1203MEDICAL SOCIETY OF LONDON.

single factor. He thought that severe cold was undoubtedlyprejudicial, though perhaps it was caused by the patientsshutting themselves up at night. In his belief it was the

strength of the wind and not its direction which wasdetrimental.

Dr. GORDON, in reply, said that he did not wish to statethat the south-west wind was detrimental in all parts of theworld, but it certainly seemed to increase the phthisisdeath-rate in Devonshire. He thought it was quite possiblethat the evils of wind might be partly due to shutting up atnight. He doubted whether occupation much affected hisstatistics. He believed that the chief reasons why thesouth-west and west winds were bad was because theywere the most prevalent, the most violent, and the wettestwinds in Devonshire, to which, of course, all his remarkswere confined.

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MEDICAL SOCIETY OF LONDON.

Some Remarkable Cases of 8arooma.-The Occurrence ofArthritis in AS8ooiation with Appndicitis.

A MEETING of this society was held on Oct. 22nd, Mr.JOHN H. MORGAN, the President, being in the chair.

Mr. A. MARMADUKE SHEILD read a paper on SomeRemarkable Cases of Sarcoma revealing some of the sourcesof error which attend the diagnosis of that disease. Thepaper is published in full on page 1190 of this issue.-Mr.G. R. TURNER referred to some cases which he had publishedin the Transactions of the Clinical Society. One of these was acase of sarcoma of the thyroid gland pressing on the tracheaand necessitating tracheotomy. The tumour subsequentlydisappeared entirely, although microscopical examination hadshown it to be undoubted sarcoma. The patient remainedhealthy for six months and then the swelling again appeared.Removal was attempted unsuccessfully and after this thetumour again subsided. The patient ultimately died and thenecropsy confirmed the sarcomatous nature of the growth,though at the time of death it had undergone considerableinvolution. The second case was one of multiple melanoticgrowths at the back of the neck which were removed, andalthough the patient remained under observation for somethree years or more the growth never recurred. He was

surprised to find wbat a number of cases-35 or more atthe time he investigated the subject some years ago-were onrecord of undoubted sarcoma which had entirely disappeared.He referred to the great difficulty which might be experiencedin the diagnosis between abscess and sarcoma and mentioneda case in point of alveolar sarcoma of the spine which bad ihad all the features of abscess.-Surgeon-Major A. G. BLACKreferred to a case of abscess of the breast which had beenmistaken for sarcoma and also another case which wasdiagnosed as abscess which proved to be an encystedhsematocele.—Dr. H. D. ROLLESTON referred to the capriciousbehaviour sometimes exhibited by melanotic growths. Thoughusually very malignant some of those arising on the skinwere slow in their development. He referred to cases whichhe had seen in St. George’s Hospital where melanotic growthsremained local for some time and then spread slowly bythe lymphatics. Some of the cutaneous melanotic cases werecarcinomatous rather than sarcomatous.-Dr. CAMPBELLPOPE referred to a case which he had seen some

years ago of a man who presented all the symptomsof phthisis and subsequently abscess of the medi-astinum. He one day brought up from the mouth a

quantity of material which turned out to be of sarcomatousnature. This patient pursued an occupation which involvedthe inhalation of a good deal of dust.-Mr. H. F. WATER-HOUSE referred to the case of a girl, aged 19 years, who wentto the Charing-cross Hospital after an accident which re-sulted in fracture of the right humerus. The arm was putup in splints, but the bone was ununited at the end of fourweeks. At the end of eight weeks, as there was still nounion, an operation was performed and sarcoma was foundto be deposited in the bone-ends. Amputation at theshoulder-joint was then performed. She had no return foreight years ; then pleurisy developed on the opposite sidewhich turned out to be of a sarcomatous nature and sheshortly afterwards died from sarcoma of the left lung. Hecommented upon the length of time between the primaryand secondary growths.-The PRESIDENT remarked on the advantages of reporting such cases. Nothing was moreinteresting than the growth and variety of sarcoma and itoften caused much difficulty in diagnosis. The presence

of suppuration was a most interesting point in Mr.Sbeild’s first case, for this was very unusual in sar-

coma, though he remembered the case 01 a littleboy in which this had occurred in the os calcis.He also referred to a case very closely resembling Mr.Sheild’s second case, which commenced as an ulcera-tion of the big toe, followed by melanotic enlargement ofthe glands in the groin. He doubted the advisability ofalways giving patients with tumours iodide of potassium asa matter of routine.-Mr. SHEILD, in reply, said his chiefobject had been to illustrate the difficulties of diagnosisrather than rarity in his cases. Of all situations tumours ofthe breast were, perhaps, most likely to lead to mistakes.He thought that the giving of iodide of potassium shouldnever be allowed to impair patients’ chances of recovery byoperation. He would have liked to have heard remarks onthe occurrence of a rise of temperature in cases of sarcoma.It was not generally known that this occurred, and it wasspecially liable to give rise to errors in diagnosis becausethere was a daily rise and the chart exactly resembled one ofsuppuration. He would also have liked to hear the viewsof other surgeons on the occurrence of thrombosis in thesecases.

Dr. F. J. POYNTON read a paper on the Occurrence ofArthritis in Association with Appendicitis. He commencedby stating that the association of arthritis and appen-dicitis, though not common, was of interest because itseemed likely to throw light upon the etiology of peri-typhlitis. Some observers had suggested that rheumaticfever was an important cause of appendicitis and based thatopinion upon (1) the associative occurrence of perityphlitiswith acute rheumatism ; (2) the occurrence of a polyarthritisresembling that of acute rheumatism coincident with, orshortly after, an attack of perityphlitis ; (3) the favour-able reaction of some cases of perityphlitis to treat-ment by salicylates; and (4) the similarity in structureof the tonsil and vermiform appendix which it was.suggested implied a similarity in pathological tendencies:Dr. G. A. Sutherland, in the Edinburgh Hospital Reportsfor 1895, published examples of this association occurring inchildren. Dr. Poynton brought forward a somewhat similarcase which occurred during an attack of rheumatic chorea,and alluded to the generally received opinion that abdominalpain was common in rheumatic children. He pointed outthat all these cases were mild cases and lacked in his opinionabsolute confirmation of the theory. Dr. Burney Yeo, in theBritish Medical Journal, June 16th, 1894, had published thecase of a girl the subject of an acute rheumatic attack whosome months before had developed another attack of arthritis,a fortnight after which a sharp attack of perityphlitis com-menced. Rapid improvement was followed by a relapse and afresh outbreak of arthritis. Complete recovery ensued withoutoperation under salicylates. The pyrexia was high andvery irregular. As to the value of the treatment of peri-typhlitis by salicylates many explanations were offered. Dr.A. Haig considered it to be an evidence of the gouty origin,others of a rheumatic origin, of appendicitis, while Dr.

Beverley Robinson had been unable to convince himself thatrheumatism and perityphlitis were causally associated. It

might be justly inferred from the views expressed above thatthe success obtained by the treatment with salicylateswas no proof of the rheumatic nature of the symptoms.Dr. Poynton thought that the evidence in support of therheumatic origin of perityphlitis was not conclusive as yet.He had while registrar at St. Mary’s Hospital investigated60 cases of perityphlitis with the idea of gaining somemore information upon the clinical side of the question. Ashis guide he had taken the manifestations of the rheumaticstate as laid down by Dr. Cheadle in the Harveian Lecturesfor 1888. Every type of case was represented in this series,and in 31 the diagnosis had been verified by operation. In11 there was a history of family or personal rheumatism, butin none of the cases could any causal relation between thetwo diseases be traced. In two of these cases there was

polyarthritis. A good deal of light seemed to be thrown uponthese difficult cases of polyarthritis by the papers of Piardupon metastatic suppurations in connexion with appendicitisand by the researches of Akerman upon the experimental pro-duction of osteomyelitis in young rabbits by injections of purecultures of the bacillus coli. Piard in his papers had empha-sised the point that metastases were especially liable to occurwhen the local lesion in the right iliac fossa was not wellmarked. Akerman had shown that intravenous inoculationsof the bacillus coli into young rabbits would produce

1204 HARVEIAN SOCIETY OF LONDON.

osteomyelitis and also effusions into the neighbouringjoints. These effusions were clear, turbid, or purulent,according to the local virulence of the process. Manyobservers had laid stress upon the importance ofthe bacillus coli in appendicitis and these organismshad been demonstrated in the metastatic abscesses. Dr.

Poynton thought it was not surprising that the polyarthritiswhich sometimes complicated appendicitis should in the faceof these observations closely resemble a rheumatic arthritis.The joint affections were multiple, might disappear duringlife, and might, as he had seen, react to treatment by theuse of salicylates. Yet if death resulted a gangrenousappendix and visceral abscesses might be found, pointingindubitably to the metastatic origin of the arthritis. The

severity of the joint lesions was probably dependent upona local virulence at those sites. Death or recovery was prob-ably dependent upon the virulence of the general poisoning.It seemed most probable that this polyarthritis was usuallyof the nature of a pyæmic rather than of a rheumatic lesion,and if this was the case it was an indication for immediateoperation. Finally, allusion was made to cases of mon-

articular rheumatism of the right hip-joint in children, whichfor a while might closely simulate perityphlitis. The

diagnosis was usually an easy one, for other rheumaticmanifestations soon appeared in such cases as these, and theposition was then clear. The active surgical measures thatwere now adopted for perityphlitis made the diagnosis ofsome importance. In conclusion, he was inclined to thinkthat clinical evidence was, on the whole, against the

explanation that appendicitis with polyarthritis was rheu-matic, but upon this point he was anxious to obtainthe opinions of the fellows of the society.-The PRESI-DENT remarked that he thought that Dr. Poynton’s viewthat the arthritis was of pyæmic and not of rheumatic

origin was a correct one. He had seen cases which sup-ported this opinion.-Dr. H. D. ROLLESTON had hoped that

. Dr. Poynton would advance bacteriological evidence in

’support of the rheumatic origin of appendicitis. Dr. J.

Cavafy had long been in the habit of treating appendicitiswith salicylates. He (Dr. Rolleston) thought that thestructural analogy between the tonsil and the appendix sup-ported the view that appendicitis might be of rheumaticorigin. There seemed to be a prejudice against this viewfounded on the idea that operation might in consequence beneglected. He suggested that the initial stage of appendi-citis might be rheumatic but the other forms of infectionmight be added later and introduce a septic element. Somecases of appendicitis certainly recovered under salicylates.He could not remember to have seen appendicitis duringrheumatic fever, nor had he seen definite joint mischief inthe course of appendicitis.-Mr. F. C. WALLIS expressed theopinion that arthritis might be due not only to appendi-citis but to other lesions of the bowel as well. He hadseen and recorded cases of ulceration of the lower bowelassociated with painful condition of the joints accompaniedby swelling and effusion which were entirely relieved byremoving the portions of the diseased bowel. He thought thata good many of the unexplained joint cases might be due toseptic matter absorbed from some ulcerating surface. He wasinclined to question the rheumatic nature of appendicitis.-Dr. T. D. SAVILL mentioned the case of a man, aged 30years, who had suffered from prolonged arthritis of manyjoints which would not yield to salicylates or other remedies.The patient died from perforated appendix and there seemedevery reason to believe that the chronic joint mischief was ofa pyæmic nature secondary to septic absorption from theappendix. He could not subscribe to the rheumatic originof appendicitis.-Dr. H. A. CALEY referred to the scarcityof arthritic or other rheumatic manifestations in associationwith appendicitis, which he regarded as a strong argumentagainst the existence of an intimate relationship betweenrheumatism and appendicitis. There seemed, however, tobe a distinct bearing upon some cases of catarrhalcolitis and rheumatic symptoms, and in this way-throughthe medium of the colitis-the rheumatic state might attimes be concerned in the etiology of appendicitis.-Surgeon-Major A. G. BLACK thought that a connexion mightbe traced when an abscess round the appendix becameabsorbed into the femoral sheath.-Dr. POYNTON, in reply,said that he had no wish to dogmatise. Certainly Dr, G. A.Sutherland’s cases were very instructive. The childrenwere undoubtedly rheumatic and they had had appen-dicitis. The occurrence of arthritis in appendicitis wasprobably rare but this might be accounted for in the present

day by the prompt surgical measures which were adopted.As regards Mr. Wallis’s question, he could not say whetherany of the cases he referred to had had colitis or not.:

HARVEIAN SOCIETY OF LONDON.

The Advisability of Early Operation in Cases of AcuteInflammation of the Appendix.

A MEETING of this society was held on Oct. 18th, Dr. W. H.LAMB, the President, being in the chair.

Mr. C. W. MANSELL MOULLIN read a paper urgingthe Advisability of Early Operation in cases of AcuteInflammation of the Appendix. After giving a briefaccount of the pathology of inflammation of the appendix,.showing that it always originated from invasion of themucous membrane by septic organisms from the interiorof the bowel, he divided the cases, so far as surgicaltreatment was concerned, into three main groups. Thefirst, by far the largest, included all those mild attackswhich subsided of themselves or under the simplesttreatment. In these the organisms were destroyed or

removed before they could do any permanent harm ; thelymph, which had been poured out, disappeared again withoutleaving any adhesions, and the appendix regained its normalshape, size, and mobility. These cases needed no surgicaltreatment. In the second group were comprised all thosecases in which the absorption of the exudation was in-

complete. In some it became organised ;. in others it brokedown into pus; in others, again, a concretion was left.behind. But all agreed in this one particular-that perfectrecovery did not take place and was impossible withoutoperation. Finally, there was the third group, fortunately byfar the smallest, in which acute septic peritonitis broke outand in which the only possible chance of recovery wasimmediate operation. In all acute attacks it was absolutelyessential to group the case in one of these three divisionswithin 36 hours of the onset of the symptoms or it might be-too late. It was known that the interior of the appendix wasfull of septic organisms ; it was known that if the conditions.were favourable to them they could penetrate the wall withease and infect everything ; and it was known that the-

appendix was hanging free in the peritoneal cavity. Thedanger was not in performing a simple exploratory operation.but in delaying to do so. All that was necessary was anincision one and a half inches long and the introduction ofthe finger in order to ascertain exactly the condition of theappendix and the peritoneum around it. Mr. MansellMoullin then discussed the symptoms by which the cases-which would recover of themselves might be distinguishedfrom those in which operation would be required, sooner orlater, either because of diffuse septic peritonitis or becauseof the formation of adhesions, strictures, or concretions.The pulse was the most valuable of all. If the pulse rate atthe end of 36 hours while the patient was lying in bed wasover 100 in the minute, or if in the course of the last fewhours it had increased much in frequency, there was nodoubt that the attack was a severe one and that operationwould be required. The temperature was no certain guideunless it continued to rise. The intensity of the pain was ofgreat significance, and so were also, but perhaps in less

degree, local tenderness, muscular resistance, and a sense offulness in the right iliac fossa. Vomiting, constipation,and the other symptoms usually present could not be reliedupon in the same measure. Mr. Mansell Moullin laid

great stress upon the fact that the absence of anyindividual symptom was of no account and that operation.should be performed in any case in which the pulse was veryrapid, even if the other symptoms did not point to any greatdegree of severity. If morphia had been given this ruleshould be even more stringent. The limit of 36 hours, headmitted, was a perfectly arbitrary one. All could not waitso long. Some could wait longer without undue risk. Each.case must be judged upon its merits and this must be

regarded merely as an average. The point to bear in mindwas that at the beginning of a severe attack they couldnot as yet distinguish cases which might be allowedto wait from those which might not; that they wouldall of them have to be operated upon at last, some-

for adhesions, some for abscesses, and some for concretionsor other causes (for severe cases did not recover withoutleaving some complication behind) ; and that it was wiser-