Twelve tumors of the appendix are described which show histologic features different from both ordinary carcinoid and adenocarcinoma. The principal cell type has a close resemblance to the normal goblet cell in the epithelium of the intestinal tract. Paneth's and argentaffin cells were present in considerable numbers in some of these tumors. The histology and prognosis suggest a tumor of very low grade of malignancy, comparable with the behavior of argentaffin and non‐argentaffin carcinoid of the appendix. However, the histology is sufficiently distinctive to justify separate classification, and we therefore recommend the expression „goblet cell carcinoid”︁ of the appendix.

THE patient was a man of 80 years who was referred from another hospital for supervision of his diabetes. He had had the latter for ten years and was controlled by dietary means until March, 1949, when he was started on P.Z.I. 10 units daily on an 1800 kg.-calories diet. At the end of 1948 he had noticed the appearance of small hard lumps under the skin of his trunk, and on examination at the hospital he was then attending, a large mass was found in the abdomen. Biop;y of one of the nodule;in the skin was reported on as a typical neurofibroma .In view of this, and the size of the mass in the abdomen, it was felt that the two were not causally connected.He was seen in the Out-patients Department at Ashford Hospital on May 20, 1949, and on examination was found to be a thin, aged man who had obviously lost weight and was in poor general condition. He had evidence of emphysema and arteriosclerosis, and in the left hypochondrium was a hard, craggy mass. The liver was palpable to four fingerbreadths below the costal margin and was hard, nodular, and tender in places. Multiple firm mobile subcutaneous nodules were seen and felt on the trunk and upper arms and some of these were tender (Fig. 65). No enlarged lymph-nodes were FIG. 6s.-Drawing of patient to show distribution of nodules.felt. His blood-sugar at the time was 370 mg./Ioo ml.He was admitted on May 25 for stabilization. Whilst an in-patient a biopsy was made of one of the skin nodules, and this showed the following appearances : it was rounded, 10 x 8 x 6 mm. in size, firm, and having a homogeneous white concave cut surface. Microscopically it showed fibrous tissue in which were numbers of spindleshaped cells arranged for the most part in a disorderly manner but in places tending to be regimented. Many were elongated and there was a good deal of variation in size and shape, but no mitoses. I t was thought to be possibly a neurilemmoma (Fig. 66), but a radiograph of the chest was reported as showing multiple shadows of neoplastic appearance, and the diagnosis appeared unlikely.AUTOPSY FINDINGS.-External Examination.-The body was that of a wasted aged male with a protruberant abdomen due to a palpable mass. Scattered throughout the skin of the thoracic and abdominal walls were firm nodules varying in size from 5 to 15 mm. diameter, being characterizedThe patient died shortly afterwards. FIG. 66.--Photomicrograph of skin nodule (biopsy). ( x 60.)by exceeding mobility in all directions. One nodule larger than the rest, with a lobulated edge and less mobility, was present in the anterior axillary fold on the right. One or two nodules were also present in the skin of die back of the trunk, fronts of both thighs, and scalp.lnternal Examination,-Shull: Some small tumour nodules present in the diaid but none in the pia arachnoid or brain itself, although tt: choroid plexuses were studded with tumour deposits.Skeleton : Multiple nodular metastases were found in all the bones examined, replacing marrow but causing no visible bony changes. Mouth: Edentulous. No nodules in...

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