ARTERIAL PRESSURE IN ITS CLINICAL ASPECTS
Authors: J. F. H. Dally
Journal: BMJ (1930)

OSTEITIS FIBROSA.I THE BRITIDU (leveloped in June, wlhen the patient had to be confined to bed.Although the pain in the arm anid chest was persistent, her general condition improved witlh rest, and she was eventually able to carry out her household duties to a limited extent.In August, howevei, while stepping on io a vehicle, she experienced a sudden severe pain in the left upper arm with a sense of " something having snapped."Examiniation inmmediately after this incident revealed subcutaneouis liaenorrhage along the inner aspect of the left upper arm and imrnobility of the affected part.A fortnight later the patient was admitted to a nursing home.A hard, fuisiform swelling about the size of a tangerine orange was present over the lower third of the left lhumerus.Crepitus and-undue mobility were absciet.Tenderness was slight, but movements around the left elbow-joint were painful and limited.Sensations were uinimnpaired.Radio-grams showed a complete oblique fracture at the lower end of the left humerus, with the fragments in fairly good position and calluis formation.The hard bone in the region of the fracture was greatly rarefied.The appearances were definitely indicative of pathological frac-ture (see Fig. 1).This finding was supported by the history of the case, in which there had been no question of external violence.Other areas of rarefaction were present in both epicondyles, in the head of the radius, and in the olecranon on the left side, while the right humerus, radius, and uilna (see Figs. 1 and2), and the ribs on both sides, were also involved.Although the evidence pointed to the fracture having been pathological rather than traumatic in origin, healing had not been delayed, since bony union was firm.The differential diagnosis between secondary carcinoma of bone and some form of rarefying osteitis then fell to be considered.A small nodule, about the size of a haricot bean, was palpable in the left mamma.The patient was examined by Mr. G. T. Mowat of the Glasgow Royal Cancer Hospital, who expressed the opinion that the nodule was more likely to be associated with chronic mnastitis than with carcinoma.It was subsequently removed by Mr. Mowat, Histological examination revealed dense patclhes of fibrous tissue with very scanity adenomatous elenments, indicative of chronic mastitis.It was pronounced non-malignant.Exaniination of the pelvis, the clhest, and the abdomen gave no evidence of neoplasm.Gastr ic analysis, after an Ewald's test breakfast, showed a normial acidity.The blood picture was that of a secondary anaemia.The urine contained a trace cf albumin.Mitral stenosis was the only other point of note in the gelleral sur vey.The above findinigs, taken in conjunction with the fact that the fr-acture was well healed, were considered sufficient to exclude the presence of a primarv carcinoma in any of the regions from which metastases to bone usually originate, and to confirm the non- malignant nature of the disease in the bones.Fur thermore, the patient's nutrition was improving on ordinary diet.The weight of evidence, then, turned in favour of some form of rarefying osteitis.A metabolic experiment, in which the calcium intake and output were measured over a period of four days, showed, however, that there was no excessive decalcification.The retention of calcium was slightly positive (0.3 gram CaO per day), and the calcium content of the blood was normal (0.014 per cent.CaO).After returniing home, on October 22nd, pain became more generalized, and the patient was completely confined to bed.Mild pyr3xia, dyspnoea, and cough with blood-stained sputum com- menced in Decemiiber, following upon a chill.Anorexia and vomiting, not preceded by hausea and unassociated with food, supervenied; oedema of the legs developed, and the patient died in January, 1930, with all the signs of cardiac failure.Altliough the featuLres of the case at one stage suggested that the pathlological fracture might be associated with tunicur of bone, the subsequent history as well as the cliniic.alfindings inidicate(d that it was due to a localized or arrested osteitis fibrosa.