METABOLISM IN DISEASES OF BONES AND JOINTS 759 



the apposition of new salts to the bones may not make up for those re- 

 moved, and the newly laid down bones becomes poor in lime salts. If 

 the deficiency in lime salts is great enough and extensive enough, the 

 bones will become soft and fragile. In other words, in osteomalacia 

 we are dealing with extreme grades of a normal process. 



The reason that castration has been followed .by beneficial results in 

 many cases of puerperal osteomalacia is simple enough. A great many 

 different kinds of treatment besides castration are followed by either tem- 

 porary or permanent cure. Thus, chloral (Petrpne), sulphur baths 

 (Latzko, Weisz), chloroform narcosis (Petrone), and especially phos- 

 phorus (Sternburg(a), Hoxter, Siegert, Bernstein (a.)) have been fol- 

 lowed by good results. The cures following injection of adrenalin have 

 led Bossi to the conclusion that osteomalacia is a disease of the suprarenal 

 glands. Good hygiene alone is very effective. And, as already pointed 

 out, the condition shows a natural tendency to cure, following termination 

 of pregnancy and lactation. On the other hand, all these measures, in- 

 cluding castration, sometimes fail. It is to be noted that the cases of 

 osteomalacia cured by castration are cases of puerperal osteomalacia. No 

 case of non-puerperal osteomalacia permanently cured by castration is on 

 record in the literature. The important feature of castration in making 

 a cure permanent is that, once cured, the cause of a future relapse 1 preg- 

 nancy is made impossible. 



A good example of the beneficial effect of castration is seen in a case 

 reported by Neumann (a). The patient had some symptoms of osteo- 

 malacia during her seventh and eighth pregnancies but recovered. The 

 disease came on again during her ninth pregnancy. The ninth child 

 was born January ninth ; the patient began to show improvement by 

 March first; by April first she was fairly well recovered. Osteomalacia 

 came on again during her tenth pregnancy. At this time Neumann re- 

 moved the uterus land adnexa, and the result was a permanent cure. 



Summary: Puerperal Osteomalacia. To summarize briefly the eti- 

 ology and nature of the process in osteomalacia: Just as the subcutane- 

 ous fatty tissue acts as a store of fat, and the liver glycogen as a store 

 of carbohydrate, so the skeleton acts as a store of calcium salts, to be 

 called on in time of need. During the later months of pregnancy and 

 during lactation, the need for calcium salts is great, greater than the 

 intake in the food, and it becomes necessary to draw upon the calcium 

 supply in the bones. The result is that, the new bony tissue laid down 

 to replace old bone as it disappears is poorer in lime salts than the 

 normal. Ordinarily the quantitative change in the composition of the 

 bones is not great enough to produce symptoms. At the end of gesta- 

 tion and lactation, when the extra need for calcium has ceased, normal 

 bone is again laid down. The calcium content of the bone becomes low 

 enough to induce symptoms of osteomalacia only when, as a consequence 



