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320ETHE CANADIAN MEDICAL ASSOCIATION JOURNAL

Eetroppect
NOTES ON THE CLINICAL SIGNS OF
INFANTILE RICKETS AS OBSERVED
IN VIENNA*
H. P. WRIGHT, M.D.t
Montreal
All recent clinical investigation has emphasized the difficulty of establishing a standard
for the diagnosis of rickets. Moreover when
signs are definite the stage of the disease is
difficuilt to determine and for this x-ray plates
are almost essential. Cases are frequently seen,
in young infants, where marked clinical stigmata are associated with an x-ray picture showing the bone lesions nearly healed.
In the Vienna experience, which was concerned exclusively with infants under 18
months, craniotabes, beading of the ribs and
cranial bossing proved the most reliable signs
of early rickets.
Craniotabes is by most writers believed to be
a rachitic change. Holt and Howland state
that it occurs in infants under six months of
age; that it is a rachitic manifestation, and depends in no wise upon syphilis. Hess and
Meyer (1922) are of the opinion that on account of the many qualifications with which
it is attended, craniotabes must be regarded as
an unreliable sign of rickets. In young infants
under three months there i, the difficulty, insurmountable in many cases, of differentiating
it from the cranial softening of the new born,
which is not truly rachitic. They consider it
has its greatest significance after six months
of age.
Hughes inclines to the view that craniotabes
is always a sign of rickets and divides this
sign into (1) foetal, and (2) infantile craniotabes. Dalywell and Mackay are of the opinion
that the presence of craniotabes supervening
after birth can in practice be accepted as evidlence of rickets. The possibility of confusion

*Pat III., No. 3, Special Report Series No. 77 of the

Medical Beseaich Council of Great Britain, 1923, by E.J.
Dal,vwell and Helen M. M. MacKay.
tRead before the Osler Reporting Society, Montreal,
Dec., 1923.

with congenital softening is a very real difficulty, but in the experience of these writers
the distribution of the softening is somewhat
different. Congenital delayed ossification, especially in premature babies, was not infrequent, and affected particularly the vertex of
the skull between the anterior and posterior
fontanelles, as well as all sutures. Craniotabes
usually appeared first as a patchy softening
along the occipito-parietal sutures. The vertex
of the skull was not usually involved, but it was
common to find all sutures abnormally pliable.
In the most severe cases seen, the whole
cranial vault was affected and a large part of
it was of ru-bber-like consistency. The distribution was uisually a-symetrical which is another
point of difference from congenital softening;
the opinion is widely held in. Vienna that it is
more extensive on the side on which the infant's head habitually rests.
The acceptance by the writers of craniotabes
as a sign of active rickets is based on the following evidence:(a) The seasonal incidence of craniotabes
corresponded with that of rickets.
(b) The majority of young untreated infants
with craniotabes also developed other signs of
rickets.
(c) Young infants with radiographic evidence of active rickets usually had craniotabes
as well. (Of twenty-four infants under twelve
months with radiographic evidence of rickets,
twenty-one had craniotabes).
(d) Therapeutic test, cleared up quickly
under treatment.
The absence of craniotabes in older children
with active rickets is probably due to an alteration in the rate of growth of different bones;
possibly craniotabes is especially likely to develop in any youmg rachitic infants.
In the experience of these writers craniotabes
was usually the earliest sign of infantile rickets
in Vienna and could sometimes be diagnosed
before three months of age. It is a less subjective sign than minor grades of beading, and
its persistence denotes active rickets. Though
frequently present in infants between nine and

THE CANADIAN MEDICAL ASSOCIATION JOURNAL

thirteen months of age associated with rickets

of moderate severity its absence after nine
months of age is of no diagnostic significance.
Rachitic Rosary, an enlargement of the costoclhrondral junction is an important sign of early
rickets but less easy to determine than craniotabes. A. minor degree of beading was practically iuniversal and in order to determine its
significance histological examination was made
of cases in the post-mortem room. Section of
the ribs showed that histological evidence of
rickets was sometimes present without enlargement of the costo-chondral junctions; that
lesser grades of beading were frequently
rachitic but might be associated with other abnormalities such as osteoporosis, and that the
more marked enlargements were either rachitic
or scorbutic in, origin. The rachitic rosary is
usually developed later than craniotabes. It
was commonly seen in the fifth to the sixth
nonth of life. A rapid rate of enlargement
proved very significant although eventually responding to treatment. Diminution in size was
not manifest for from four to ten weeks by
which time by x-ray calcification could be
shown to be far advanced.
Cranial bossing is not easily diagnosed in infants of mixed races. As an early slight sign
it is not of much value, but when associated
with other early signs it is helpful in early
diagnosis.
Epiphyseal Enlargement-is a later sign than
either craniotahes or the rachitic rosary and is
of little valuie in indicating the onset of the
disease. Radiographic evidence of rickets at
the epiphyses can usually be demonstrated be-

321

fore the development of any enlargement by

clinical examination.
Towards the end of the first year of life some
increase in the size of the wrist and ankle occurs in normal limbs and complicates the diagnosis of rachitic enlargement. When enlarged
epiphyses are present their -significance can only
be interpreted in association with other clinical
signs or radiographic evidence, as the enlargement persists long after the active stage of the
disease is past..
Delayed closing of fontanelles is frequently
m!et with in rickets and is sometimes present in
cases with no signs of rickets and in some
definite cases of rickets the fontanelles closed
at an early age. Thoracic deformity is a secondary defect from mechanical stress, etc. Curvature of long bones is not an early sign.
As regards the signs of rickets other than
the bone lesions, it is a matter of observation
that they vary considerably in individual cases.
Shipley, Park and others have suggested recently that different clinical and histological
pictures of rickets may develop as the ratio of
calcium to phosphorus is varied in the diet.
Rickets has been subdivided into two groups(1) Rickets with low blood calcium and normal
phosphorus; (2) Rickets with low blood phosphorus and normal calcium.
Such an explanation might explain the high
incidence of tetany (low calcium) in Glasgow
where 40%c of cases of rickets showed tetany,
while in Vienna tetany as a complication was
comparatively rare. Pallor, sweating of head,
enlargement of spleen and anaemia were not
noted to be more marked than in non-rachitic
infants.

Nasal Operations in Bronchial Asthma.-In of no benefit. In most cases the improvement

analyzing ninety-four consecutive cases of that resulted, even as concerned the local conbronchial asthma that have been under his personal observation for a number of years, Morris
H. Kahn, New York, had the opportunity to
notice the effects of nose and throat operations
on thirty-three of these. In fifteen cases, relief of nasal obstruction was obtained. IRn two
of these, atrophic rhinitis resulted as a serious
sequel. In the other cases, the operation was

dition, was only temporary and incomplete;;

and in many cases the local condition for which
the operation was performed, recurred. Even
in patients in whom there was definite relief
o:f obstruietion and in whom nasal breathing
became free, the asthma was not influenced.Jotur. Am. Med. Ass., Feb. 16, 1924.