(c) Other Organs.—A very small number of cases of rachitis present a generally excellent condition of nutrition and a rosy clear complexion. This is especially true in breast-fed children that are only slightly rachitic. The majority of children, although they may have been thriv ing before the beginning of the disease cease to gain in weight at its on set, and their body weight then remains more or less below the normal throughout. the course of the affection. Coincidentally the skin becomes pale and flabby and not infrequently assumes a dirty grayish yellow cachectic hue. The examination of the blood has so far given no characteristic results. Elevations of temperature which are observed in rachitis are always seen at the onset of complications.
The mental development is usually not retarded, except. in very severe cases in which the general condition is much depressed, and also in those children who by being unable to run about and play are pre vented from learning from other children. The typical disposition of rachitic children, although it is by no means marked in all cases, is one of irritable ill-temper. In protracted cases with bone pains the children finally greet every one coming near them with piercing cries; moderate eases usually show evidence of pain only when handled.
The muscles, especially of the lower extremities, may become extra ordinarily atrophied in those severe cases in which the children for a long time shun all movement, but the normal electrical excitability always remains. In consequence of the fact that the thoracic muscles are involved in the general muscular weakness the respirations are mainly diaphragmatic. Continued rapid breathing, frequently with dilatation of the nostrils occurs in all cases of extreme thoracic rachitis, although no complication may be present in the lungs or bronchi. Even with normal breathing every inspiration retracts the already flattened or even concave lateral chest walls.
The percussion note is deep and loud over the concave areas; over the prominent parts of the chest higher and shorter. With considerable thickening of the shoulder blades one can find almost absolute flatness in the supraspinous fossi. The area of cardiac dulness may be increased in marked deformity of the chest even without cardiac hypertrophy and the heart shock can be felt beyond the usual boundaries. The respiratory murmur, provided no pulmonary complications exist, is loudest where the percussion note is fullest. In rachitis auscultation is of far more value than percussion for the establishment. of a diagnosis
of pulmonary disease. In doubtful cases it is always advisable to form one's final opinion only after many very careful examinations. The kyphoscoliotic bowing of the vertebral column causes further displace ment of the organs and consequently leads to further errors in the usual topographical diagnosis. With a severe thoracic rachitis the pulse is usually quickened.
The appetite is frequently very good, particularly for sweet and starchy foods. The abdomen is almost always markedly distended with gas and therefore soft and not sensitive to pressure. The condition of the bowels is not at all characteristic. In many cases constipation ex ists and often the feces show a striking lack of the normal pigments. The liver may be depressed by marked thoracic deformity and may, upon superficial examination, appear to he enlarged although in reality it is only dislocated downward; with severe rachitis occurring in anaemic children in poor condition it is often truly hypertrophied. A marked enlargement of the spleen is rather rare, and only occurs when a high grade anfemia exists. In many of these cases one has to deal with a complicating hereditary syphilis. The swelling of the lymph-nodes, which is frequently noted, has nothing to do with rachitis per se but is always an evidence of complications.
Time of Onset, Duration and positive case of con genital rachitis has as yet not been observed. The so-called foetal rachitis has no connection with true rachitis. In the great majority of cases the first clinical symptoms in the bones are noted only after the third month, as a rule even in the second half year. After the beginning of the second year the number of recent cases diminishes, and the dis ease only exceptionally develops after the end of the second year.
It usually lasts for several months; often more than a year, some times more than two years. An acute form of rachitis is not recognized. Very frequently in an individual case certain of the very numerous clinical symptoms are absent, and at any stage of the disease its develop ment may cease; especially is this true of craniotabes which often heals without the development of any further rachitic symptoms. The first evidence of a beginning recovery is a lessening of the general symptoms. In very severe and prolonged cases the children may remain weakly for at least a year after the final cessation of the rachitic process.