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quiescent stage. Three of these were tuberculous,two having tuberculous peritonitis, another was acase of actinomycosis of the appendix. The othercases, No. 4 and No. 101, were purposely performedafter the acute attack had subsided.

Results.

Complications which Occurred amongst the 114Cases Operated npon During the Acute Attack.

The 7 cases which developed a fecal fistula were operated uponlate in the attack.

Whenever possible, in acute cases of appendicitis iwith abscess formation the appendix should beremoved. In only two cases (23 and 120) the

appendix was not removed at the first operation,but at a later date. In these cases the abscesscavity was a large one and well walled off, theappendix could not be felt, and the condition of thepatient grave.

Case 120, musician, aged 18. This boy had justreturned from seven days’ leave, during whichtime he was unwell. He went three times to a

chemist, who told him he was suffering from colicand gave him some medicine. On rejoining hisship, as he felt worse, he reported to the sick-bay,and was immediately transferred to hospital.As regards complications, Cheever 7 points out

that the most frequent complication of acuteappendicitis is post-operative intestinal stasis.This is generally due to paralysis of the bowel wallcensequent upon the peritoneal infection. Thereare other cases, however, in which the obstructionis caused by a twist or kink, most frequentlyaffecting the terminal ileum. Many of the formergroup recover spontaneously, or are relieved bysuitable non-operative treatment. Obstructionfrom mechanical causes, however, needs earlyoperative treatment if the case is to recover, and itis therefore of the greatest possible importance torecognise these cases.Cheever thinks that a certain number of cases

of this latter group are due to adhesion of theileum to the inflamed bed of the appendix on thelateral pelvic wall, a condition to be suspected ifafter a few days of normal convalescence, symptomsof intestinal stasis appear in a patient whoseinflamed appendix has been stripped away from theside wall of the pelvis.

References.—1. R. Short: Appendicitis, Index of Prognosis, 1915.2. S. R. Macphail: Jour. Anat., vol. li., p. 308. 3. Hertz : THE LANCET,1913, vol. i., p. 308. 4. J. E. Adams: Practitioner, April, 1917, p. 301.5. R. J. Gladstone: Jour. Anat. and Phys., vol. ccccxvi. 6. Keibeland Mall: Manual of Human Embryology. 7. Cheever: Bost. Med.and Surg. Jour., 1913, i., 179.

A NOTE ON

DEXTROCARDIA, COMPLETE ANDINCOMPLETE,

WITH FOUR ILLUSTRATIVE CASES.

BY BASIL PARSONS-SMITH, M.D., B.S. LOND.,M.R.C.P. LOND.,

LATE CAPTAIN, R.A.M.C. (T.C.).

DEXTROCARDIA, or right-sided heart, is a conditionsufficiently uncommon to merit a most careful

inquiry into the physical state, resistance value, andwork capacity of all cases that come before ournotice, and the four examples hereunder noted maybe taken to call for special interest in that eachwas a soldier who had, for a time at any rate, per-formed full duty on active service. Dextrocardia,as seen clinically, must be clearly differentiatedfrom a condition to which it is closely allied-viz.,pseudo-dextrocardia, where we are dealing with adisplacement, not a transposition. True dextro-cardia is a congenital anomaly; as the name inplies,it indicates a heart situated on the right side,associated, more often than not, with transpositionof the stomach, spleen, and liver. By such visceraldispositions one would expect a practical andefficient compensation for the abnormal site adoptedby the heart in its evolution.

Recital of Four Cases.The following cases may assist us in arriving at

reasonably definite conclusions.CASE 1.—Tpr. R., age 30. The patient came under

observation in August, 1918, suffering from " D. A. H."and symptoms of general incompetence which had com-pelled him to leave his unit some two months previously.In size, height, and general development patient is wellabove the normal standard. The family history is un-important, and exhibits no features of note in the presentcontext. The past history from the medical point ofview is negative, except for bronchitis at the age of 7.

During boyhood the usual athletic pursuits were followed,and until joining the army patient had been employedas a farmer. It is noteworthy, however, that he wasunable to make sustained effort, and, being his ownmaster, he was in a position to choose the light workand miss that of a heavy and laborious nature. Forthis apparent disability no intrinsic medical reason isgiven by the patient; the only explanation he advancesis that he was always subject to colds and pains in theright side of the chest on exertion.In March, 1917, patient joined the army (R.H.Gds.) and

commenced his training in riding, foot-drill, gymnastics,&c. This he managed perfectly satisfactorily for threeand a half months ; at the end of this time he was seenby the medical officer in consequence of a persistentpain in the chest and a general condition of debility,and for this reason he was transferred for lighter dutyto the clipping staff, at which work he remained untilcoming overseas in March, 1918. On arrival in Francehe was at once attached to the M.G.C. and performedfull duty in the line for two months, when, the oldsymptoms returning, patient was sent down the line.

The symptoms were few but definite : Shortness ofbreath with effort, pains in the chest (right), dizzi-ness (postural), tremor and nervousness. On exa-

mination, apex beat, sixth intercostal space (right),1 inches internal to the mid-clavicular line, heavingin character, not tender to palpation. The A.C.D.begins above the fourth right costal cartilage,extends down the left sternal margin, and outwardshalf an inch beyond the apex beat in the sixth inter-costal space. Sounds clear, relative intensity normal.No thrill at apex or base. No abnormal exocardialsounds. Heart’s reaction to effort test not good, rate ofbeat, elevation of blood pressure, and respiratory

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excursions one and all unduly exaggerated. Pulmonaryexpansion normal and lungs free from physical signs.X ray report: Transposition of heart, liver, and

stomach; bismuth was given and seen very distinctlyon the right side in the fundus of the stomach.CASE 2.-Rfn. H., age 19. Evacuated from his unit

with gas poisoning, presented the usual symptomswhich follow exposure to the vapour of the so-called"mustard gas" (di-chlor-ethyl-sulphide); was treatedby routine methods and made a satisfactory and com-plete recovery. Patient’s family history is good, andhis past life, except for an attack of typhoid fever atthe age of 13 and diphtheria when 16, has been per-fectly normal from the exercise and athletic point ofview. At 18 patient joined the army and underwentthe usual course of training without experiencing theleast difficulty.To outward appearance patient is a normal healthy

lad, well proportioned and developed; the colour is

good; there is no tendency to cyanosis or clubbing ofthe fingers ; the conformity of the thorax and trunk isnormal; the heart’s apex is seen and felt in the fifthright intercostal space 1 inch internal to the mid-clavicular line, and in the lateral decubitus it isobserved to travel outwards (1 inch) and downwards tothe sixth space. The cardiac dullness begins above atthe level of the third intercostal space, extends downthe mid-sternal line, and outwards to the apex beat.The first sound at the apex is split, otherwise thesounds, at both apex and base, are normal in tone andrelative value; the rhythm is regular. The responseto effort is good and satisfactory. The manometric

readings, before and after the test exercise, conform tothe normal type. The respiratory excursion is goodand equal on the two sides, and the healthy vesicularmurmur is heard over both lungs, gastric tympanyextends downwards from the sixth intercostal space onthe right side, and the note characteristic of hepaticdullness extends from the sixth rib to the costal marginon the left side. Extract from X ray report says :"Transposition of heart, liver, and stomach; bismuthgiven and seen on the right side in the fundus of thestomach."CASE 3.-Pte. R., age 31. Was admitted August, 1917,

complaining of shortness of breath, choking sensationsat nights, exhaustion with the slightest effort, and lossof weight. His past history was not good, all the usualchildish complaints with persistent delicacy duringadolescence compelled him to adopt a sedentary occupa-tion. After four months of active service, the above-mentioned symptoms of incompetence made their

appearance, and patient was sent down the line. The

appearance of the man when first seen was noted asfollows: medium height, poor physique, and expressionof anxiety, sallow complexion, with a definite cyanotictinge.On examination, an impulse typical of the heart’s

apex was seen and felt in the sixth right intercostalspace 4 inches from the midsternal line ; to percussion,dullness, characteristically cardiac, was found to extendfrom the third space above, down the left sternal

margin and outwards to the impulse; this area was

unduly prominent and hyperaesthetic to both palpationand percussion ; extra-systoles, with change of positionand following exercise, interfered with the otherwiseregular rhythm ; the first sound at the apex was re-duplicated, no bruit was detected, and the basal soundswere clear. The stomach was proved to occupy itsnormal position, both by percussion and inflation ; theliver was situated in its usual quarters on the rightside ; the heart’s response to effort was bad, testexercises were productive of visible distress, the objec-tive phenomena, rise in pulse-rate, respiration andblood pressure, were both exaggerated and prolonged,and sustained effort, even of a mild description, wasunsatisfactorily performed. Under treatment slightprogress in general condition was manifest, but it

rapidly became clearly obvious that patient wouldnever arrive at the standard of fitness which full duty ion active service demands.

CASE 4.-Pte. B., age 27. Admitted November, 1917,labelled V.D.H. His history in brief was as follows :

Persistently poor health during childhood, inability forgames or strenuous exercise of any kind, a sedentaryoccupation (clerk), and a permanent tendency tobronchitis which invariably incapacitated him duringthe colder months. Patient experienced great difficultywith his training, and was more often than not on lightduty. On arrival overseas he was drafted to his unit;symptoms of general incompetence soon becameevident, and patient was sent to hospital at the end ofthe fifth week.At the first examination patient was observed to be a

poorly developed man of delicate build and sallow,anaemic complexion. The main symptoms includedshortness of breath, faintness, giddiness, pains andconstriction in the chest. The conformity of the chestwas irregular in that the right side was undulyprominent and the left side appeared decidedlyflattened; the heart’s apex beat was seen and felt inthe sixth right intercostal space one inch external tothe nipple line; the cardiac dullness (deep) beganabove at the level of the third rib and extended downthe left sternal margin and outwards to the apex beat;this area was prominent and hyperaesthetic to palpationand percussion; the heart-rate was rapid (124 resting),the rhythm was regular and undisturbed ; the diastolicinterval curtailed; the sounds at the apex were short,sharp, and accentuated, especially the first sound; thebasal sounds were complicated by a soft and long-drawn-out bruit which was audible over the upper halfof the pr2ecordial area. This bruit varied in intensity,being distinctly louder during the systolic phase andtailing off rapidly in the diastolic interval. Afterexercise one could easily pick up the murmur pos-teriorly at the angle of the scapula. A fine thrill wasfelt on light palpation in the third intercostal spaceone inch from the right sternal margin. The pulse wasrapid, low in tension, and small in volume, thoughlarger in the left radial than the right, possibly owingto the fact that patient was left-handed. The blood-

pressure readings confirmed the impression one hadformed of the pulse by palpation. The systolic readingwas 90 mm., the diastolic 75 mm. ; these readings weretaken with the patient at rest. Effort, even the

elementary tests, was badly borne, the usual sym-ptoms of distress were complained of, and objectivephenomena-viz., dyspnoea, cyanosis, pallor, perspira-tion, and the typical facies of anxiety-were noted.Stomach resonance occupied the normal position on

the left and reached the sixth rib in nipple line,merging at this point directly into pulmonary resonance(confirmed by the inflation test). The liver was

situated on the right side, and the percussion dullnessof this organ extended downwards in direct continuityfrom the heart dullness above to the costal margin below.

SUmma1’1! of Cases.In briefly summarising the above it is clearly

evident we are dealing with two entirely differenttypes of right-heart. In the first two cases thetransposition not only affects the heart but alsothe liver and the stomach ; in the other two cases(Cases 3 and 4) the heart is transposed, but theliver occupies its normal position on the right andthe stomach is in its usual bed on the left side.Comparing now these objective phenomena withthe individual symptoms complained of, the reac-tion to effort, and the response to strain both

present and past, one realises how widely differentin importance from the prognosis point of view thetwo types of the condition appear to be. In one

variety we recognise an apparently satisfactorysolution to the congenital anomaly. In the otherit is evident that we are faced with a state ofaffairs totally inimical to even an ordinary degreeof efficiency.

Conclusions.

1. In dextrocardia we recognise one of the rarerof the abnormalities of development which appearfrom time to time.

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2. The significance of a right-sided heart entirelydepends upon whether it is associated or not withsimultaneous transposition of liver, stomach, andspleen.

3. Associated with complete transposition ofviscera dextrocardia does not incapacitate and isusually diagnosed by accident.

4. Dextrocardia without transposition of viscerais of serious moment. Symptoms of incompetenceare bound to appear sooner or later; these latterinclude dyspncea, palpitation, insomnia, faintness,pain, &c., and result from a general visceral over.crowding, the liver impeding the movements ofthe heart and the upper lobes of the right lung.

5. Cases of dextrocardia without transposition in-variably lay stress on the pains they experience bothduring effort and when resting; these pains depend-ing upon the visceral overcrowding, are both localand referred, local when they denote pressure uponthe intercostal nerves or brachial plexus, referredwhen the vagus or its intracardiac endings sufferinordinate stimulation.

6. Dextrocardia without transposition is usually,if not always, complicated by actual malformationof the heart and great vessels. In the fourthcase above reported it was considered that theventricular septum was perforate. Likewise wemust be prepared to meet with other congenitalderangements, pulmonary stenosis or atresia, trans-position of great vessels, incomplete septa, patentductus arteriosus, &c.

Clinical Notes:MEDICAL, SURGICAL, OBSTETRICAL, AND

THERAPEUTICAL.

A CASE OF

ACUTE PULMONARY ŒDEMA.

BY GUY J. BRANSON, M.D.LOND.

THE following case appears to belong to the classof acute pulmonary suffocative catarrh.Mr. -, aged 50, spare and active, was seen by me

for the first time at 9.30 P.M. on August 6th. He statedthat 20 years ago he had had rheumatic fever, andbelieved that "his heart had been affected." Whenexamined by a recruiting medical board he had beentotally rejected, because (he understood) of his heart; ’,but he had never consulted a doctor, as it never gavehim trouble. Earlier in this year he had been unwellfor about one month with an indefinite illness, but hadreceived only domestic attention. Otherwise he hadled an active business life until this sudden attack,though he admitted not having felt so well as usual forabout a week past. About an hour before I saw him hewas, whilst playing the pianola, suddenly seized withviolent palpitations, which made him retch (not cough)slightly, and he was alarmed to find that a little fluidwhich he brought up was slightly tinged with blood,but the palpitations were the outstanding feature in hiscomplaints. I found him sitting in a chair. His appear-ance did not suggest grave illness, and he volunteereda long statement as to his condition. His mental

clarity was quite unimpaired and remained so through-out. There was no cyanosis and no dyspnoea. (Edemaof the legs was carefully looked for and was not present.The mouth temperature was 98° F. The fingers weremarkedly clubbed. The heart’s action was notablyviolent, the whole praecordium and epigastrium showinga widely diffused impulse. The A.B. was in the sixthinterspace, inch external to V.N.L. The beat was

irregular and tumultuous, and a loud-blowing systolicmurmur was audible at the apex, and was conducted

widely into the left axilla. It was clearly audible atthe left scapular angle. No adventitious sounds wereaudible in the lungs. There was a trifling cough whichbrought up a thin watery sputum, faintly blood-tinged,and in very small amount. It appeared that fibrilla-tions of sudden onset had supervened on an old mitrallesion, and that cedema of the lungs was starting.At 9 A.M. on August 7th the heart was steadier,

Pulse 120, action still violent, but vessels ill-filled. Heagain complained chiefly of palpitations which hadprevented rest; and, although there was no notabledyspnoea, the breathing was a little more laboured.Fine, moist crepitations were audible over both lungs,back and front. There was now a troublesome cough,and he showed me a large teacup filled with pink, thin,serous fluid. At 7 P.M. he was obviously dying. Theface and lips were pale, and there was now some slightdistension of superficial veins. The chest was full ofrhonchi, as the oedema had obviously involved thelarger tubes. Death took place at 8.30 P.M., 24 hoursfrom the onset.

In my view, the heart failed before the fullasphyxiating effect of the pulmonary complicationcould come into operation.

References.—Sir J. Mackenzie: Diseases of Heart, third edition,p. 56, and Principles of Diagnosis and Treatment in Heart Affec-tions, p. 184. F. W. Price: Diseases of Heart, p. 327.Edgbaston.

A CASE OF

PERIPHERAL MULTIPLE NEURITIS

ASSOCIATED WITH PRIMARY MALIGNANT DISEASE OFTHE LIVER.

BY T. DAVIES PRYCE, M.R.C.S.,CONSULTING SURGEON, NOTTINGHAM GENERAL DISPENSARY.

THE following case appears to be interesting aspointing the lesson that when there are symptomsof sensory peripheral neuritis unassociated withdiabetes and other known toxic causes, a carefulsearch for malignant disease should be made.

J. B., female, aged 70. Eighteen months prior to herdecease the patient began to lose flesh and com-plained of a slight degree of fatigue on exertion. Asso-ciated with these symptoms there was paraesthesia ofboth legs and hands. The subjective sensations oftingling and formication were well marked, but nodefinite loss of tactile or thermal sensibility could bedetected. The knee-jerks were diminished, but theplantar and other skin reflexes were normal, as alsothose of the pupil. The blood pressure was normal.No organic disease was discovered. In the course ofthree months the patient complained of constrictivepains at the waist and the sensation of cold when thelower limbs were apposed. At nine months there wasconsiderable anaemia and cachexia. Only slight patellarreaction could now be obtained, and there was somedegree of ataxia, consisting of difficulty in maintainingthe balance with the eyes closed and on sudden move-ment. In walking the sole of the foot was broughtdown flat to the ground, as in the early stages of somecases of locomotor ataxy. There was no "steppage,"and no evidence of paralysis. The reaction to bothcontinuous and interrupted currents was normal. At15 months from the onset the patient complained ofpersistent pain in the hepatic region, and this wasfollowed by vomiting, fever, and sweating, togetherwith slight jaundice. These attacks (which were

probably due to gall-stones) were repeated at

varying intervals. The liver was irregularly enlargedand extended variably to 3 inches below the costalborder. Slight patellar reaction on reinforcement. She

gradually sank, dying on August 3rd. Unfortunately, apost-mortem examination was not obtained, but therecan be no reasonable doubt as to the nature of herailments.