On deficiency diseases, with special reference to rickets / by Edward Mellanby.

Mellanby, Edward, Sir, 1884-1955.

Date:: 1924

Catalogue details

Licence: In copyright

Credit: On deficiency diseases, with special reference to rickets / by Edward Mellanby. Source: Wellcome Collection.

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punity, so far as rickets is concerned, if the diet is constituted as described. The- Treatment of Rickets. Rachitic changes improve rapidly on the above diets. Bone calcification and growth are resumed, and can be readily observed by radiographic examination (see Fig. 5). Concurrently with the bone change the clinical condition is transformed : lethargy is replaced by activity, even when the infant is confined to a cot, the flabbiness of the muscles disappears, and with this the protuberant abdomen becomes less prominent. When great bone deformity has been pro¬ duced by rickety changes the restoration to healthy growth will ultimately bring about striking reduction in this deformity, but the process is slow. Figs. 1 (a and n), 2 (c and n) illustrate the reduction in deformity of the legs in cases of genu varum and valgum respectively after the children had been eating the above diets for about six months. No doubt the legs would still further improve and become practically normal if the feeding of the children continued along these lines for a longer period. Fig 3 demonstrates the reduction in size of the abdomen resulting from improved muscular tone following good feeding over the same period. In the case of adult rickets—a disease rarer than it was a few years ago—treatment is not so satisfactory as in the case of children. The bones begin to calcify on giving the diet (Fig. 4), but the limited powers of growth that remain do not afford the same chance of recovering from the bone deformity. In these cases, therefore, the assistance of the surgeon to correct deformity may be more necessary. Another cause of relative failure in the satisfactory treat¬ ment of late rickets is the difficulty of overcoming the tendency to infantilism and delayed general development so often met with in these cases. No doubt in infantile rickets there is the same cessation of all mental and physical development as in the adolescent, but in the former case curative treatment has a longer time and better chance of bringing the patient up to the normal standard than in the case of adolescent rickets. After osteotomy for rachitic deformity it is essential that a diet with strong calcifying influence should be given, otherwise the deformity may be actually increased by the operation. In cases of very bad deformity of the legs in young children it is possible, although I do not advocate the practice, to give a rickets-producing diet, and, while keeping the bones soft, straighten them by wrenching and splinting. Having improved the alignment the bone- hardening diet may then be started. In one case Professor Connell and I treated bad deformitv of the lower limbs in this way and obtained a satisfactory result. Malnutrition and Wasting of Infants. Apart from the treatment of rickets, diets made up along i the lines indicated will often be found to bring about great improvement in other conditions of malnutrition and wasting in infants. I do not put forward these diets as a panacea, more especially in the case of the marasmic child under 3 months of age, but the form of treatment has at least a rational and an experimental basis, and ought therefore to be tried, and, if possible, developed. The solution to the problem of the marasmic infant under 5 or 6 months seems to me to lie with the proper feeding of the mother during pregnancy. Experimentally it is easy, by feeding pregnant bitches on diets defective in the direc¬ tions already discussed in this lecture, to produce litters of puppies which die off one by one in the first few weeks of life, and it is probable that the production of true marasmus in children has often a similar cause. The older methods of feeding children suffering from malnutrition, still widely practised and even recommended by those who do not appreciate modern work on diet, are usually based on the teachings of either Czerny or Finkelstein. Since these methods were advocated before the development of recent views on dietetics, it is perhaps not surprising that sharp conflict exists between the old and the new views. The basis of this conflict has not, however, been previously formulated. Any method of feeding sick children which begins by reducing or completely removing fat-soluble vitamins from the diet must, in my opinion, be wrong. While fat dyspepsia in infants is undoubtedly a reality, although probably greatly exaggerated, it is, after all, only sym¬ ptomatic of a more general disturbance, and ill health cannot be permanently improved by cutting out of the diet what is definitely known to be an essential constituent. Reduction in the fat qua fat is probably of but little importance in the nutrition of children so long as they get sufficient food to eat, but if its vitamin content goes with it, then ultimately further ill health will ensue. Thus if fat is reduced in or removed from the diet it is essential that the concomitant reduction in fat-soluble vitamin should at least be restored by adding small quantities of cod-liver oil or egg yolk. A specific instance of the detrimental results of the older views on infant feeding has been definitely proved by Hess, who found that Ri weiss-milch actually produced acute rickets in children. This fact is not unexpected in view of the results of my animal experiments. It can hardly be hoped that a concoction which produces rickets will prove an ideal diet, even over short periods, for other conditions of malnutrition in children. The conflict between the old and the new views is not confined to the feeding of children, but embraces all dietetic treatment of disease. The following instance, recently brought to my notice by Professor Hall, illustrates this. The patient, a girl of 19, of well-to-do parents, had been first treated for dyspepsia at the age of 9 by having the fats removed from her diet. As her indigestion con¬ tinued vegetables were then excluded, and ultimately she lived on little but bread and other cereals. The develop¬ ment of very bad scurvy associated with late rickets is not surprising in the light of our present knowledge, nor her rapid improvement when her diet was made complete. This is only a gross example of what is probably in a less degree a common result of dietetic treatment, but serves to emphasize that, although our knowledge of dietetics is still limited, we must feed wasting infants and other con¬ ditions of malnutrition by giving diets which experimental evidence has shown to be complete in quality and balanced in quantity. Only diets of this character are compatible with the proper development and functioning of each organ, including the alimentary canal. The results of treating two cases of severe malnutrition by the diets described can be seen in Figs. 6 and 7. Combined Dietetic and Light Treatment. Experimental evidence having shown that one method by which exposure to light works is by stimulating to activity the fat-soluble vitamin supplies of the body, and since the only means of access of this substance is via the food, it would seem desirable, when making use of light therapy m the treatment of disease, that the diet should be con¬ trolled at the same time. This is also borne out by the fact already described that, at least as regards bone calcifi¬ cation, the influence of light can be completely antagonized by a defective diet. Whether exposure to ultra-violet rays enhances the calcifying influence of a very good diet still remains to be proved. I have treated rickets and many other pathological conditions by the combined therapy, but in no case has it been possible as yet to control the results by treating precisely similar cases only by diet or only by exposure to light. Cases of rickets respond well to the com¬ bined diet and light therapy, as can be seen in Fig. 5, where intense stimulation to bone calcification is obvious after three weeks’ treatment, but correct feeding alone also brings about rapid cure of this disease. The diets given are those already described, and the mercury-vapour quartz lamp is used as the source of the ultra-violet radiations. Patients are exposed for intervals gradually increasing from five to thirty minutes back and front daily at a distance of about 5 to 6 feet from the lamp. Care is taken that only a mild degree of skin irritation is ever produced, and, of course, the eyes are protected during exposure either by dark spectacles or by bandaging in the case of infants.