Osteomalacia and Foetal Rickets 375

OSTEOMALACIA AND FOETAL RICKETSBy J. PRESTON MAXWELL, M.D., F.R.C.S.

Professor of Obstetrics and Gynecology, Peiping (Peking) Union Medical College.(Read Feb. 20, 1930.)

OSTEOMALACIA is a disease of adult life, practically unknown in thiscountry and rarely diagnosed though it is possible that it is more often

present in a mild form than is usually realised.Recent years have witnessed a great development of our knowledge as

regards Osteomalacia and kindred diseases. The classification of these affec-tions is still in flux, but it seems to be clear that true Osteomalacia is the mani-festation of rickets in an individual whose bones have reached maturity, and isconnected with a shortage of Vitamin D, and in the majority of cases an actualcalcium starvation. Although characterised by osteoporosis, it has to bedistinguished from other diseases causing osteoporosis, such as hyperpara-thyroidism, pseudo-osteomalacia malignum, and in rare instances hyperthy-roidism. It is a matter of doubt whether the so-called physiological Osteo-malacia of pregnancy (Hanau) is not a mild form of Osteomalacia.

One of the principal means of establishing the diagnosis and checking upthe treatment of Osteomalacia is radiology. Let us then consider briefly theaspect of a patient who is sent to a radiologist for his examination and diagnosis.

First, as to the clinical picture: A patient with active Osteomalacia willbe in pain (pain in the back and thighs is often the first sign of the disease), andwill resent any but the most careful handling. Partly on account of this sheis apt to have a resigned, rather melancholy face. She walks with difficulty,the knees slightly bent, the head somewhat forward and the thighs kept closelytogether. There is a marked sinking of the head into the chest in many cases,with a diminution of the standing height. The sternum may be crumpled upand pushed forward, and there may be marked deformity of the limbs. Herintellect is clear, but dull, and cerebration is slow. The bones are often tenderto the touch, and this is specially noticeable in the chest. In a marked case,when a finger is run along one of the ribs, soft tender spots may be discovered.In the maj ority of cases the blood calcium will be reduced to 5-8 milligrams per100 cc. of serum, and the phosphorus to 1-2*5 milligrams per 100 cc. of serum,though these figures are not constant, and normal figures do not excludeOsteomalacia. Tetany may be present.

Second, as to the deformities one is likely to find in these cases. They maybe divided into three classes, those affecting the chest, those affecting the pelvis,and those affecting the long bones, and it is well to remember that you may have

376 / . Preston Maxwell

only one of these to the exclusion of the others, or they may be all combined inone individual.

As to the chest, there are two forms of deformity—a pure kyphosis whichis rare, and a kyphoscoliosis which is common. The osteoporosis in Osteo-malacia tends first to affect the bones at their junction, and the first yielding topressure or pull comes at these spots. There is no actual destruction of bone,but the normal resorption of bone goes on, and the new material laid down isosteoid. Signs such as one gets in caries of the spine are absent, and com-pensatory bone is not as a rule laid down, at least in the active stage. The ribstend to become flattened, producing a modified form of pigeon breast, and ashas been already stated the sternum crumples up, often projecting forward, sothat the distance from the episternal notch to the ensiform cartilage may bereduced to as little as two inches.

As to the pelvis, there are four characteristic deformities. There isyielding at the acetabulum and ilio pubic junction, producing rostration of thepelvis; there is yielding at the ischio pubic junction, resulting in the narrowingof the transischial diameter, and a curious twisted crumpling of the ascendingramus of the ischium and descending ramus of the pubes; the sacral index ismarkedly shortened, its anterior surface becoming much more concave and thecoccyx being carried forward so as almost to block the pelvic outlet; and thecrests of the ilia tend to roll in, so deepening the iliac fossae. The general pictureof the inlet is triradiate, though in many cases which have gone on for some timeit may be irregularly deformed.

As to the long bones: Bending and fractures are the two principaldeformities. The fractures are usually transverse, and may be produced byslight force, and are not as painful as the ordinary traumatic fracture. Theymay be single or multiple, and the femora, the humeri and the ribs and pelvisare the usual places. The bending is as a rule irregular, and some cases seem tohave bending mainly or entirely, and others more fracture than bending.Coxa vara is very common, and in an extreme case the clavicle may be almostbent double.

Rough handling may produce these fractures, so care should be taken inthe shifting of a patient from the stretcher on to the X-ray table.

Are there any X-ray characteristics which may enable one to distinguishone osteoporosis from another? This is a difficult question to answer. My ownimpression is that the well-marked cases can be so distinguished, but that in themilder cases radiology cannot as yet do so. In Osteomalacia the characteristicstriated appearance seen in an osteitis fibrosa is as a rule absent, and is replacedby a trabeculated appearance. The cysts seen in osteitis fibrosa are as a rule

FIG. I.—Skiagram of wrist from newbornchild with antenatal rickets, and infantilescurvy.

Fig. 2.—Skiagram of legs from newbornchild with antenatal rickets and infantilescurvy.

FIG. 3.—Skiagram of wrist from newbornchild with antenatal rickets.

PLATE XVI

FIG. 4.—Skiagram of wrist from the samechild, the mother having been treated forfive weeks with irradiated ergosterol andcod liver oil and the child breast fed only.

Facing page 377

Osteomalacia and Foetal Rickets 2>77

absent in Osteomalacia, though it is possible that the soft spots found in the ribsmay prove to be somewhat of the same nature.

In a well-marked case of Osteomalacia the transparency of the bone maymake the taking of a satisfactory radiogram a matter of great difficulty, and oneof the best signs of progress towards recovery is the increasing density of thebones.

Besides the question of diagnosis and of progress towards calcification,radiology can often give definite aid in the milder cases in pregnant women indetermining the shape and degree of contraction of the pelvis; though often insuch a case one has to be patient, and possibly risk a trial labour, being preparedto intervene at once with Caesarean section should the head of the foetus not bedescending properly.

The question of the foetus is one where the radiologist may be able to givemuch help. It is now known that the foetus does not escape the ill effects ofthe disease. It may not merely be starved of calcium, and suffer from osteo-porosis; but it is now certain that in the severer cases of Osteomalacia the childmay be born, not merely with a tendency to acquire rickets readily, but withantenatal rickets actually present, as in the cases shown you to-night. Herethe mothers had active and prolonged Osteomalacia, and whilst in the case ofthe child which died shortly after birth there is not merely rickets, but Barlow'sdisease (Infantile scurvy) present, the child that lived presents a good pictureof rickets, and the radiological studies have not merely enabled one to diagnosethis, but have shown conclusively that the appropriate treatment for themother may be depended upon to provide the necessary vitamin, and calcium,and phosphorus, for the healing of the child, and it is precisely in cases of thiskind where radiology becomes an invaluable adjunct to treatment.

As to treatment, it is known that the disease is one which yields to asufficient supply of calcium and phosphorus; a sufficient supply of Vitamin D,which can be given in the form of irradiated ergosterol and cod liver oil, thelatter being efficient, but having to be taken in such large doses, that it is muchbetter to give a combination of the two. It is also necessary to get the patientout into the sunshine; or, if possible, supply this by means of ultra-violet light,and see to it that she gets a sufficiency of movement.

In conclusion, it must be noted that although women are spoken of as pro-viding the bulk of cases, it is by no means confined to the female sex. Likeconditions will and do produce the disease in the male. It must also be notedthat although pregnancy and lactation, with their calcium demand, are oftenthe starting point of the disease; it may appear, and often does, in a mild form

378 / . Preston Maxwell

at puberty, or even after the menopause, and must not be ruled out on accountof the age of the patient.

As to the radiograms shown you to-night; I am indebted to Dr. PaulHodges now of the University of Chicago, and to Dr. Hsieh of the Peiping UnionMedical College, both for the skiagrams and for advice as to diagnosis andguidance in treatment.

DISCUSSIONThe CHAIRMAN (Dr. L. A. Rowden) said he had not thought that China was so scientifi-

cally advanced, especially on the radiography side, as Professor Maxwell's paper had shownthat country to be. It was a very important address, and he was sure it contained a lot ofmaterial which was new to most of them.

Dr. A. E. BARCLAY said he intervened chiefly to show one slide. It was difficult to followsuch a speaker as Professor Maxwell, who had shown slides and given a great deal of informationabout a disease which was not met with in this country. But they did have rickets in rats. Inhis slide they saw a series of radiographs of rats; he and his colleagues took these once a week tosee if the rats were developing rickets or not. They gave the rats food devoid of Vitamin D,and in one line on the screen rats so treated were shown to have well-marked rickets, while inthe other line, which dealt with rats which had been given i-ioo,oooth of a milligramme ofVitamin D, there was no sign of the disease. It was surprising to find what a small amount ofVitamin D was sufficient to prevent the disease. He would like to thank Professor Maxwell forhis extremely interesting paper.

Dr. G. B. BUSH expressed his sincere thanks to Professor Maxwell for his interestingpaper. He had himself been particularly interested in the question of irritability of the foetusin the uterus as shown in some of the cases described. A lady of his acquaintance, who wentto him to have her pregnancies X rayed, had complained to him that the child she was at pre-sent carrying had been extremely active. She had been taking calcium fairly regularly. Shealso complained of pains in the thighs. He did not quite know what to advise, but he hadsuggested that she should take cod liver oil. He acted rather empirically in this matter. Thatwas about a month ago, and since then the child had ceased its activity and the pains in thethighs had lessened.

He asked whether it was necessary to take large doses of cod liver oil in these cases, orwhether one or two teaspoonfuls was enough. He usually put the child on cod liver oil to pre-vent bad teeth.

Dr. M. WEINBREN asked Professor Maxwell what the climatic conditions were in thebelt where Osteomalacia was prevalent. Was there a general lack of ultra-violet light incertain periods of the year?

Dr. A. J. H. ILES asked if the Canadian patient mentioned by Professor Maxwell hadbeen living'on a rice diet?

Dr. R. CONNELL asked if there had been any tendency to abortion or miscarriage inpatients suffering form Osteomalacia? He remembered reading an account some time ago ina brochure, sent out by one of the firms recommending cod liver oil and other articles, whichtold of a certain lady in Sweden who began by having healthy children, then had numerousabortions, and after taking cod liver oil had full-time children again. Would the giving ofcod liver oil, which must contain some Vitamin D, have that effect if abortions or miscarriageswere frequent in Osteomalacia in China?

Professor MAXWELL, in reply, said that in marked cases of Osteomalacia large doses ofcod liver oil had to be given, something between i-| and 2 ounces a day at least, but since theyhad the use of irradiated ergosterol, he had found that giving a milligram of that daily with asmall dose of cod liver oil produced better results than by using cod liver oil alone. There wasa question about climatic conditions. A large number of the patients were up in the highlands,

Osteomalacia and Foetal Rickets

and most of the northern part of Shansi was an elevated plateau. But the Shansi people calledOsteomalacia "the lazy disease." The rich did not get it, and neither did the poor who had towork hard in the fields; it was the middle class, the people who were too proud to work, too poorto buy good food, and who kept in the house away from the air and the sunlight, who got thedisease. It was that feature rather than climatic conditions that had to do with it. Therewas enough sun, if the people would get out into it.

The Canadian lady about whom a question was asked, did not have a rice diet, but anordinary diet. Her husband, who was a doctor, had been giving her calcium on the way out. butthis had not prevented the fall of the blood calcium to 8 mgm. per ioo cc. of serum and thecalcium was evidently not being utilised. It was a question of a lack of Vitamin D ratherthan a lack of calcium.

He had not satisfied himself that abortions were more common in the regions whereOsteomalacia was prevalent than they were elsewhere.

The CHAIRMAN again expressed his thanks to Professor Maxwell for his most interestingcommunication, and on his proposition a hearty vote of thanks was passed by acclamation.

BIBLIOGRAPHICAL INDEXZeitschrift fur Physik

May 30, 1930. Versuche an bewasserten Steinsalzkristallen (E. Schmidt and 0. Vaupel).Zu Herrn. G. I. Pokrowskis Arbeiten: "Uber das Wahrscheinlichkeitsgesetz bei demZerfall radioaktiver Stoffe sehr kleiner Konzentration" und "Uber das Herausschleudernvon oc-Teilchen aus Atomkernen radioaktiver Stoffe durch kurzwellige Strahlung"(H. Herszfinkiel and H. Dobrowolska).

June 18, 1930. Zur Spektroskopie der ultraweichen Rontgenstrahlen. I. (M. Siegbahnand T. Magnusson). Fokale Eigenschaften der optischer Beugungsgitter und Einflussder Gitterfehler auf die Messgenauigkeit im ultraweichen Rontgenstrahlen bei Verwendungvon ebenen Gittern (S. Fagerberg). Zugversuche an Gold-Silberkristallen (G. Sachs andJ. Weerts).

Physical ReviewJune 15, 1930. Possible Effects of Nuclear Spin on X-Ray Terms (G. Briet). On the

Reflection of the Ka Line of Carbon from a Glass Mirror (J. Thibaud). MolybdenumL-Series Wave-lengths by Ruled Gratings (J. M. Cork). Independance of X-RayAbsorption on Temperature (J. A. Bearden). Effect of an Electric Field on the X-RayDiffraction Pattern of a Liquid (R. L. McFarlan). Resolving Power of Calcite for X Raysand the Natural Widths of the MoKa Doublet (S. K. Allison and J. H. Williams).Contribution to the Quantum Mechanical Theory of Radioactivity and the Dissociationby Rotation of Diatomic Molecules (0. K. Rice). Concerning the Absorption Method ofinvestigating /J-Particles of High Energy: The Maximum Energy of the Primary j8-Particle of Mesothorium 2 (N. Feather).

Philosophical MagazineJuly, 1930. The Influence of Chemical State on Critical X-Ray Absorption Frequencies

(H. R. Robinson and C. L. Young).

Proceedings of the Royal SocietyJuly I, 1930. Comparative Study of the Excitation of Soft X Rays from Single Crystal

Surfaces and from Poly crystalline Surfaces of Graphite and Aluminium (O. W. Richardsonand U. Andrewes). Excitation of Soft X Rays from Some Polycrystalline Metal Surfaces(0. W. Richardson and S. Ramachandra Rao). Excitation of Soft X Rays from a SingleCrystal Face of Nickel (0. W. Richardson and S. Ramachandra Rao). Total SecondaryElectron Emission from Polycrystalline Nickel (S. Ramachandra Rao). Total SecondaryElectron Emission from a Single Crystal Face of Nickel (S. Ramachandra Rao). TheEmission of Secondary Electrons and the Excitation of Soft X Rays (0. W. Richardson).