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THE ÆTIOLOGY OF OSTEITIS DEFORMANS
1286
-
articles. It was indeed fortunate that Dr. Billings set out to index the journals just when the tide began to flood. Our gratitude to him and to his successors is a little tinged with envy when we turn at the end of this volume to the Collection of incunabula and early medical prints " to find nearly 500 books printed before A.D. 1500 and half as many again from the next quarter-century, with prize upon prize among them. But what more fitting reward could there be for the bibliographers to whom we are so much indebted No subject has been so well treated as bibliographically medicine, and now we learn that our luck will hold. It was rumoured that the end of the third series was to be the end of the IndexCatalogue, and that after 1926, the last year yet indexed, the deluge would be over us. Now we learn with real gratitude that "work on the fourth series will be begun at once." Dr. Billings lies in the grave, but his great catalogue goes marching on.
after operation might show that deficient intake of essential substances played a part. Meat and green vegetables, so essential to normal hsemopoiesis, are too often lacking from the menu of the gastric patient. It is obvious that prolonged study of a large series of post-operative gastric cases would be of great interest. Biochemical investigations of the blood, the gastric juice, and the faeces should be correlated with the heamatological picture and the dietary
history.
____
THE ÆTIOLOGY OF OSTEITIS DEFORMANS
Dr. T. J. O’Reilly and Mr. Joseph Race, F.I.C.,l have investigated 30 cases of Paget’s disease which found their way, with a diagnosis of rheumatism, to the Hospital for Rheumatic Diseases in Buxton. Forty per cent. of them showed the physical signs of osteitis deformans ; 33 per cent. had the symptoms but none of the physical signs ; and 27 per cent. had neither symptoms nor signs, the condition being accidentally revealed by radiography. In the first ANÆMIA AFTER GASTRIC OPERATIONS group the average duration was seven years, and in THERE is apparently no gastro-intestinal disorder the second group four years ; the pelvis was affected that may not be associated with anaemia, and evidence in 26 cases and the lumbar spine in 24, while the femur is accumulating to suggest that this association is and tibia were both affected more often than the skull. no mere coincidence. Deficient diet, deficient gastric The earliest radiographic change recognised is a and faulty absorption in the intestines coarsening of the bone due to decalcification, which digestion, have all been proved experimentally to play a part accentuates the normal bone lines and produces an in the development of both hypochromic and hyper- appearance of simplification of the normal bone chromic megalocytic anaemias; while other factors, structure ; this was most often seen in the pelvis and such as pregnancy, have been shown to have a vertebrae. The second change is a complete loss of disturbing effect upon haemopoiesis, at least in some the normal sharp texture of the bone outline, so that degree, through their effect upon gastric secretion. the bone looks as though it were seen through ground Dr. R. A. Rowlands and Dr. S. Levy Simpson in our glass. The third change is a deposition of amorphous last issue, and Dr. Janet Vaughan this week, have calcium salts which spreads throughout the bone like reviewed the published records of relationship between a steamy white cloud, and, becoming dense, obliterates gastric operations and anaemia. Though less thanall detail in the radiograms. In the 21 cases where the 130 cases in all have been reported, it is clear that serum calcium and plasma phosphorus were examined, such operative interference may result in disturbance the figures were within the limits of normal. In every of blood formation. Dr. Rowlands and Dr. Simpson, case examined the plasma phosphatase figure was writing of Addisonian anaemia, comment upon the increased. The suspension stability of the blood was long latent period between operative interference normal, except when concurrent disease or sepsis and the development of symptoms ; the average existed, and in O’Reilly and Race’s opinion this period in their series was 6 years and the longest finding is strong presumptive evidence that osteitis 15 years. This may explain why, in a recent deformans does not belong to the infective group of symposium on the late results of gastric operation diseases. They rightly lay emphasis on the work of in which a large number of cases was reviewed, post- Snapper and others, which has shown that generalised operative anaemia was only mentioned in order to osteitis fibrosa is a separate affection, with distinct state that it did not occur. The hypochromic micro- biochemical and radiological findings, having a cytic type of anaemia, unless severe, is rarely a definite ætiological relationship to tumour of the presenting symptom, and careful examination would parathyroid gland and amenable to surgical treatment. probably show it to be more common than it appears. (Incidentally, Prof. Snapper’s work was done not in Why some patients develop hypochromic microcytic Austria, as they imply, but in Amsterdam.) anaemia and others hyperchromic megalocytic anaemia So much for a carefully conducted investigation after the same operative procedure is hard to see, of Paget’s disease. Turning to another part of their and the position is further complicated by Dr. paper, however, we learn that O’Reilly and Race Vaughan’s observation on a patient whose anaemia " have not had an opportunity of making a satisfacchanged within 36 days from a typical microcytic to tory histological examination of the bones in this a typical megalocytic type. At present it is impossible disease." How, then, can they "regard the disease to say exactly why operative interference causes as a local one, the reticular cells primarily affecting anaemia at all, and the evidence is insufficient to of the bones," and a close relationship to the having incriminate one type of interference rather than reticulo-endothelioses and an analogy to Hodgkin’s another, though attempts have been made to do so. disease’? Is this not another example of the error of Cases have been recorded in which the patient was casting aside years of work in morbid anatomy ? without anaemia six years after complete gastrectomy. Though modern physiological and biochemical There is no apparent relationship between the degree methods have served to show that hyperparaof hypochlorhydria and the severity of the anaemia, is a distinct entity, different from osteitis thyroidism nor between the occurrence and character of the deformans, respect is still due to the histologist who diarrhoea and the anaemia. The rapidity with which finds similarities between the two diseases. In the food leaves the stomach and the nature of the osteitis deformans there is great resorption Paget’s intestinal flora are also, it seems, without significance. 1 Quart. Jour. Med., October, 1932, p. 471. Perhaps a study of the type of diet taken by patients
1287
ventricle
associated with great apposition of bone, completely the higher reading is the significant one. altering the normal architecture ; but appositioni The possibility of asymmetry should be borne in mind, preponderates. In von Recklinghausen’s generalised1 especially in examination for life assurance. Serious osteitis fibrosa widespread resorption is the essential, error may result from an estimation which is just ,
focal and relativelyT within the normal limits in one arm, if it happens This seems to be the only definite to be 10 mm. Hg of mercury higher in the -other insignificant. difference. less it is, of course,, untested arm. None the histological The paper describes among others the case of a big difference, and the contention of Germanspeaking pathologists that " osteodystrophia fibrosa " a man, aged 36, in whom at one examination the is a great unity, with many subdivisions such as; pressure in the right arm was 170/130, and in the Paget’s disease and von Recklinghausen’s disease, left arm 130/80. A cervical rib was found on the seems to ignore what has been discovered throughleft side. This was removed surgically, and afterwards the asymmetry in the blood pressure gradually experimental physiology and biochemistry. It is difficult to agree with O’Reilly and Race in disappeared until five months later the pressure in their analogy between Hodgkin’s disease and osteitis the right arm was 150/85 and in the left 142/86. deformans. Paget’s disease and granulomatous Stieglitz and Probst endeavour to explain this case inflammations appear to be poles apart. The available by the assumption that the cervical rib, by pressure evidence suggests that osteitis deformans has a on the brachial plexus, produced a decrease in the chemical and not an inflammatory origin, and the tone of the vessels in the left arm, and that as a result histologist who assures us that the changes seen in a compensatory hypertension developed in an attempt the bones of hyperparathyroidism and of osteitis to maintain an efficient circulation. In the absence of deformans differ only in degree, leaves us free to hope any organic cause the asymmetry in the arterial that the aetiology of Paget’s disease is in some way tension probably tends to be transient, but it may analogous to that of hyperparathyroidism. If Paget’s be recurrent, and the suggestion is made that the disease be comparable to Hodgkin’s disease, then the continued reduction of the arterial pressure in a cause must lie inside the bones. This is unthinkable. limb, from whatever cause, may be a factor in the The cause must surely be just as much outside the production of " essential hyperpiesia " by producing bones in osteitis deformans as it is outside the bones a prolonged compensatory arterial hypertension. in generalised osteitis fibrosa. We even feel entitled to expect a solution of this problem in that near future when methods of gauging inorganic salt metabolism TREATMENT OF BRONCHIAL ASTHMA have advanced beyond the crude standards of to-day. IT has long been realised that asthma is a symptom or syndrome rather than a disease, and it has been established that the larger proportion of those ASYMMETRICAL BLOOD PRESSURE from this syndrome show a hypersensitivity suffering IT is customary to take the blood-pressure reading of the mucous membrane of the respiratory tract from one arm only, and the time involved in making to a variety of stimuli. These stimuli may also an additional estimation on every patient would be a produce, either independently or in conjunction with serious consideration to busy practitioners. Yet if asthmatic symptoms, such phenomena as vasomotor the observations of E. J. Stieglitz and D. W. Probst1 rhinitis, and urticaria. As Sir James hay-fever, are of general application, there is a real danger in Dundas-Grant said at a meeting of the section of unilateral estimations, for they found that in 15 per of the Royal Society of Medicine last laryngology cent. of cases where the reading was taken from one week, " the nasal mucosa is the detonator and asthma arm only the systolic pressure in the other arm was is the explosion." Prof. van Leeuwen, of Leyden, higher or lower by as much as 10 mm. Hg and 5 mm. who opened the discussion, supported the view that Hg diastolic. These findings, which agree closely the etiology of vasomotor rhinitis is nearly always with the experiences recorded by W. E. Kay and allergic, and said that the white or bluish-grey K. D. Gardner in 1925/have been arrived at as the on the nasal mucous membrane characteristic patches result of the examination of 600 patients, all adults, of vasomotor rhinitis were present in 90 per cent. comprising private patients, dispensary patients, of 200 cases of asthma treated in his clinic. Of these and applicants for life assurance, the age-groups 200 cases 46 per cent. showed abnormalities of the ranging from 18-60 years. The determinations were septum, 5 per cent. had polypi, and 32 per cent. taken with mercury manometers and repeated read- showed abnormalities of the turbinates ; 26 per cent. ings on the right, left, and again on the right arm had had operations on the nose prior to admission. were made in all cases of asymmetry of the arterial He had observed that there was generally no direct tension. Such asymmetry is apparently not very relation between nasal abnormalities and the asthma, unusual, and the teaching that it is limited to casesand concluded that as a rule the effectiveness of antiof aortic aneurysm and trauma will have to be allergic therapy was not dependent on the nasal reconsidered. Stieglitz and Probst carried theircondition, though in rare cases an operation on the investigations further and attempted to find whatnose or cauterisation has undoubtedly brought relief. types of cases were more likely to give different He recommended the postponement of operation as readings, apart from such obvious causes as cervical long as possible while specific and non-specific rib, injury to a limb with resulting atrophy, arterio-(desensitisation was being tried. Mr. Walter Howarth venous aneurysm, and the like. They found that it[agreed that the results of nasal treatment were was more common in adults with hypertension, and( disappointing ; 10 per cent. of his cases showed in those showing marked vasomotor instability, sexi mprovement after cauterisation, and there were a not being a factor ; they showed also that the higher few definite cures. He was, however, more favourably systolic and diastolic readings were generally foundlisposed towards nasal interference in vasomotor on the right rather than on the left side. Since the r°hinitis, in particular the establishment of a free origin of the pressure is the pumping force of the left irway and empirical cauterisation. Approaching the subject from the pathological standpoint, Dr. A. F. 1 Amer. Jour. Med. Sci., 1932, clxxxiv., 335. 2 Calif, and Western Med., 1925, xxxiii., 578. Wright stressed the importance of secondary bacterial
and excessive
apposition
is
’
,
THE
-
articles. It was indeed fortunate that Dr. Billings set out to index the journals just when the tide began to flood. Our gratitude to him and to his successors is a little tinged with envy when we turn at the end of this volume to the Collection of incunabula and early medical prints " to find nearly 500 books printed before A.D. 1500 and half as many again from the next quarter-century, with prize upon prize among them. But what more fitting reward could there be for the bibliographers to whom we are so much indebted No subject has been so well treated as bibliographically medicine, and now we learn that our luck will hold. It was rumoured that the end of the third series was to be the end of the IndexCatalogue, and that after 1926, the last year yet indexed, the deluge would be over us. Now we learn with real gratitude that "work on the fourth series will be begun at once." Dr. Billings lies in the grave, but his great catalogue goes marching on.
after operation might show that deficient intake of essential substances played a part. Meat and green vegetables, so essential to normal hsemopoiesis, are too often lacking from the menu of the gastric patient. It is obvious that prolonged study of a large series of post-operative gastric cases would be of great interest. Biochemical investigations of the blood, the gastric juice, and the faeces should be correlated with the heamatological picture and the dietary
history.
____
THE ÆTIOLOGY OF OSTEITIS DEFORMANS
Dr. T. J. O’Reilly and Mr. Joseph Race, F.I.C.,l have investigated 30 cases of Paget’s disease which found their way, with a diagnosis of rheumatism, to the Hospital for Rheumatic Diseases in Buxton. Forty per cent. of them showed the physical signs of osteitis deformans ; 33 per cent. had the symptoms but none of the physical signs ; and 27 per cent. had neither symptoms nor signs, the condition being accidentally revealed by radiography. In the first ANÆMIA AFTER GASTRIC OPERATIONS group the average duration was seven years, and in THERE is apparently no gastro-intestinal disorder the second group four years ; the pelvis was affected that may not be associated with anaemia, and evidence in 26 cases and the lumbar spine in 24, while the femur is accumulating to suggest that this association is and tibia were both affected more often than the skull. no mere coincidence. Deficient diet, deficient gastric The earliest radiographic change recognised is a and faulty absorption in the intestines coarsening of the bone due to decalcification, which digestion, have all been proved experimentally to play a part accentuates the normal bone lines and produces an in the development of both hypochromic and hyper- appearance of simplification of the normal bone chromic megalocytic anaemias; while other factors, structure ; this was most often seen in the pelvis and such as pregnancy, have been shown to have a vertebrae. The second change is a complete loss of disturbing effect upon haemopoiesis, at least in some the normal sharp texture of the bone outline, so that degree, through their effect upon gastric secretion. the bone looks as though it were seen through ground Dr. R. A. Rowlands and Dr. S. Levy Simpson in our glass. The third change is a deposition of amorphous last issue, and Dr. Janet Vaughan this week, have calcium salts which spreads throughout the bone like reviewed the published records of relationship between a steamy white cloud, and, becoming dense, obliterates gastric operations and anaemia. Though less thanall detail in the radiograms. In the 21 cases where the 130 cases in all have been reported, it is clear that serum calcium and plasma phosphorus were examined, such operative interference may result in disturbance the figures were within the limits of normal. In every of blood formation. Dr. Rowlands and Dr. Simpson, case examined the plasma phosphatase figure was writing of Addisonian anaemia, comment upon the increased. The suspension stability of the blood was long latent period between operative interference normal, except when concurrent disease or sepsis and the development of symptoms ; the average existed, and in O’Reilly and Race’s opinion this period in their series was 6 years and the longest finding is strong presumptive evidence that osteitis 15 years. This may explain why, in a recent deformans does not belong to the infective group of symposium on the late results of gastric operation diseases. They rightly lay emphasis on the work of in which a large number of cases was reviewed, post- Snapper and others, which has shown that generalised operative anaemia was only mentioned in order to osteitis fibrosa is a separate affection, with distinct state that it did not occur. The hypochromic micro- biochemical and radiological findings, having a cytic type of anaemia, unless severe, is rarely a definite ætiological relationship to tumour of the presenting symptom, and careful examination would parathyroid gland and amenable to surgical treatment. probably show it to be more common than it appears. (Incidentally, Prof. Snapper’s work was done not in Why some patients develop hypochromic microcytic Austria, as they imply, but in Amsterdam.) anaemia and others hyperchromic megalocytic anaemia So much for a carefully conducted investigation after the same operative procedure is hard to see, of Paget’s disease. Turning to another part of their and the position is further complicated by Dr. paper, however, we learn that O’Reilly and Race Vaughan’s observation on a patient whose anaemia " have not had an opportunity of making a satisfacchanged within 36 days from a typical microcytic to tory histological examination of the bones in this a typical megalocytic type. At present it is impossible disease." How, then, can they "regard the disease to say exactly why operative interference causes as a local one, the reticular cells primarily affecting anaemia at all, and the evidence is insufficient to of the bones," and a close relationship to the having incriminate one type of interference rather than reticulo-endothelioses and an analogy to Hodgkin’s another, though attempts have been made to do so. disease’? Is this not another example of the error of Cases have been recorded in which the patient was casting aside years of work in morbid anatomy ? without anaemia six years after complete gastrectomy. Though modern physiological and biochemical There is no apparent relationship between the degree methods have served to show that hyperparaof hypochlorhydria and the severity of the anaemia, is a distinct entity, different from osteitis thyroidism nor between the occurrence and character of the deformans, respect is still due to the histologist who diarrhoea and the anaemia. The rapidity with which finds similarities between the two diseases. In the food leaves the stomach and the nature of the osteitis deformans there is great resorption Paget’s intestinal flora are also, it seems, without significance. 1 Quart. Jour. Med., October, 1932, p. 471. Perhaps a study of the type of diet taken by patients
1287
ventricle
associated with great apposition of bone, completely the higher reading is the significant one. altering the normal architecture ; but appositioni The possibility of asymmetry should be borne in mind, preponderates. In von Recklinghausen’s generalised1 especially in examination for life assurance. Serious osteitis fibrosa widespread resorption is the essential, error may result from an estimation which is just ,
focal and relativelyT within the normal limits in one arm, if it happens This seems to be the only definite to be 10 mm. Hg of mercury higher in the -other insignificant. difference. less it is, of course,, untested arm. None the histological The paper describes among others the case of a big difference, and the contention of Germanspeaking pathologists that " osteodystrophia fibrosa " a man, aged 36, in whom at one examination the is a great unity, with many subdivisions such as; pressure in the right arm was 170/130, and in the Paget’s disease and von Recklinghausen’s disease, left arm 130/80. A cervical rib was found on the seems to ignore what has been discovered throughleft side. This was removed surgically, and afterwards the asymmetry in the blood pressure gradually experimental physiology and biochemistry. It is difficult to agree with O’Reilly and Race in disappeared until five months later the pressure in their analogy between Hodgkin’s disease and osteitis the right arm was 150/85 and in the left 142/86. deformans. Paget’s disease and granulomatous Stieglitz and Probst endeavour to explain this case inflammations appear to be poles apart. The available by the assumption that the cervical rib, by pressure evidence suggests that osteitis deformans has a on the brachial plexus, produced a decrease in the chemical and not an inflammatory origin, and the tone of the vessels in the left arm, and that as a result histologist who assures us that the changes seen in a compensatory hypertension developed in an attempt the bones of hyperparathyroidism and of osteitis to maintain an efficient circulation. In the absence of deformans differ only in degree, leaves us free to hope any organic cause the asymmetry in the arterial that the aetiology of Paget’s disease is in some way tension probably tends to be transient, but it may analogous to that of hyperparathyroidism. If Paget’s be recurrent, and the suggestion is made that the disease be comparable to Hodgkin’s disease, then the continued reduction of the arterial pressure in a cause must lie inside the bones. This is unthinkable. limb, from whatever cause, may be a factor in the The cause must surely be just as much outside the production of " essential hyperpiesia " by producing bones in osteitis deformans as it is outside the bones a prolonged compensatory arterial hypertension. in generalised osteitis fibrosa. We even feel entitled to expect a solution of this problem in that near future when methods of gauging inorganic salt metabolism TREATMENT OF BRONCHIAL ASTHMA have advanced beyond the crude standards of to-day. IT has long been realised that asthma is a symptom or syndrome rather than a disease, and it has been established that the larger proportion of those ASYMMETRICAL BLOOD PRESSURE from this syndrome show a hypersensitivity suffering IT is customary to take the blood-pressure reading of the mucous membrane of the respiratory tract from one arm only, and the time involved in making to a variety of stimuli. These stimuli may also an additional estimation on every patient would be a produce, either independently or in conjunction with serious consideration to busy practitioners. Yet if asthmatic symptoms, such phenomena as vasomotor the observations of E. J. Stieglitz and D. W. Probst1 rhinitis, and urticaria. As Sir James hay-fever, are of general application, there is a real danger in Dundas-Grant said at a meeting of the section of unilateral estimations, for they found that in 15 per of the Royal Society of Medicine last laryngology cent. of cases where the reading was taken from one week, " the nasal mucosa is the detonator and asthma arm only the systolic pressure in the other arm was is the explosion." Prof. van Leeuwen, of Leyden, higher or lower by as much as 10 mm. Hg and 5 mm. who opened the discussion, supported the view that Hg diastolic. These findings, which agree closely the etiology of vasomotor rhinitis is nearly always with the experiences recorded by W. E. Kay and allergic, and said that the white or bluish-grey K. D. Gardner in 1925/have been arrived at as the on the nasal mucous membrane characteristic patches result of the examination of 600 patients, all adults, of vasomotor rhinitis were present in 90 per cent. comprising private patients, dispensary patients, of 200 cases of asthma treated in his clinic. Of these and applicants for life assurance, the age-groups 200 cases 46 per cent. showed abnormalities of the ranging from 18-60 years. The determinations were septum, 5 per cent. had polypi, and 32 per cent. taken with mercury manometers and repeated read- showed abnormalities of the turbinates ; 26 per cent. ings on the right, left, and again on the right arm had had operations on the nose prior to admission. were made in all cases of asymmetry of the arterial He had observed that there was generally no direct tension. Such asymmetry is apparently not very relation between nasal abnormalities and the asthma, unusual, and the teaching that it is limited to casesand concluded that as a rule the effectiveness of antiof aortic aneurysm and trauma will have to be allergic therapy was not dependent on the nasal reconsidered. Stieglitz and Probst carried theircondition, though in rare cases an operation on the investigations further and attempted to find whatnose or cauterisation has undoubtedly brought relief. types of cases were more likely to give different He recommended the postponement of operation as readings, apart from such obvious causes as cervical long as possible while specific and non-specific rib, injury to a limb with resulting atrophy, arterio-(desensitisation was being tried. Mr. Walter Howarth venous aneurysm, and the like. They found that it[agreed that the results of nasal treatment were was more common in adults with hypertension, and( disappointing ; 10 per cent. of his cases showed in those showing marked vasomotor instability, sexi mprovement after cauterisation, and there were a not being a factor ; they showed also that the higher few definite cures. He was, however, more favourably systolic and diastolic readings were generally foundlisposed towards nasal interference in vasomotor on the right rather than on the left side. Since the r°hinitis, in particular the establishment of a free origin of the pressure is the pumping force of the left irway and empirical cauterisation. Approaching the subject from the pathological standpoint, Dr. A. F. 1 Amer. Jour. Med. Sci., 1932, clxxxiv., 335. 2 Calif, and Western Med., 1925, xxxiii., 578. Wright stressed the importance of secondary bacterial
and excessive
apposition
is
’
,
THE