have been rickety, especial attention must be paid to the diet and general management of the new-born babe. The mother may still suckle the infant during the first month, but after that time she should give up all idea of rearing the child from her own breast, and a wet-nurse should be provided. If from circumstances this is impossible, the breast-milk must be limited to two meals a day; the child being fed at other times upon ass's milk, or cow's milk and lime-water, as recommended in an earlier part of this volume. At the same time, all the other precautions so essential to perfect heath must be carefully observed. Perfect cleanliness, warm clothing, fresh air, well-ventilated rooms, sunlight, are all indispensable. If the parents reside in a cold, damp situation, the child should, if possible, be removed to a neighbourhood where the quality of the air is drier and more bracing. For full particulars as to the best method of preventing the occurrence of rickets the reader is referred to the section on the treatment of simple atrophy. If the management of the child is conducted according to the rules there laid down, rickets cannot occur, for the causes which produce the disease will not be in operation.

Treatment. In the treatment of rickets, our first care must be to endeavour to restore healthy nutrition. This can only be done by attention to diet and to general hygiene, taking care at the same time to correct any disordered condition of the alimentary canal which may be present to interfere with the proper digestion and assimilation of the food supplied. This is indispensable as a first step, for to give tonics while the causes which have produced the disease, and sustain it, continue in operation, is a course which cannot possibly be attended with any good result.

The diet of the child must be regulated to suit the degree of debility to which he may be reduced, remembering that the greater his weakness, the more nearly does his digestive power resemble in degree that of a new-born infant. Full

directions about diet have already been given in a former chapter (see Treatment of Simple Atrophy), and need not here be repeated. The stomach and bowels must also be attended to according to the rules laid down in the same section.

Plenty of fresh air is indispensable to the successful treatment of rickets. The child should be taken out regularly into the open air, and as he gets gradually stronger should pass more and more of his time out of doors. The quality of the air is of much importance, and sea-side places where the air is dry and bracing, as Lowestoft, Scarborough, Brighton, and Eastbourne, are especially to be recommended.

Great attention must be paid to the clothing. The belly should be kept covered with a flannel bandage,* and the child should be dressed from head to foot in flannel or merino.

The whole body

Great cleanliness must be observed. should be well washed every morning with soap and warm water, and be sponged every evening with warm water; and as he gets stronger, warm or tepid sponging with salt water may be used to the back and loins. The bed and bedding should be removed from the room every morning, and be freely exposed to the air; the sheets must be changed frequently and must be carefully aired. The ventilation of the nurseries must be attended to, and at night a lamp placed in the chimney is useful to promote a free current of air.

The influence of the preceding measures is usually most marked, and it is at this time that tonic medicines are so valuable. They ought not, however, to be given until, by suitable treatment,† the motions have become healthy and the tongue clean.

Iron is one of the most important medicines we have at

* The abdominal bandage has another use in retarding the too rapid descent of the diaphragm. This, when the bones are much softened, affords great relief.

+ See treatment of Simple Atrophy, p. 42, et seq.

INTERNAL REMEDIES.

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our disposal. A good form for its administration is the following:

B. Liq. ferri pernitratis;

Acidi nitrici diluti, āā 3ss;

Syrupi zingiberis, 3j;

Infusi calumbæ, ad 3iij. M. Zij ter die.

If the debility is very great, the ammonio-citrate may be given with sal volatile

R. Ferri ammonio-citratis, gr. xij;

Spirit. ammonio-aromat.,

Æther. chlorici, āā 3ss;

Infusi calumbæ, ad 3iij. M. Zij ter die.

or the tincture of the sesquichloride may be combined with dilute hydrochloric acid and chloric æther in the same infusion. Other preparations of iron are recommended, as the syrup of the iodide, the syrup of the phosphate, and reduced iron. The latter from its small bulk is very convenient, and may be given in doses of half a grain three times a day.

Chalybeate waters, such as those of Tunbridge Wells, are also of service.

Quinine is very useful. Sir William Jenner* recommends half a grain of the alkaloid to be given with one or two drops of dilute sulphuric acid, in a teaspoonful or two of steel wine. The double citrate of quinine and iron is a good form; three or four grains may be dissolved in glycerine, and given three times a day.

Cod's liver oil is an important remedy. It should not however, be given in too large doses. Ten to twenty drops may at first be poured into each dose of the mixture, and the quantity can be gradually increased to a teaspoonful. During its administration the stools should be examined.

* Medical Times and Gazette, May 12, 1860, p. 467.

from time to time. Any smell in them of the oil is a sign that more is being given than can be digested, and the quantity must therefore be reduced.

Tannin is recommended by Dr. Alison. It may be given in doses of from half a grain to a grain, two or three times a day, in a little dilute citric acid. I have seen very marked improvement follow the use of this drug.

Nux vomica has been advocated by some authors, but on account of the tendency to convulsions so often present in this disease, it must be given with very great caution. It is well to postpone its use until some improvement has already taken place, and the evolution of the teeth has recommenced. It will then be a useful addition to the other medicines.

There is little to be done in the way of special treatment of the bone deformities. Splints applied to the limbs, as supports, do more harm than good, The child should be prevented as much as possible from walking until reconsolidation of the bones has sufficiently advanced. Careful watching, however, is required to prevent his getting upon his feet, for as his strength improves his delight in his newlyacquired powers is prodigious, and he seems anxious by incessant activity to make up for his previously enforced quiet. Sir W. Jenner has recommended that splints which project below the feet should be applied to the legs. These, if properly arranged, effectually prevent his walking.

When the tenderness has subsided, the spine, and back generally, are much strengthened by careful shampooing. Each morning, after his bath, the child should be laid upon his face on the bed, and the whole back should be well and firmly rubbed with the open hand from the neck to the buttocks. The frictions should be continued for about ten minutes. In the evening the same process may be repeated before the child is put to bed.

In cases where the ligaments of the joints are very weak and relaxed, a carefully applied elastic bandage affords the best support.

TREATMENT OF CATARRH.

127

Treatment of the complications. The first symptoms of catarrh should always be attended to at once, for there is no complication which is so dangerous to rickety children.

The whole chest should be immediately covered with a hot linseed-meal poultice frequently renewed, and the following mixture should be ordered :

B. Potas. iodidi, gr. v;

Potas. nitratis, 3j;

Liq. ammon. acetatis, 3iij;

Syrupi simplicis, 3j;

Aq. cinnamomi, ad 3iij. M. 3ij quartâ quâque horâ.

The object is to produce as rapidly as possible free secretion from the bronchial tubes, for the tough mucus which is first secreted lines the walls of the air-tubes, greatly diminishing their calibre, and also is apt to form plugs which, driven farther and farther into the tubes, act as valves, permitting egress, but forbidding ingress of the air. This is, as has already been explained, the cause of the collapse so often found after death occupying the posterior and inferior parts of the lung. The thinner the secretion, the smaller the liability to the formation of these plugs, and therefore the less the danger of collapse.

When the cough has become quite loose, a little ipecacuanha wine, with a few drops of sal volatile, may be added to the mixture, and oxymel of squill may be substituted for the simple syrup.

If the debility is very great, a little wine or a few drops of pale brandy can be given every few hours while the mixture is being taken, but no stimulating expectorants should be prescribed until the secretion is copious.

If there is much rattling of mucus in the chest during respiration, a teaspoonful of vinum ipecacuanhæ may be given at once, and be repeated every ten minutes until vomiting is produced. An emetic, by its mechanical action, helps to clear the tubes of mucus.