Prognosis.—Rickets is not a fatal disease in itself unless the bony change be far advanced, nor even in such a case does death often ensue except as a consequence of some catarrhal complication. As a rule, improvement be gins directly measures are taken to amend the unwholesome conditions in which the patient is living. The dangers of pulmonary catarrh and atelec tasis in a child with great deformity of chest are elsewhere referred to ; and the serious consequences which may result from diarrhoea in an infant reduced to a state of serious weakness by chronic malnutrition need not be insisted upon. Of the nervous complications, laryngismus stridulus is sometimes a cause of sudden death, but reflex convulsions excited by some trifling irritant rarely have any ill results.
Enlargement of the spleen, liver, and lymphatic glands generally is very rare, but if present should excite great anxiety. It is more common to find enlargement of the spleen alone without any affection of other in ternal organs. In rickets, as has been said, the spleen is often the seat of simple hyperplasia. This lesion, as it is an additional cause of aniemia, no doubt introduces into the case a further element of danger, but the danger is dependent more upon the intensity of the rickety process than upon the degree of splenic swelling. If the symptoms of rickets are com paratively mild, and due care be taken to shield the child from catarrhal complications, the presence of a big spleen does not indicate the probabil ity of a fatal termination to the illness.
Age has no influence upon the prognosis of rickets, and when the disease occurs as a sequel of inherited syphilis, it presents no special diffi culties in its treatment.
With regard to the permanence of the unsightly deformities of bone, it is often astonishing to note the improvement which takes place after recovery from rickets in the deformities which seemed the most unlikely to be reduced. Large joints grow smaller, crooked bones become almost straight, and a distorted chest will recover itself in a surprising manner. In some children, however, improvement goes on farther than it does in others, and therefore, while encouraging the parents to believe that there will be considerable improvement, we must not be too sanguine as to the complete disappearance of all disfigurement.
Treatment —In every case of rickets our first care should be not to give cod-liver oil or tonics, but to inquire into the conditions in which the child is living ; to ask about the food he is taking, the quantity allowed for each meal, the frequency with which the meals are repeated, and the degree of cleanliness of the feeding apparatus. We should then turn to the subject of his clothing, the ventilation of his bedroom, and the number of hours he is passing out of doors. The real treatment consists in attention to all these important matters, and not solely in the administration of any par ticular drug. Medicines are uo doubt useful as helps in the treatment,
but their importance is trifling as compared with that of a reformation of the unwholesome conditions under which the failure in nutrition has taken place. The reader is referred to the chapter on the treatment of infantile atrophy for general directions with regard to the feeding and management of young children.
Almost all cases of rickets have been preceded by symptoms of diges tive derangement or bowel complaint, and unless improvement has already begun we often find signs of looseness or intestinal derangement still per sisting. This should at once be remedied. The belly should be kept warm with an ample flannel binder, and the child should take a drop of laudanum to control the undue peristaltic action of the bowels, with a few grains of the bicarbonate of soda to correct acidity, in an aromatic water sweetened with a few drops of spirits of chloroform three times a day. In many cases there is a special difficulty in digesting starch. In almost all instances we find that this variety of food has been given in great excess. The quantity must be therefore considerably reduced, and that taken should be guarded with malt, as iu food. Hoff's extract of malt, in doses of two or three teaspoonfuls three times a day, is of .great service in these cases. If the child be no longer an infant, the diet should be arranged as directed under the heading of " Chronic Diarrhoea " (see page 640).
Plenty of fresh air should be insisted upon. The child, warmly clad, should be sent out in all suitable weathers, and if care be taken that his feet are well warmed before he leaves the house, there will be little danger of his catching cold. If the patient have reached the age of eight or ten months he should be carefully packed with cushions in a perambulator, and in cold weather should always have a hot bottle to his feet while out of doors. The ventilation of his sleeping-room must be attended to. A. small fire in the winter, and a lamp placed in the fender during the stun mer months, will insure a sufficient circulation of air through the bed chamber. Both the patient and his immediate surroundings must be kept scrupulously clean. Every morning the whole body should receive a thor ough washing with soap and water, and be well sponged in the evening before the child is put into his cot. On account of the copious perspira tions his body linen, as well as that belonging to his cot, soon becomes saturated with moisture. His underclothing should therefore be changed as often as is necessary. Every morning, too, his mattress and bed-cov erings must be thoroughly exposed to the air. The sheets also should be changed frequently and be carefully aired.