak, 315 
 
 War service and rickets, 6-8, 14, 
 
 254, 418-9 
 WeUs, H. Gideon, 132-3 
 Whistler, Daniel, 270-2 
 Whitechapel, collection of bones in, 
 
 334 
 Whitman, Royal, 142, 149 
 Whooping cough and rickets, 159,253 
 Wieland, 96 
 Wild animals and rickets, 67, 75, 
 
 409-13 
 Window tax, 303 
 Women, employment of, 12, 424 
 
 Xerodermia in rickets, 209-10, 228 
 Xerophthalmia, 220-1 
 
 Zeviani, 308 
 
 Zoological Gardens, rickets in. See 
 
 Wild animals. 
 Zymotic diseases and rickets, 252-4, 
 
 309 
 
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