2
123 of rheumatism was denied, and the size and shape, and the entire absence of concomitant symptoms, tended to disprove its syphi- litic origin. On the other hand, the account of its gradual and slow growth, the absence of severe pain, and the apparent good health of the patient, without any affection of surrounding glands, were not the ordinary features of a malignant tumour. Perhaps its situation, and its peculiar oblong shape, with the fact that unless a growth can be pronounced to be certainly innocent there is always a strong bias in favour of its ma- lignancy, were the most suspicious of its characters. When the operation had cleared up its exact nature, the disease might be called " osteoid cancer," occurring in an unusually inactive form. Its gradual growth for three years is not incompatible with this view, since Mr. Paget has recorded a case in which a similar tumour was removed from the arm of a woman aged thirty-two, after ten years’ growth ; and Mr. Stanleyt another, in which the thigh was amputated on account of such a tumour of eighteen years’ growth. The peculiar density of the bone-tissue, the obliteration of the outline of the bone in the disease around, and especially the excavations containing the softer fibrous material, with cell forms scattered throughout it, mark the nature of the dis- ease with sufficient clearness. In such cases as this the micro- scope can throw great weight into the scale which determines the malignancy or innocency of a growth. The periosteal thickenings, with or without enlargement of the subjacent bone, so often occurring at the extremities of long bones, and especially of the femur, present very many of the so-called characters of malignant growths ; and even after amputation (for this is sometimes their fate) the deposit of soft plastic material around condensed bone-tissue helps to bear out the resemblance, until the microscope throws light upon the subject, and perhaps proves what we are pleased to call plastic material to be the nidus of germs of a more fatal nature. The resemblance is still further maintained when in such a case amputation has been performed through apparently healthy bone, and shortly the end of the stump assumes the same action. A case of the kind occurred in this hospital under Mr. Wormald’s care, which is briefly as under :- A man aged thirty-two, working for years as an arsenic and copper smelter, was admitted, exceedingly out of health, on account of an oblong, ill-defined enlargement of the lower end of the right thigh. Opinions were divided as to the malignancy or innocency of the enlargement. Under the impression that the tumour was malignant, the limb was removed. The abun- dant soft material, with enlargement and condensation of the ’bone, even now could not absolutely settle the case. The dis- ease was, however, generally believed to be the result of in- flammatory changes in the bone and its periosteum. After the operation the man never did well: the remaining portion of the femur became inflamed; the entire periosteum became de- stroyed by diffuse suppuration ; and the bone after death had become superficially necrosed, the exfoliating portions being bordered by irregular deposits of new bone. In such a case, should the structure or the progress of the disease rather serve as a guide to its nature ? The after- progress of the case was, as too often occurs, favour- able up to a certain point. Then suddenly there comes a change- not a matter of surprise, however much of regret; for in spite of all our precautions, symptoms which, for want of a better term, are called " pysemia," almost without our suspecting their approach, too often make their appearance. Certainly here the dangers to be dreaded were diffuse suppuration around the wound, or some pulmonary affection; instead of which the man suddenly succumbs to symptoms which in themselves might pass for those of acute rheumatism, though of the most grave nature, inasmuch as the pericardium was undoubtedly in- volved. The appearance of these symptoms after a wound, the preceding rigor occurring without warning, the partial affec- tion (at first) of the joints, the absence of the peculiar odour in the perspiration, all tend to throw doubt on the rheumatic origin of the attack. It so rarely happens, too, that the peri- cardium suffers without the valves in rheumatic carditis, that we may consider this limited cardiac affection as favouring the probability of pyaemia. Dr. Kirkes has clearly shown this in his papers on "Pericarditis consequent on Pysemia." Still it must be confessed the diagnosis between the two conditions is by no means easy, or, perhaps, always possible. In a case of removal of an exostosis from the femur in this hospital, similar symptoms occurred. There was great difference of opinion amongst the physicians and surgeons who saw the case. The man eventually recovered. Another man, the subject of stric * Paget’s Surgical Pathology. t Diseases of Bones. ture, after being an inmate for some time, was believed to suffer from, and was treated for, rheumatic fever. Subsequently he had purulent deposits in various joints, and died, the autopsy disclosing a large abscess between the bladder and rectum, the result of a. "false passage." Curiously enough, there are at present in Kenton ward two patients who both, while in appa- rent health, met with accidents, in each case without any wound resulting. The one, a man not liable to rhenrnatism, was knocked over a table, and sprained his wrist. When re- action came on, several of his joints became swollen, and on the fourth day after the accident, his case was thought to be one of acute rheumatism. The injured wrist was the last to recover itself. The case yielded readily to the ordinary alkaline treat- ment. The other case, a man liable to rheumatism, fell from a house, was admitted with great collapse, and supposed rupture of the kidney. When reaction ensued, he went through all the ordinary stages of rheumatic pericarditis, with endocarditis, but he had no joint affection. The appearances disclosed after death tally with those re- corded by Dr. Kirkes and others, as those of pyæmial cardiac disease. It is remarkable, however, that the pulmonary lesion was exceedingly limited, hardly more than commencing; but though slight, it was still evidently sufficient to give rise to grave cardiac mischief. ST. GEORGE’S HOSPITAL. OBSTRUCTION OF THE PULMONARY ARTERY BY COAGULA, CAUSING SUDDEN DEATH. (Under the care of Dr. PITMAN.) THE details of the remarkable and rare cause of sudden death in the following case render it one of much pathological in- terest:- Mary A-, aged twenty-three, was admitted on the 30th of September, 1863, with slight febrile symptoms. She was an hysterical but healthy girl. The symptoms rapidly sub- aided, and she became convalescent. She was about to leave the hospital recovered, when some stiffness and swelling of the left leg was observed, and she decided to remain a day or two longer. The same day the nurse was called to her at the water- closet, and found her in a fainting state, barely conscious. She died a few minutes afterwards. An inquiry into her history showed that her previous health had been always good until five weeks before admission, when she had complained of pain in the chest. Ten days before she entered the hospital these symptoms bad increased so far as to induce her to keep her bed, and she had had several distinct rigors. The severity of the attacks must have subsided before admission, when the skin was cool, and the tongue clean. She had quiet, rather frequent pulse, and the aspect of health. The patient had been treated at first with ammoniated salines, and afterwards was given valerian and aloes. Close questioning of her friends after death proved that she had always enjoyed good health. Autopsy, sixteen hours after death.-The body was plump and well nourished ; a good deal of fat was present in the ab- dominal walls. The legs were slightly oedematous. The brain and its arteries were healthy. The left ventricle of the heart was quite uncontracted ; the right was partly contracted. The pulmonary artery was entirely filled with a partly decolorized clot, which was more or less adherent to its walls. This ex- tended from the pulmonary valves to the bifurcation, and thence into both branches, and so on to the smallest branches which could be reached by dissection. In the lung, here and there a small ramific,tion was found which was empty; but the right and left pulmonary artery, as well as the main trunk, were entirely obstructed. The fibrin was hard, and it had the appearance of having been formed for some time. The valves of the heart and the aorta to its end were natural, as also were the carotid and vertebral arteries. Lungs, bronchi, and pleura- were healthy. The right leg was more obviously oedematous than the left, and its vessels were therefore examined. The deep femoral artery contained a partly bleached coagulum, which commenced with a point at the origin of the vessel, and filled it up as far as it could be followed. The femoral veins of the same limb also contained a clot, which began in a tapering form at the middle third of the thigh, and extended downwards to the ultimate ramifications of the vein. This was black in the centre, partly fibrinous at the edges. It was firm, and fully distended the vessel. Some slight adhesions held together the liver and spleen; these readily broke down, and allowed of the escape of a quantity of creamy matter, which was contained in a cavity between the liver and spleen, formed, however,
