The differentiation may be very difficult if hydrocephalus begins to develop in a rachitic child. Often in such circumstances only the further course of the disease can bring a sure diagnosis.
The sharply localized tuberculous kyphosis which cannot be re duced without the use of force may be in almost all cases very easily differentiated from the like deformity due to rachitis, as the latter al ways involves many vertebrae, in a gentle curve rather than an acute angle, and can be partially or entirely reduced by raising the patient's legs when he lies in a prone position. The congenital "Trichterbrust," or Funnel Chest., differentiates itself from the similar deformity due to rachitis by the tremendous retraction of the inferior end of the sternum.
Rachitic coca vara can simulate congenital dislocation of the hip by the high position of the trochanter major, and by the waddling gait. Other marked rachitis deformities usually point at once to the right diagnosis and in doubtful cases radioscopy throws a deciding light upon the subject.
As for the erosions of the teeth, the Hutchinsonian semilunar defects of the edges and the rounding off of the corners of the upper central incisors, while at the same time these teeth are shortened and di minished in size and are so placed that the cutting edges converge, must always, even in the slight cases, arouse a very strong suspicion of hered itary syphilis. The other forms of erosions so far as they affect. the incisors and the first molars are due to a long standing rachitis.
Frequently such a high grade of atrophy, flaccidity and inactivity of the muscu lature, especially of the lower extremities, is met with, that it is not possible, without other symptoms, to exclude with cer tainty a paralysis due to ante rior poliomyelitis. In such cases an examination of the electri cal reactions of the affected muscle-groups is necessary.
In especially marked ra chi tic met eorism with disten tion of the abdomen the differentiation from tuberculous peritonitis may be very difficult if the child is elsewhere possibly tuberculous; for indistinct dulness may be present in the dependent portions of the abdomen in both diseases, and the bowel movements may present the same greasy consistence, the same striking light color and the same very intense odor. In such cases, especially in the absence of fever, the examination of the urine for the diazo reaction is of value. In other cases the differentiation bet ween the conditions mentioned can be safely made only after long observation.
Prognosis.—The light and medium cases of rachitis all progress to complete recovery provided they remain free from serious complica tions, and fall soon enough into expert hands for treatment. The warmer part of the year is more suitable for recovery from rachitis than the cold. The majority of the severe deformities disappear gradually during childhood; only in very severe cases do. considerable disfigure ments remain throughout life. In the most severe cases rachitic dwarf ing may result. The danger of a persisting scoliosis lies in the fact that static influences may increase the deformity even after the cessation of the active rachitic process. Malformations of the thorax and spine may lead in later years to cardiac insufficiency, and malformations of the pelvis to obstetrical difficulties.
our present knowledge rachitis cannot with surety be prevented; but careful dietetic man.agement is very valuable and the earliest possible antirachitic treatment is very important. The disease seldom takes a severe hold upon breast-fed children who live in dry sunny rooms, who are much in the fresh air and are bathed frequently. With artificially fed children an important point is the pre vention of overfeeding. Children with severe thoracic rachitis should be carefully protected from whooping-cough, measles and influenza. If severe softening of the bones exists, the occurrence of multiple fractures should be guarded against by encasing the limbs in stiff dressings.
best therapeutic agent for rachitis, according to my opinion, is codliver oil with phosphorus. This always acts especially quickly upon the general symptoms and upon the dangerous spasm of the glottis, a feature which shows an extraordinary superiority and one which no other antirachitic remedy shares with it. It is best begun with the close of teaspoonful daily of the usual solution [phosphorus .01 Gm., codliver oil 100 Gm. [phosphorus gr. and codliver oil iiij and gradually increased to teaspoonful twice a day. With this method of exhibition it usually agrees well with the patient. Codliver oil without the phosphorus is also a valuable remedy. One begins by giving a scant teaspoonful increasing the dose gradually to about three teaspoonfuls daily. It is best taken at meal time because it is then acted upon by the richly secreted pancreatic juice at the same time with the other food.