During the progress of the bone-changes which have been described, the general symptoms continue and become more severe. The head per spirations are profuse ; the child can hardly be kept covered in his bed, but whether it be night or clay pushes off the bed-clothes and exposes hip naked limbs to the air. In bad cases his tenderness and dislike to move ment are extreme. So long as he is left alone he is patient and still, but when approached or noticed he at once becomes fretful and apprehensive of disturbance. He will sit for hours together, heedless of his toys, crouched up in his cot ; his legs doubled beneath him, his spine bowed, and his head thrown back ; supporting his body upon his hands placed be fore him on the bed. On account of the softened ribs and his consequent difficulty in expanding the lungs, his breathing is rapid, and his whole at tention seems concentrated upon the efficient discharge of this function. His appetite varies. Sometimes it is poor, but more often it is good and may be ravenous, If attention has not been paid to his diet, and the child continues to pass large quantities of pale, putty-like matter, he will usually swallow almost anything that is given to him. Sickness is not common, and severe diarrhea is only occasionally met with ; but moderate attacks of purging are frequently -seen, the stools being green, slimy, and offensive.
The belly in rickety children is always large, even in cases where no dis ease of the liver or spleen can be detected. The swelling is principally due to feebleness of the muscular walls, allowing of accumulation of flatus, and to the shallowness of the pelvis, which throws all the abdominal viscera above the level of the pelvic brim. If the spleen is very large it may cause a special swelling on the left side of the belly, sometimes reaching below the umbilicus. It may be remarked here that in cases where the liver and spleen can be felt below the level of the ribs we must not at once conclude that their size is abnormal. The organs may be merely pushed down by the depression of the diaphragm and diminished capacity of the thorax. Therefore, after ascertaining the position of the lower edge the upper limit of the organs should be estimated by careful percussion. In addition to enlargement of the liver and spleen the superficial lymphatic glands are sometimes swollen, and can be distinctly felt larger than natural in the asillae and groins.
Rickets is not a cause of pyrexia. If the temperature rise above the normal level a complication may be at once suspected. If fever occur during the stage of improvement it often announces the return of denti tion, and shows that a tooth is pressing through the gum. The degree of wasting varies. If the disease be mild the child, although pale, is often exceptionally plump from over-nourishment of the subcutaneous fat ; but unless recovery take place shortly the limbs quickly begin to feel soft, and soon the child can be seen to be evidently wasting. The complexion is always pale, the lower eyelid is frequently discoloured, and the borders of the mouth have a bluish tint. If great enlargement of spleen be pres ent the tint of the face becomes peculiarly bloodless and the mucous membranes are very pale. Rickety children are backward in every way, both in mind and body. Their . intellect seems to grow as slowly as their bones. On account of their inability to join in ordinary childish games they are much in the society of older persons, and therefore acquire an unchildish way of expressing themselves ; but they talk very late and are chill at picking up new words and phrases.
The progress of the disease is slow, and unless the insanitary condi tions which have led to it be removed, it goes on from bad to worse. These children often die from some catarrhal complication. A bad diaaThcea is very dangerous on account of their general weakness, and a compara tively mild pulmonary catarrh may prove fatal through the softening of the ribs. Death rarely takes place from the intensity of the general dis ease. When improvement begins under judicious treatment, the general tenderness is usually the first symptom to subside. The child is less fret ful when noticed and takes more interest in what passes around his bed.
At the same time the softening of the bones diminishes, and as the ribs regain their firmness the marked improvement in breathing which results from the greater rigidity of the chest-wall cannot escape notice. Teething also begins again ; the wasting ceases ; the belly is less distended ; the sweats diminish and all the symptoms undergo great improvement. These children often become very sturdy and strong, but usually remain short in stature even when their full growth has been attained.
A form of the disease has been described which has been called "acutt, rickets." In this variety the articular ends of the long bones undergo rapid enlargement and become tender on pressure. Secondary cylindrical swellings are also seen about the limbs. The temperature is high. It seems probable, from the investigations of Drs. Cheadle and Barlow, that these cases are instances of scurvy grafted on to rickets. They are referred to more fully in the chapter treating of the former disease.
Complications.—It is not often that a case of rickets remains uncompli cated by some intercurrent complaint. The subject of a pronounced form of rickets has but little resisting power, and is readily affected by any kind of injurious influence. But he is in addition peculiarly liable to certain forms of derangement on account of the special tendencies of this phase of mal-nutrition. The sensitiveness to chills manifested by a rickety child has been already remarked upon. This proneness to catarrh may be the consequence of the profuse and ready action of the sweat-glands, and it is no doubt encouraged by the child's practice, when his perspirations begin, of throwing off the coverings of his bed. The various forms of catarrh are therefore especially liable to occur, and pulmonary and intestinal catarrhs are the most frequent of these derangements. Few rickety children are without a cough, and this symptom, on account of the unnatural flexibility of their chest-walls, must be always regarded with anxiety. The danger of even a mild pulmonary catarrh in these patients, and the readiness with which this derangement gives rise to collapse of the lung, is referred to elsewhere (see p. 467). To this cause a large proportion of deaths is due. Again, more or less intestinal catarrh is a common derangement in this disease, and after any unusual exposure the looseness of the bowels may pass into a severe attack of purging. Diarrhoea, on account of the great general weakness, is a source of extreme danger, and during the changeable seasons of the year many children are carried off by this com plaint.