Vitamin D and osteoporosis. Manifestations of softening of bone tissue

it occurs at the age of 30-40 (Fig. 1); in Skrobansky’s statistics, out of 50 cases, only one noted a woman under 20 years old]. In earlier (childhood and youth) and old age, O. is extremely rare. In men, isolated cases are described (for example, in Litzmann's statistics, out of 131 cases, it was noted only in 11 cases; in Tikanadze, out of 50 cases, it was noted once).

Pregnancy and lactation also play an important role. Thus, observations show that O. predominantly affects women who have given birth, and develops most often during pregnancy or shortly after childbirth, with prolonged feeding; According to some authors, cases of O. in nullipara are as rare as in girls, old women and men (in the latest Russian statistics, the puerperal form occurred 64 times out of 71 cases). Cases of O. are not common during the first pregnancy; on the contrary, the majority believes that women who have undergone repeated births, and that osteomalatics even have increased fertility (the average number of births in osteomalatics according to different authors is from 4.0 to 8.2). Although increased fertility in O. is disputed by some, and in general this issue requires further development, the fact of the influence of the number of pregnancies suffered is undoubted, and the opposite point of view (admittedly, a few authors) is hardly correct, that a large number of pregnancies suffered even as would protect a woman from disease. Apparently, often successive pregnancies, accompanied by prolonged feeding and debilitating the body, can also play a major role in this regard. Therefore, we can say (Guggisberg) that O. is not a cause, but a consequence of numerous births, and the issue of excessive fertility should be comprehensively reconsidered, since statistics relate to more early period, when only emergency cases were subject to observation. The fact of higher frequency with O, noted by Eisenhart. multiple pregnancy(1: 15) did not receive further confirmation, and is not mentioned in Russian statistics (Skrobansky noted it only once in 50 cases). - In addition to pregnancy, the first appearance of O., as well as its course (see below) in some in more rare cases, other biol can also influence. phases of the female body and some diseases of the reproductive system (menstruation, menopause, abnormalities of the ovarian-uterine cycle, uterine bleeding). The previously expressed opinion about the great predisposing influence of syphilis was not confirmed by later data. Among the predisposing factors, constitutional factors are noted. Thus, O. is more often observed in persons with a tendency toward obesity, with dark hair and dark skin. Theories O. The most widespread for some time was the acid theory (Schmidt). The basis for its occurrence was the presence of lactic acid only in the affected areas of bone tissue (as well as observations about the identity of osteomalatic changes in bone with those when exposed to acids). Despite the fact that this theory was subsequently confirmed by new research (for example, the presence of lactic acid in the urine of patients), it was soon refuted, since lactic acid was also found in people who had never had O ., and besides, it was not always in the affected O. bone. From a modern point of view, the acid theory, at least in relation to cases of the predominant puerperal form, can receive a slightly different light thanks to more definitely clarified predisposing factors from both pregnancy itself and all the processes associated with it. Observed during pregnancy physiol. hyperfunction of the whole organism, individual systems and organs and modified metabolism are always on the verge of becoming pathological. This hyperfunction of the body and the observed state of acidosis in almost every pregnancy is accompanied by a number of characteristic symptoms(eg nausea, vomiting, chlo-asma gravidarum, etc.); they can, of course, directly affect bone tissue; the requirements for cut from the fetus are especially increased. In other words, along with other physiological, pregnancy-related changes in individual bodies , the same can be observed in bones. This gives grounds in addition to the stalemate. changes and disorders of bone tissue during pregnancy, talk also about physiol. its changes, that is, about “physiological osteomalacia”. The possibility of such existence is confirmed by the observed wedge, symptoms, as well as the research performed. Thus, microscopic examination revealed changes in the bones, similar to osteomalatic ones, in pregnant women and postpartum women, who did not have any pathologies during their lifetime. manifestations; in a wedge, in practice, pain in the pelvis, in the symphysis pubis, increased sensitivity when pressed, as well as passing physiol, are quite often noted. normal mobility of the joints of the pelvis and its ligamentous apparatus. It is possible to observe in such cases an altered gait, changes in the inclination of the torso and pelvis. Guggisberg believes that, based on available research, both these and deeper changes can be explained by the intrasecretory influence of the placenta; for cases of non-puerperal origin, a similar condition acidosis can be explained by increased ovarian activity. Fowweatber (1927) considers this acidosis as “hungry” and believes that it occurs due to chronic: malnutrition; By the same acidosis, he explains the special tendency of pregnant women to O. The theory of nutrition, devoid of substances necessary for building bones, was also quite widespread. This theory of lime starvation arose due to the established lack of salts in the affected bones, as well as observations of O. in animals (see below). This theory, which aroused great objections based on experiments and on the study of water in the relevant areas (the water contained the usual amount of lime; during the experiments, not changes of an osteomalatic nature were noted, but simple osteoporosis; it was also indicated that a lack of lime cannot be the main point, since its administration does not cure the disease), has recently attracted attention again; many authors believe that for certain forms of O. it cannot be completely rejected. Especially demonstrative in this regard are the experiments of Korenchevsky (1922) with rats; they, on the one hand, confirmed the great influence of vitamins on the metabolism of lime and on their role in the etiology of rickets and O., on the other hand, they allowed us to come to the conclusion that there is no significant difference between rickets and O. and that some of their differences are due to age. Quite a few studies have been devoted to clarifying the question of whether O. some kind of microbe. At first, on the basis of its endemic distribution, some (Kehrer) equated it with hron. infections, and subsequently its supposedly specific pathogens were even discovered, but not confirmed by further research. Infectious theory ch. arr. shared by the Italian school. At this time, this theory has been abandoned by almost everyone, but the increase in temperature sometimes observed with O. and the sudden onset of the disease with fever can be easily explained not by infection, as some believe (Hutchison, Patel), but by the same reasons, which sometimes cause an increase in temperature in other pregnancy disorders. Endocrine theories. The greatest development in the study of O.'s pathogenesis in recent decades has been the intrasecretory glands, especially those of them that take one or another part in calcareous metabolism. Originally put forward by Fehling (1887) the so-called. The ovarian theory has been the most widespread since its inception. In the form proposed by the author, it is now almost no longer accepted by anyone (according to Fehling, O. is a trophoneurosis caused by the fact that irritation emanating from the ovaries is reflexively transmitted by the sympathetic nerve to the vasodilators of the bones, resulting in their hyperemia and resorption). This theory was soon criticized. So, from the very beginning, observations with ovarian transplantation showed that the issue is not a reflex irritation and nervous influence, but the entry into the blood of some substances produced by the ovary. Although the opinion about the exceptional significance of increased ovarian activity (hyperovaria) persisted almost until very recently, it could not but cause criticism thanks to the new published wedge observations. So, along with a certain percentage of cases, in which castration did not provide any therapy. effect, cases of O. (though occurring much less frequently) in the menopause, in old women and, finally, osteomalacia virginalis could not fail to attract attention. The data and microscope studies were also contradictory (see below). Because of this, it is more correct to adhere to the view that the ovary really plays a big role in the occurrence of O., but besides it, other endocrine glands are also involved in the process and that, given the insufficiency of our knowledge about the ovarian hormone, it is better to consider the changes occurring from the point of view of ovarian dysfunction. Gistol. Studies of removed ovaries also do not yet allow us to definitively say that with O. Indeed, hyperovaria is always present, and in addition, not in every case a homogeneous characteristic picture is stated. Thus, atrophic processes, a decrease in the number of follicles, degeneration of the vascular wall, strong development interstitial gland, increased number of atretic follicles with strong proliferation of thecae internae, pronounced hyaline degeneration of the vessel walls, sharp proliferation of thecae internae elements with slight atrophy of the follicle, a large number of Call-Expeg's corpuscles various stages development, hypersecretion of the follicular apparatus, increased development of follicular atresia (Kushnir, Selitsky), etc. There is also opposite data. For example, some authors could not find an increase in the interstitial gland during O., while others, on the contrary, observed its strong development during normal pregnancy, as a result of which it was difficult to put its development in a causal connection with O., especially since it did not always occur (in addition, in general, the significance of the interstitial gland as an endocrine organ is still controversial). A number of researchers have indications that there is nothing characteristic in the changes found, that they also occur in physiol. conditions and that when taking them into account, one must also take into account the age of the patients. In view of all of the above regarding the phenomena of hyperovaria, as well as in view of cases in which reverse changes were observed (for example, Curschmann with ovarian aplasia) or where other endocrine glands may be predominant, it is better to interpret O. with a more acceptable for all cases of point of view, namely from the point of view of ovarian dysfunction.The view of the connection with O. and the parathyroid glands, first expressed by Erdheim and then confirmed in experiments with rats, seems to be sufficiently justified. These experiments indicate the increased activity of epithelial bodies during O. and their great influence on calcareous metabolism. Their increase and hyperplasia are noted. It was also indicated that they participate and even play a leading role in O. thyroid gland(Hoenicke), but the question of whether there is hyper- or hypothyroidism here and whether the observed changes are primary or secondary in nature has not yet been resolved; Apparently for now it is more acceptable to talk about secondary origin them and consider them one of the manifestations of pluriglandular osteomalatic syndrome. Predominant importance in O.’s pathogenesis was also given to other endocrine glands—the adrenal glands, the cerebral appendage, and the thymus gland, but not in relation to them either. such data were obtained, on the basis of which it would be possible to associate the disease with damage to any one gland. So eg. The adrenal theory proposed by Bossi, who believed that the root cause of O. was decreased activity of the adrenal glands (in experiments with partial or complete removal of them in the bones, changes similar to osteomalatic ones occurred), was not fully accepted. Studies by other authors have shown that there is indeed a reduced function of the entire chromaffin system (this is confirmed, among other things, by the fact that osteomalyats are less sensitive to adrenaline and that they do not have adrenal glycosuria), but this is due to the inhibitory ovarian secretory effect, which disrupts existing relationships between the chromaffin system and other glands that regulate lime metabolism and bone growth. (Varaldo, injecting animals with adrenaline, found that under the influence of injections the ovary increases in volume and degenerative changes occur in it.) The pituitary theory also found few supporters, and few shared the opinion about the greater participation of the thymus gland (this theory was based on a decrease in the lime content in bones after removal of the thymus gland and the similarity of bone changes in thymectomized young dogs with O., etc.). The entire sum of the data obtained regarding the intrasecretory glands allows us to see in the osteomalatic process not an isolated lesion of any one gland, but a violation of the chemical. correlations throughout the endocrine system during pregnancy, in all likelihood also with the participation of the new placenta gland, which plays a large role in metabolism. Classifications of O. Naturally, with the beginning of the scientific study of O., a desire appeared to classify the observed cases of it, but both before and now, in view of the unclear etiology, none of the classifications can be considered satisfactory. Just as the original classification of Kilian (1857), which distinguished O. according to the changes occurring (O. fragilis, S. fracturosa, characterized by fragility of bones, and O. segea, with waxy flexibility of bones), seemed incorrect, so the subsequent ones are unsatisfactory. and modern classifications, based on the etiological moment, wedge. symptoms or severity of the disease. Litsmav? (1861) distinguished 4 forms: 1) rheumatic, 2) syphilitic, 3) senile and 4) nervous; at this time, Zondek divides O. into * 1) puerperal (strongly predominant), 2) rheumatic-marantic senile, 3) youthful and 4) hungry. Aschner takes two main forms - youthful or maiden and O. multiparous - and believes that rheumatic-marantic is rare. Some also divide O. into atrophic and hypertrophic, into vagosympathicotonic, etc. The most correct is to separate puerperal O. into a special group, which Pashutin considered the main type (he also proposed the special name “genitogenic” O. in view of the close connection with gonads); Skrobansky considers it as a form sui generis, completely independent both in the nature and gradualness of the changes occurring, and in the course of the process and outcomes (he also distinguishes puerperal O. of three types - malignant, heavy and mild, occurring hidden, without skeletal deformations and standing on the verge of “physiological” changes during pregnancy). Pat. anatomy. The most significant changes occur during O. in the skeletal system. Bones decrease in size, lose weight, become soft and very pliable. The hallmark of this change in the skeletal system is the disappearance of the old dense bone substance and its replacement by soft, calcareous osteoid tissue. However, the question is how this happens, i.e. what kind of stalemate. the process takes place in the bones during O., but has not yet been completely resolved. A fairly widespread opinion in the past, which has not yet been completely abandoned even now, is that the main process here is gali-sterez(see), was significantly shaken by very compelling research showing that the softening of bones consists not only in the simple disappearance of lime from the finally formed bone, but also in the new formation of bone tissue, devoid of lime (osteoid tissue) and then remaining in this state (Schmorl and etc.). As is known, such an explanation of the essence of the process of formation of osteoid tissue at 9° O. brought the changes in bones during O. very close to those that are characteristic of rickets. This observation, however, does not exclude the possibility that, along with the new formation of steoid tissue, galisteresis may also occur, in other words, the process of disappearance of calcareous salts of bones may be based on changes of an atrophic and hyperplastic nature [some based on the predominance of one or the other Some of these processes even have different forms - atrophic (porotic) and hypertrophic (hyperplastic)]. Nikiforov believed that new formation of osteoid tissue occurs unevenly and predominantly where bone tissue is subjected to increased pressure. All of these changes occur with a certain gradualness and are not equally expressed in individual ■component parts of the bone; The trabeculae of the cancellous bone are affected first, while the bone marrow, as well as the substantia compacta, are affected later, the periosteum usually does not change or is slightly thickened; in severe, advanced cases, the picture becomes more monotonous, and osteoid tissue is noted almost everywhere instead of normal bone. The most characteristic appearance is the bone crossbars of the cancellous bone (thinning, layering, violation of the correct location), from which the loss of lime actually begins. They ■appear to be composed of two completely different parts, delimited by a sharp boundary and clearly distinguishable by their structure; one part, facing the Haversian canals and the bone marrow space, appears to be devoid of lime and bears traces of the atrophic process (atrophy of bone bodies), while the other, distant from the bone marrow tissue, consists of bone of a completely normal structure. At further development During the process, decalcification spreads further, the crossbars become increasingly thinner, while the medullary spaces expand (Fig. 2 and 3). In parallel with this, the substantia compacta also undergoes changes, and depending on the degree and stage of the process, it can become thinner to one degree or another. In advanced cases, the diaphyses of long bones may appear as thin-walled, flexible tubes. In the bone marrow itself, apart from the blood supply, there are no noticeable changes, and in general the bone marrow in its appearance and structure is in accordance with age. Only in places of strong bone restructuring does the bone marrow acquire a connective tissue character (German: Fasermark). Osteoclasts and osteoblasts in the affected bones in O. are extremely rare. Along with changes in the skeletal system, in severe forms there are changes in the muscular system and nerves (the latter, however, rarely change). Thus, Schlesinger (Schlesinger; 1893), when examining peripheral nerves in one case, O. noted lesions of the nn. ischiadici, radialis and ulnaris and considered them as degenerative neuritis. Changes in muscles are more common; they consist in atrophy of muscle fibers and fatty degeneration (Friedreich, Chambeis, Hosslin, etc.); sometimes complete disappearance of muscle tendons occurs. Clinic, symptomatology, diagnosis, course, prognosis. Pathological symptom complex O. seems quite complex and varied; nature, intensity of pain, everything individual symptoms generally vary depending on the stage and extent of the process. A certain systemic pattern is also observed in the changes in the skeleton, which also depends on the form of the tumor (puerperal and non-puerperal). The predominant symptom is pain. They appear at the very initial stage of the disease, being one of the earliest symptoms. Pain or localized predominantly

Figure 2. Sectioning of a normal femur.

Figure 3. Sectioning of the femur for osteomalacia. mainly in one place (in the sacrum, in the pelvic area - a feeling of heaviness) or seem more widespread (in the chest, spine, lower extremities and even throughout the whole body) and depend not only on changes in the skeletal system, but also on changes in the nerves and muscles, which can be affected earlier. Pain is nagging, rheumatic in nature, occurring even in a calm state. Early symptoms also include easy fatigue, difficulty moving, muscle weakness (decreased tone, tremors, subtetanic state) and associated these are changes in gait (the so-called duck-like, uncertain, “waddle”). characteristic feature Contracture of the adductors also serves (the patients cannot raise their legs and spread them apart) (Fig. 4 and 5). Paresthesia and paresis appear quite early, even in cases of moderate severity; There is a sharp pain and with light pressure, increased galvanic and mechanical excitability and increased knee reflexes develop. In the puerperal form of bone disease, the pelvis is first affected, then the spine and chest; the lower extremities are affected less frequently (rarely the bones of the skull). With further development of the disease, individual symptoms progress and pain intensify, movements become completely impossible, deformations begin in the skeleton (cystic

Figure 4.

Figure 5.

phosis, scoliosis), decreased height due to shortening of the spine; asymmetry of the pelvis and the entire torso is not uncommon (Fig. 6 and 7); bones become fragile, labile; curvatures, cracks and fractures of individual bones are common (with puerperal O. in a chronic course, repeated fractures are described only during a new pregnancy - Savulescu, 1921, during the 11th, 12th and 13th pregnancy). Nerve-related phenomena also progress (osteo-malatic paralysis), and are more deeply affected. muscular system(atrophy, fatty degeneration, cases of lipomatosis have been described). Mental disorders are also observed, general swelling tissues, nephropathy and other general disorders. General condition - Figure 6. in mild forms does not affect

Rusheno, in more severe cases, dyspeptic symptoms, loss of appetite, constipation are noted, breathing becomes difficult, congestion in the lungs, circulatory and cardiac disorders are common. Sex life is possible only in the initial forms, when sexual feeling is apparently not impaired. Previously, when almost entirely only advanced cases came under observation, lung tbc, hron were often observed. bronchitis, nephritis, general insanity. On the part of the blood during puerperal O., nothing characteristic was noted; so eg indicated a moderate decrease in Hb, leukocytosis, severe eosinophilia, lymphopenia, and in severe cases- anemia. Reduced blood alkalinity is also noted. Data regarding metabolism are extremely contradictory: there was an increase and a decrease in the excretion of phosphorus and calcium in the urine; Observations about increased content are not yet conclusive

Figure 7.

Lime in the blood. The latest research by Klyuchevsky shows that with puerperal< остеомаляции происходит значительная потеря извести (усиленное выделение Са через кишечник). Диагностика О. в далеко зашедших случаях не представляет затруднения; в начальных же формах-при медленно и постепенно развивающемся процессе, при незначительно выраженных симптомах и отсутствии клин, проявлений со стороны костей-О. легко может быть просмотрена или смешана с другим заболеванием. При диференциаль-ном диагнозе в случаях пуерперальной О. надо иметь в виду гл. обр. ревматизм, нев-ральгии (особенно седалищного нерва), а также общий фиброзный остит и множественную-миелому (нек-рыми принимается во внимание и истерия); при старческой форме-osteoporosis(see), arthritis dei "ormans, 6-HbPaget, progressive muscular dystrophy, malignant bone marrow diseases. X-rays have recently become a great help in diagnostics. O.'s course is clearly dependent on a number of accompanying conditions; of them highest value has the onset of a new pregnancy, which usually aggravates and worsens the process. In general, the course of O. is wave-like in nature. - The problem is generally serious [in the first statistics (Litzmann) - mortality from puerperal O. is noted in 80%, in the latter, on the contrary, recovery is stated in 85-■ 90 %], however, a number of authors consider the prediction to be favorable. Cases of self-healing have been described even during ongoing pregnancy. After recovery, of course, deviations and deformations of the skeleton remain. Non-puerperal forms of O. differ significantly from puerperal, both in the nature and gradualness of changes, as well as in the course and prognosis (the spine and chest are affected first, and later the pelvis; in male O. the latter is very rare). These forms also differ and according to the localization of pain, which in such cases are predominantly observed in the spine and lower extremities. The pathological symptom complex can be more pronounced, and additional dystrophic disorders are also observed, serving as an expression of the general insufficiency of the body. So eg. often combined with general obesity, tetany, severe mental disorders, dementia praecox; cases of Charcot, trophic disorders (severe hair loss, sudden changes in skin), multiple neurofibromatosis, etc. have been described; Thyrotoxicosis is also often observed. In general, there are frequent cases of O. in mentally ill people. A certain difference was also noted in relation to blood (for example, Chistovich et al. described a sharp lymphocytosis - up to 60%). Malignant forms are often observed, with a more rapid course; these forms are more difficult to treat, especially in men, and are considered by many to be incurable Their course is usually chronic (also wave-like), it depends on the form, external conditions and the observed combined symptoms; they can last for several years, either worsening or weakening in their course. Of the cases of non-puerperal O., the prognosis is most favorable. - "3 Dimomu with O. infantilis. This last form can be confined to the period of puberty (according to Grace Stapleton - usually in India); on the other hand, cases are described where it occurred with the appearance of menstruation. The most severe prognosis is for male O. (rapid progression, high mortality rate). Prevention and therapy (obstetrics, see Pelvis). All the still indicative information that is available regarding the etiological aspects of O., as well as the insufficiency (by no means in isolated cases) of both drug treatment, and more radical interventions force us to pay attention to prevention. In view of the fact that with O. symptoms are often observed that characterize the osteomalatichka as an inferior subject, this prevention should consist not only in the appropriate education of youth and gigabytes. environment, but also carried out antenatally. Prevention should be of particular importance in areas where O. is noted as an “endemic” phenomenon; here, along with paying special attention to social services. conditions (housing, nutrition, in particular increasing vitamins in food), a systematic fight against harmful habits, customs and prejudices in the life of an Eastern woman must be carried out. Prevention should be especially deepened at the first symptoms of the disease, as well as with its further development. Favorable climate effect. conditions, the importance of improving hygienic, preventive factors and nutrition have been noted recently by many authors. So eg. Miles and Feng (Miles, S. T. Feng, Beijing) saw good results only with an appropriate modification of the diet in Chinese women; This is indicated by Stone (Emerson Stone, 1924) and Stapleton (Grace Stapleton, India), who considers a vegetarian diet (milk, butter) to be among the main therapeutic measures. The basic principles of therapy are directly dependent on the type and nature of O. With puerperal O. in mild and moderate cases, preliminary conservative treatment is permissible under strict control; If this fails, immediate termination of pregnancy is necessary, followed (depending on the case) by removal of the ovaries. The principles of gradualism in relation to conservatism or radicalism in therapy should also be carried out in cases of non-puerperal O. From therapy. Phosphorus preparations (Kassowitz, Latzko) enjoy deserved success, which are recommended in combination with fish oil (Vogt successfully used fish oil alone). So, Latsko advises using the following composition: 0.06 G phosphorus per 100 G fish oil daily, a teaspoon; in cases that are difficult to treat, the dose is increased to 0.1 G; Gruzdev adheres to the same doses. Kurshman believes that it is better to administer relatively large doses, for example Phosphor 0.1, Succus et Pulv. liq. q. s. ut i. pil. No. 150 two or three times a day, 1 pill and use it for many weeks; According to Kurshman, phosphorus is tolerated better by osteomalatics than any other means. Mykertchyants A.M. (1905) pointed out that phosphorus is a reliable and reliable remedy and that it should be taken “in proper doses and for a sufficiently long time.” Other authors (Seitz) also point out the advisability of using large doses of phosphorus; by the way, Tsondek considers its effect in combination with lime or fish oil in some cases even specific (average doses, according to Tsondeis, phosphorus - 0.01, fish fat - 100.0 two to three times a day, a teaspoon + Calc. la-ctici 0.3 per os - 3 times a day). Complete recovery was noted by Latskov in 78%, Schmidt in 62%. There are indications of better the effect of phosphorus in non-puerperal O. (the mechanism of its action is not clear; Ashner believes that it does not affect the intrasecretory glands, but the metabolism, may directly affect bone cells). Along with phosphorus and fish oil, it is recommended to administer organotherapeutic drugs, some of which are used separately. Of the latter, adrenaline was used most often; Pituitrin, like ovarian and anti-thyroidin, is used much less frequently. The milk of castrated goats, monkeys (anti-malacin-Hoffmann), an-ovarthyreoidserum, etc. is not widely used. The value of thymus a implantation, carried out successfully in one case (Scipiades, 1924), has not been confirmed. Adrenaline, according to Bossi, should be used 10-12 days, administering 2 times a day up to 1 cm 3 0.1% solution and repeat the course of treatment after a few weeks. Cristofoletti cites statistics in 46 cases (24% recovery, 35% noticeable improvement, 41% no result) and believes that the effect of adrenaline is indirect (decreased ovarian function). Adrenaline has been used by a number of authors; Opinions about it differ, there are indications that long-term results are unknown and that the disease often does not go away. Complications observed not so rarely during its administration (severe general symptoms, shortness of breath, palpitations, collapse, tremor, etc.), even in small doses, force one to be careful when using it. Adrenaline also has a good analgesic effect. Recently, Suprarenin (0.5 cm 9 1 0 /oo solution, 1-2 times daily; in the absence of toxic effects, the dose is increased to 1 cm d). When using pituitrin, Bab was successful in -4 cases (out of 8) „ Pal also administered the extract from the anterior lobe; Others also obtained successful results and, by the way, in the case of male O. It was also tested combination therapy(adrenaline, pituitrin). A more radical intervention should include radiotherapy. First used by Ascarelli (Ascarelli, 19("6), it is recommended by some in the present time, and it is indicated that it is more applicable in mild cases and in young patients for the purpose of temporary sterilization (there are, however, authors who believe that one cannot expect much from X-rays, especially in serious cases).The focus in O.'s therapy continues to be surgical castration (Feliling, 1887), although recently, in view of the established view that with O., along with hyper - and ovarian dysfunction is a dysfunction of other endocrine glands, voices are beginning to be heard about its more limited use. This may also be supported by cases where it did not have any effect, where after a temporary improvement relapses were observed and, finally, not isolated cases of recovery without castration. Back in 1905, Mykertchyants considered Fehling’s theory to be untenable, having no scientific justification and said that O. “in no case can serve as an indication for castration.” IN modern times some authors (Ilyin, 1930) also believe that with O. there are no indications for castration. At the moment, castration, of course, cannot be completely excluded from O.’s therapy, but undoubtedly it should not be carried out as widely as before. Castration should not be used from the very beginning of the disease without first applying conservative treatment. Some (Gug-gisberg) do not advise, however, to wait a long time (in cases that are difficult to treat) with castration, because if delayed, it no longer gives the desired result (Guggisberg at the same time believes that in mild cases there are no indications for it). A few authors share a more extreme point of view, i.e., considering castration insufficient, they also perform complete extirpation of the uterus (in view of the possible harmful effects of its mucous membrane). After castration, some additional treatment is recommended; marked e.g. good results from the use of adrenaline and phosphorus for relapses after castration. Osteomalacia in animals. O. is also observed in animals, occurs in all species, but most often it affects cattle. Just like in humans, the predominant form is puerperal O.; it occurs extremely rarely in cubs, young animals and males. The predisposing causes of its occurrence are similar. So eg. The main causes of O. in veterinary medicine are considered to be insufficient nutrition (food with a low content of lime and phosphorus), pregnancy and prolonged milk separation. The influence of nutrition has been proven by many researchers; The most characteristic are the observations of German (Germann) on 244 Egyptian horses brought to Cochin (the soils of Egypt and Cochin differ significantly in lime content). The individual cases that soon arose in O.'s horses ceased after the import of Egyptian barley, and the sick horses recovered significantly. There is a lot in common in the wedge, the picture of the disease; bone fractures are often encountered and are even considered a characteristic sign. ->L e- <ч Eating comes down to improving nutrition, adding bran and oats to food. Among the medicines, we recommend a solution of phosphorus, Nucis vomicae powder. If there are fractures, the animal is killed; during pregnancy, in the case of a living fetus, a cesarean section is first performed. As a preventive measure. Measures for pregnant cows are advised to stop milking earlier. Lit.: Klyuchevsky I. K the doctrine of osteomalacia, Collection. work in obstetrics And gin., dedicated prof. .Gruzdev, P., 1917-1923; Kurdinovsky E., Osteomalacia (Fundamentals of endocrinology, ed. V. Shervinsky and G. Sakharov, L., 1929); Kushnir M. and Selitsky S., On the issue of changes in the ovary during pregnancy, especially with eclampsia, Zhurn. obstetrics and wives Bol., book. 5-6, 1925; Mykertchyants A., On the issue of etiology and treatment of osteomalacia with a description of two own cases, ibid., 1905, No. 5; Selitsky S., Review of cases of cesarean section over the past 2 years in the Moscow obstetric clinic (statistics), Proceedings of Obstetrics and Gynecology. about-va, M., 1915; Skrobansky K., Materials on the study of osteomalacia with a review of cases observed in Russia (statistics), Zhurn. obstetrics and wives Bol., 1908, No. 1-2; 6-uggisberg H., Osteomalacie (Biologie u. Pathologie des Weibes, hrsg. v. J. Halban u. L. Seitz, B.III, V.-Wien, 1924, lit.); Hermstein A., Schwangerschaftsstorungen (Hndb. der inneren Sekretion, berausgegeben v. M. Hirsch, Lpz., 1928); Silberberg, Pathologie u. Pathogenese der osteomalatiscnen Km>-ch nsvstemerkrankung, Ergebnisse d. allg. Pathologie, Band XX, 1923.P. Selitsky.

In the absence of proper treatment, this pathology leads to gait disturbances and changes in the shape of the spine.

Softening of bone tissue

Osteomalacia is common in children and adults. This is a systemic pathology. Various parts of the body are involved in the process. In humans, calcium and phosphorus are responsible for bone mineralization. In children and adults, vitamin D has a beneficial effect on tissue development. Osteomalacia syndrome is most often observed in older people and at a young age.

Women suffer from this disease much more often than men. This is due to different hormonal levels. In childhood, the bones of the upper and lower limbs. Signs of osteomalacia often appear during pregnancy. In this case, the process involves pelvic bones. In old age, the vertebrae are affected.

The following forms of osteomalacia are known:

• children's;
• youthful;
• menopausal;
• senile;
• gestational

Damage to the skull is very dangerous, since any injury can cause a fracture and brain damage.

This pathology should not be confused with osteoporosis. In the latter case, the bones become more fragile due to a decrease in the volume of the matrix and an increase in tissue porosity.

Main etiological factors

Osteomalacia in adults and children is due to several reasons. Main etiological factors are:

• lack of vitamins in the body;
• renal dysfunction;
• cirrhosis of the liver;
• congenital malformations;
• chronic intestinal and liver diseases;
• pathology of the thyroid gland;
• following a vegetarian diet;
• uncontrolled use of anticonvulsants;
• enhanced function of the parathyroid glands.

It is not always possible to identify the cause. IN in this case A diagnosis of osteomalacia of unknown origin is made. Risk factors for the development of this pathology include:

• pregnancy;
• poor nutrition;
• physical inactivity;
• menstrual irregularities;
• alcoholism;
• regular consumption of caffeine.

Osteomalacia can be calcipenic or phosphopenic.

Lack of calcium can be caused by a lack of vitamin D, impaired absorption in the intestines or increased excretion by the kidneys. Hypovitaminosis is often observed in weakened people who do not receive the required amount sunlight.

Vegans and vegetarians are at risk. Symptoms of osteomalacia may appear in people whose diet does not include foods rich in calcium. These include:

• cottage cheese;
• yogurt;
• feta cheese;
• milk;
• mackerel;
• ice cream;
• condensed milk;
• chocolate;
• black bread;
• legumes;
• nuts;
• dill;
• cream.

Calcium leaching and impaired bone mineralization are promoted by:

• excess of sausages on the menu;
• addiction to coffee and alcohol;
• drinking sparkling water;
• smoking;
• lactase deficiency;
• hyperparathyroidism;
• pancreatitis;
• nephritis;
• taking diuretics.

The appearance of symptoms of osteomalacia during pregnancy and lactation is due to the body's increased need for calcium, as well as hormonal changes.

The phosphopenic form of this pathology is most often associated with hyperparathyroidism and kidney pathology. The risk group includes people who do not consume phosphorus-rich foods. This element is found in fish, seafood, cereals, legumes, spinach, nuts, milk, eggs, mushrooms and caviar.

Manifestations of softening of bone tissue

This pathology develops slowly. It may take years before the first complaints appear. The following symptoms are observed with osteomalacia:

• pain at rest and with exertion;
• decreased muscle tone;
• muscle wasting;
• difficulties during movements;
• paresthesia.

Often, pathological fractures occur in sick people. If treatment is not carried out, then restriction of movements is observed. Limbs are deformed. Sometimes there are signs of damage chest. In this case, rickets must be ruled out. The earliest sign of osteomalacia is increased sensitivity of the bones to external pressure.

Some patients cannot lift and spread their legs normally. When bone tissue softens, sensitivity is often impaired. Paresthesia occurs. A crawling or tingling sensation appears. As the pathology progresses, the person’s condition worsens. The pain gets worse. It occurs not only during exercise, but also at rest.

In advanced cases, the bones become deformed. Children often have a funnel-shaped chest. This may lead to displacement or compression of the mediastinal organs. In children, the tubular bones of the legs most often soften. The latter take on an O-shape. The main symptoms of osteomalacia are accompanied by signs of calcium deficiency in the body. These include:

• brittle nails;
• dry skin;
• peeling;
• nervousness;
• weakness;
• fatigue during work;
• eye damage such as cataracts;
• bleeding gums;
• tooth decay;
• muscle and joint pain;
• convulsions.

Phosphoropenic osteomalacia causes symptoms such as decreased appetite, apathy, depression and general malaise. With this pathology, immunity decreases. Such people often get sick.

Disease in pregnant and lactating women

Very often, osteomalacia develops in young women who carry a child repeatedly. The process involves the pelvic and femur bones, as well as the spine. The main symptoms are:

• pain in the back or in the sacral area;
• duck walk;
• restriction of movements.

In severe cases, paralysis develops. Damage to the pelvic bones makes natural childbirth difficult. In this case, a caesarean section may be required. After the birth of the baby it is possible residual effects. With proper treatment, symptoms disappear. Sometimes signs of softening of bone tissue on an x-ray are detected during menopause.

The spine is predominantly affected. Thoracic kyphosis develops. Sick women have drooping heads. They look stooped. The length of the body decreases due to damage to the spine. When sitting, sick people look short. Not everyone has seen photos of such people.

Treatment tactics

Before treatment, a diagnosis must be carried out. You will need:

• radiography;
• palpation;
• general clinical tests;
• densitometry;
• computed tomography or magnetic resonance imaging.

The images reveal signs of osteoporosis (in the early stage) and plastic deformation (in the late stage). Treatment for osteomalacia includes:

• taking calcium and phosphorus supplements;
• diet;
• taking vitamin D;
• gymnastics;
• physiotherapy;
• increased motor activity.

If conservative treatment for 1–1.5 years does not produce results and there are signs of bone deformation, then surgical intervention is required.

Complex and single preparations are used for tissue mineralization. Calcium gluconate, Calcium citrate, Calcium carbonate, Calcium-D3 Nycomed, Complivit Calcium D3 and Natekal D3 may be prescribed.

Patients need to cure existing diseases of the intestines, liver, pancreas and parathyroid glands. Additionally, Multi-Tabs Intensive multivitamins are prescribed. If during pregnancy conservative therapy does not help, then the question of terminating the pregnancy may be raised.

Preventive measures

Specific prevention of osteomalacia has not been developed. To reduce the risk of developing this pathology, you must:

• quit smoking and alcohol;
• exercise;
• move more;
• limit the consumption of coffee, carbonated water and sausages;
• regularly consume foods rich in calcium and phosphorus;
• prevent diseases of the kidneys, liver and pancreas;
• monitor hormonal levels;
• take multivitamins;
• Use medications only as prescribed by a doctor.

The daily calcium intake is 400–1200 mg, depending on age. Phosphorus required 1200 mg daily. Thus, bone softening is dangerous pathology. Self-medication or ignoring symptoms can cause bone deformation, frequent fractures and other complications.

Symptoms and treatment of osteomalacia (adult rickets)

Osteomalacia (from Latin - softness, softening of bone) is a systemic disease characterized by insufficient mineralization of bone tissue. In other words, this is rickets in an adult, which is observed mainly in women.

Causes of morbidity

It is believed that the cause of the disease may be a lack of vitamin D, or impaired metabolism. As well as a lack of micro and macroelements, which is caused by their increased filtration through the kidneys or impaired absorption in the intestines. With this disease, the total volume of bone matter increases, but it is depleted in minerals.

Osteomalacia has been known for a long time, but there has been no precise description of the disease. Apparently, for many centuries, rickets was identified with other pathological processes of the skeleton, and was not properly diagnosed. The disease is rare and tends to occur in a certain area, especially in the valleys of large rivers and downstream. It was established that frequent cases were recorded along the banks of the Danube, Rhine, Po, as well as in the cantons of Bavaria, Switzerland, Flanders, northern Italy, and China. In our country, cases were recorded in Transcaucasia and the Volga region.

It is difficult to judge the frequency of outbreaks, since not all cases have been described and diagnosed. This feature of the concentration of morbidity suggests the influence of climate, geographical location, soil composition, living conditions, water on the development of rickets. Many sources describe the influence of living conditions - in the poor, in combination with poor food and unfavorable living conditions, hard work, rickets occurs more often than under normal conditions.

Rickets is divided into three forms depending on the time of occurrence:

• late rickets, occurring at puberty;
• puerperal osteomalacia, which is localized in the spinal column and is extremely rare;
• osteomalacia during menopause (menopausal);
• senile osteomalacia.

However, in addition to the above, there is osteomalacia, which does not depend on age and is called excretory osteomalacia, when a pathological amount of calcium is released after a long-term kidney disease.

Signs of the disease

With four age-related forms, almost the same symptoms are present - vague pain in the back and hips, sometimes pain can be felt in the shoulders and chest. On initial stages disease, skeletal deformation is not yet noticeable. In the later stages of rickets, you can see curvature of the legs, the knee joints move to the sides when the feet are closed, and if the knees are closed, the feet spread apart. Also, in the later stages of the disease, deformation of the chest in the form of a funnel begins.

With osteomalacia during menopause, kyphosis is especially pronounced, and with the further course of the disease, the body length actually shortens. Only the torso is shortened, so the person looks like a sedentary cripple. In very rare cases, the curvature of the skeleton is so great and causes severe pain that it immobilizes the patient completely.

Osteomalacia in old people is characterized by frequent and multiple fractures, and changes in the pelvis are not so great. In the first initial stages, the gait is not disturbed; for moderate severity, a waddling gait is characteristic, either to the left or to the right. Or the gait may be shuffling, as in Parkinson's disease. It is especially difficult for patients to climb steps and stairs. The bones are sensitive to pressure. Pain is felt both when the iliac bones are compressed and when the compression is released.

Osteomalacia is characterized by depletion of the skeleton in calcium salts, the presence of zones typical of Milkman syndrome, and bone curvature. However, osteoporosis is not yet the main symptom of osteomalacia and is not always recognizable on x-rays. The most common skeletal deformity is the pelvic deformity.

Treatment of the disease

Treatment is carried out using conservative methods and includes taking vitamins and microelements, in particular vitamin D, calcium, phosphorus. Physiotherapeutic procedures are also used - UV irradiation, massage, therapeutic exercises. When bright pronounced defects bones are treated surgically in combination with mineralization and vitaminization of the body. Deformation of the pelvic bones during pregnancy is direct reading To caesarean section, and the progression of osteomalacia after childbirth, breastfeeding should be excluded. With modern treatment methods, the prognosis is favorable.

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Osteomalacia is a softening of bones caused by insufficient mineralization of bone tissue due to insufficient levels of available phosphate and calcium or due to excessive resorption of calcium from bone, which can be caused by hyperparathyroidism (which causes hypercalcemia). Osteomalacia in children is called rickets, so the use of the term “osteomalacia” is often limited to a mild form of the disease in adult patients. Signs and symptoms may include diffuse body pain, muscle weakness, and bone fragility. The most common cause of osteomalacia is a deficiency, which is normally produced by exposure to sunlight and, to a lesser extent, consumed in the diet. The most specific screening test for vitamin D deficiency in patients without other medical conditions is serum 25(OH)D levels. Less common causes of osteomalacia may include hereditary vitamin D or phosphate deficiency (usually diagnosed in childhood) or cancer. Preventive and treatment measures for osteomalacia usually involve the consumption of vitamin D and calcium supplements. Vitamin D should always be administered with calcium supplements, as most of the consequences of vitamin D deficiency result from impairment of mineral-ionic homeostasis. Residential and chronic care facilities and homebound older adults are particularly at risk for developing vitamin D deficiency because these groups of patients typically do not receive enough sunlight. In addition, the efficiency of vitamin D synthesis in the skin and absorption of vitamin D from the intestine decreases with age, thereby further increasing the risk in these populations. Other risk groups include patients with malabsorption due to gastrointestinal bypass surgery or celiac disease and patients who have moved from warm to cold climates, especially women who wear traditional burqas or dresses that block the sun's rays from penetrating the skin.

General characteristics

Osteomalacia is a generalized bone disease in which there is insufficient mineralization of bone tissue. Many of the effects of this disease overlap with the more common osteoporosis, but they are two completely different diseases. There are two main reasons for the development of osteomalacia: (1) insufficient absorption of calcium from the intestine due to lack of calcium in the diet or its deficiency or interference with the action of vitamin D; and (2) phosphate deficiency caused by increased kidney failure. The name osteomalacia comes from the Greek osteo-, meaning “bone” and malacia, meaning “softening”. In the past, the disease was known as malacosteon or the Latin equivalent of mollities ossium. Osteomalacia is associated with an increase in the maturation time of osteoid tissue.

Causes

The causes of osteomalacia in adults are varied, but primarily lead to vitamin D deficiency:

Signs and symptoms

Diffuse joint pain and bone pain (especially in the spine, pelvis and legs)

Muscle weakness

Difficulty walking, often with a duck gait

Hypocalcemia (positive Chvostek's sign)

Compression of the vertebrae and shortening of the torso

Flattening of the pelvic bones

Weakness, softening of bones

Prone to fractures

Bending bones

Clinical signs

Osteomalacia in adults begins in the form of aches and pain in the lower back ( Bottom part back) and hips, then the pain spreads to the arms and ribs. The pain is symmetrical, does not radiate and is accompanied by sensitivity of the affected bones. The proximal muscles are weak, and the patient has difficulty climbing stairs and standing from a squatting position. As a result of demineralization, bones become less strong. Physical signs include pelvic Y-shaped deformities and lordosis. Patients exhibit a typical “duck” gait. However, these physical symptoms may result from a previous condition of osteomalacia, since the bones do not return to their original shape after deformation. Pathological fractures may develop due to body weight loading. Most of the time, the only suspected symptom is chronic fatigue, while bone aches are not spontaneous, but only occur when pressure or impact occurs. It differs from nephrogenic osteodystrophy, where hyperphosphatemia is observed.

Results of biochemical studies

Biochemical signs are similar to those of rickets. The main factor is a pathologically low concentration of vitamin D in the blood serum. Key Typical Results biochemical research include:

Low serum and urine calcium levels.

Low serum phosphate levels, except in cases of nephrogenic osteodystrophy.

An increase in the level of alkaline phosphatase in the blood serum (due to an increase in the compensatory activity of osteoblasts).

Increased parathyroid hormone levels (due to decreased calcium levels).

Moreover, bone scans using technetium show increased activity(also due to the increased number of osteoblasts).

X-ray signs

Radiological signs include:

Pseudofractures, also called Looser's zones.

Otto's disease, a disease of the hip joint.

Treatment

Good results in the treatment of nutritional osteomalacia are observed with the introduction of 10,000 IU weekly vitamin D for 4-6 weeks. Osteomalacia due to malabsorption may require treatment with intravenous or daily oral intake of significant amounts of vitamin D.