RICKETS. (Rachitis.) DEFINITION.-A constitutional disease of early childhood, characterized chiefly by defective nutrition of the osseous structures. ETIOLOGY.-Rickets is rarely congenital; it usually develops between the first and second years. Poverty, artificial feeding, and bad hygienic conditions are the predisposing causes. PATHOLOGY.-The most marked changes are observed in the long bones and ribs. The cartilaginous lamina between the epiphysis and the shaft are considerably thickened, and are spongy and irregular in outline; microscopic examination reveals an excessive proliferation of the cartilage-cells with scanty calcification. The periosteum is thickened and highly vascular, and when stripped off soft porous bone is exposed. The bones are soft, being extremely deficient in lime-salts; when ossification finally results the bones become heavy, large, and irregular in outline; these changes correspond to the clinical phenomena-bow-legs, knock-knees, spinal curvature, pigeonbreast, and square cranium. The liver and spleen are often considerably enlarged. SYMPTOMS.-The early symptoms are: Restlessness and slight fever at night; free perspiration about the head; diffuse soreness and tenderness of the body; pallor; slight diarrhoea; enlargement of the liver and spleen; delayed dentition and the eruption of badly-formed teeth. Skeletal Phenomena.-The head is large and more or less square in outline; careful palpation may detect soft areas. The sides of the thorax are flattened; the sternum is prominent; nodules can be felt at the sternal ends of the ribs― "rachitic rosary"; there may be a distinct transverse groove at the level of the ensiform cartilage; the spinal column is frequently curved antero-posteriorly or laterally; the long bones are curved and prominent at their extremities. COMPLICATIONS.-Green-stick fractures, convulsions, laryngismus stridulus, paresis of the extremities, and acute pulmo nary diseases. In women the rachitic pelvis may seriously complicate labor. PROGNOSIS.-Rachitis does not kill directly, but death is not uncommon from intercurrent disease. Under good hygienic conditions recovery, with more or less deformity, generally follows. TREATMENT. The general nutrition must be improved by placing the child under the best hygienic conditions. Eggs, pure milk, malt, and broths should be recommended. Codliver oil is a valuable nutrient tonic. Iron is indicated for the anæmia. The lack of calcareous material in the bones should be supplied by the administration of phosphorus and lime-salts. R Syr. ferri iodid., f3iss; Mist. ol. morrhuæ et Lactophos. calcis, q. s. ad f3iij.-M. (STARR.) Sig. From one-half to a teaspoonful three times a day. R Elixir. phosphori, fiiiss; Ol. morrhuæ, fzij; Ol. sassafras, gtt. xv; Sig. One to two teaspoonfuls three times a day. LITHEMIA. (Lithic-acid Diathesis, Uric-acid Diathesis, Latent Gout.) DEFINITION.-A constitutional disease dependent upon malassimilation of nitrogenous products and the formation of uric acid and allied substances instead of urea, and characterized by an excess of uric acid in the urine, and varied digestive, circulatory, and nervous phenomena. ETIOLOGY.-Gout with an acute arthritic expression is uncommon in America, but latent gout, or lithæmia, is extremely common. Impaired digestion, insufficient exercise, mental strain, and over-eating are the usual causes. SYMPTOMS. Gastro-intestinal Phenomena.-The tongue is generally coated and the breath heavy; the appetite is variable, sometimes it is lost, at others it is inordinate; acid eructations, "heartburn," and flatulence are frequent gastric symptoms; the bowels are usually constipated. Urinary Phenomena.-The urine is scanty, high-colored, of high specific gravity (1025-1035), and on standing throws down an abundant brick-dust sediment. The solids render the urine irritating, so that dull aching in the loins and burning in the penis after micturition are common symptoms. A trace of sugar is sometimes detected on chemical examination. The urine often stains the clothes red. Circulatory Phenomena.-High arterial tension, accentua tion of the aortic second sound, and a tendency to atheroma. Nervous Phenomena.-Headache, vertigo, disturbed sleep, tinnitus aurium, depression of spirits, failure of memory, loss of energy, irritability, and neuralgic pain in various parts of the body. SEQUELE. Arterial degeneration, interstitial nephritis, hepatic cirrhosis, gastritis, renal or vesical calculi. DIAGNOSIS. This rests on the general symptoms and the analysis of the urine. PROGNOSIS. Favorable under prolonged and judicious treatment. TREATMENT.-Special attention must be given to the diet. It is a mistake to cut off all nitrogenous foods, for often the chief difficulty is in digesting the starches and sugars. Light meats, green vegetables, eggs, and oysters are admissible. The use of fats, heavy meats, sweets, starches, and alcoholic beverages must be restricted. Next to diet, regular exercise is the most important therapeutic measure; the patient must eat less or burn up more material, and the chief stimulant of tissue-metabolism is exercise. A change of scene may effect brilliant results. Frequent bathing with salt water followed by friction is a valuable adjunct. When the gastric digestion is weak, mineral acids, strychnine, and pepsin are useful remedies. The salts of potassium and lithium are solvents of uric acid; citrate of lithium (gr. xx), benzoate of lithium (gr. v), or citrate of potassium (gr. xx), may be given, well diluted, two hours after meals. Mineral-waters containing these salts may be recommended. The bowels should be kept regular by some simple laxative. DIABETES. (Diabetes Mellitus.) DEFINITION.-A nutritional disease, characterized by the persistent presence of sugar in the urine, polyuria, and loss of flesh and strength. ETIOLOGY.-Heredity, adult life, male sex, the Hebrew race, prolonged mental anxiety, and dietetic errors are predisposing causes. It rarely follows injury of the brain or cord. PATHOLOGY.-The lesions found after death have been so varied that the condition which is really responsible for diabetes is still undetermined. Puncture of the floor of the fourth ventricle will produce glycosuria, but the cases are rare in which lesions of this region have been found after death. In a notable number of cases the pancreas is the seat of cirrhosis and of fatty degeneration, but the relation of this condition to diabetes is still unknown. The liver is frequently enlarged and the seat of degeneration changes. The kidneys are enlarged and often reveal evidences of parenchymatous inflammation. According to one view, diabetes has its origin in the sympathetic nervous system, and results from a vaso-motor dilatation of the hepatic vessels causing a disturbance of the glycogenic function of the liver and the discharge of glucose in the urine. According to another theory, diabetes results from a functional or organic disease of those organs, particularly the pancreas and liver, which are engaged in the assimilation of starches and sugars. It SYMPTOMS. Urinary Phenomena.-The urine is increased in quantity, the amount varying from three or four pints to as many gallons; its color is pale; its specific gravity ranges from 1015 to 1050; it has a sweetish taste and an aromatic odor. In summer it attracts flies and rapidly ferments. may leave a whitish residue on the clothes. The percentage of glucose varies from a half per cent. to ten per cent.; the total amount excreted in twenty-four hours varies from a few ounces to a pound or more. General Phenomena.-There is loss of flesh and strength; the temperature is normal or subnormal; the appetite is often inordinate, and the thirst unquenchable; the tongue is often fissured and beefy-red; the bowels are usually constipated. The muscles are sometimes the seat of painful cramps. Cutaneous Phenomena.-The skin is harsh and dry, and frequently the seat of intense itching. Pruritus is especially observed at the genitalia, and this may be the first subjective symptom. Nervous Phenomena.- Headache, depression of spirits, diminished or lost patellar reflexes, impaired sexual power, dimness of vision, and neuralgia. The duration varies from a few weeks in the acute form to many years in the chronic form. COMPLICATIONS.- Pulmonary tuberculosis, pneumonia, gangrene of the lung; defective vision from soft cataract, retinitis or atrophy of the optic nerve; cutaneous lesions, as boils, eczema, carbuncles, and gangrene; nephritis; neuritis and diabetic coma, or acetonamia. This last condition is characterized by epigastric pain, dyspnoea, a fruity odor of the breath, headache, delirium, stupor, and coma; it probably results from the presence of diacetic and oxybutyric acids in the blood. DIAGNOSIS.-Care must be taken to distinguish simple glycosuria from diabetes. The former is recognized by being transient, and unassociated with the constitutional symptoms of diabetes. Pruritus and apparently causeless loss of flesh and strength should lead to a suspicion of diabetes. PROGNOSIS.-The younger the patient, the stronger the hereditary tendency, the larger the amount of sugar excreted, the less the glycosuria can be controlled by diet alone, the graver the prognosis. On the other hand, when it occurs after middle life in association with a gouty diathesis, and the glycosuria is not pronounced, the prognosis for a long duration is comparatively favorable. Absolute cure is rarely attainable. TREATMENT. Dietetic Treatment.-Sugars and starches must be restricted. Since the patient's appetite is often inordinate, it is necessary to regulate the quantity and character of those foods which are recognized as admissible. The following foods may be included in the dietary : |