, March

of varicella. They were found to extend from the neck over the chest and abdomen, genitals, thighs and legs as far as the ankles; a very few were found on the arms and still fewer on the face; one of these last, however, formed a phlyctenule on the left cornea. A few of the largest had a slightly inflamed area around them, but all formed dry scabs, which finally dropped off without leaving an ulcerated surface underneath. From first to

last these discrete vesicles were visible for about a fortnight. Meanwhile the hæmorrhagic patch became very foul smelling; the whole patch of skin became gangrenous, and had to be snipped away with scissors bit by bit until a healthy granulating surface was left. The patient then began to take exercise in the open air on fine days, and his appetite, except during the first week of the illness, had been surprisingly good. In spite of this, however, and the use of a little wine, to which he was unaccustomed, the pains became if anything more severe, and sleep was only possible after a subcutaneous injection of morphia at bed time and repeated at five or six in the morning. Cicatrisation of the ulcerated surface was exceedingly slow, and on the 8th ultimo, when the patient returned to the country, there were a few minute spots still open. Thanks to a suggestion of Mr. Knox Shaw I had substituted hydrobromic acid for the hypodermic morphia injections, and for a time with the happiest results, the patient describing it as a specific for the pain," but, alas! when last I heard from him he had returned to the morphia injections at the hands of his local medical attendant.

An interesting point, and one worth recording here for its possible bearing upon the specific infectious nature of zona as contended for by Besnier and Kaposi, was the fact that the patient's wife had had shingles five months previously, and curiously enough on the right side of the forehead, and accompanied by a small phlyctenule on the right cornea.

Except for the subsequent appearance of the diffuse herpetic rash, a feature not previously recorded, the case of R. P. resembles in all essential particulars the form of zona described by Kaposi under the name of zoster gangrenosus.

Arch. f. Dermat. u. Syph. 1889. No. 4, p. 561.

Review, March 1, 1897.

ON SOME RECENT CASES OF THE LESS COMMON FORMS OF ABDOMINAL LESIONS.

By GEORGE BURFORD, M.B.

Physician to the Gynecological Department, London Homœopathic Hospital.

THE ensuing cases of abdominal and pelvic disease have each some notable characteristic which specialises them from the ordinary forms of local lesion requiring operative relief. They have occurred in the practice of the last six months, interspersed among cases of a more usual type. In each instance convalescence has followed operative procedure.

Mesenteric Cyst, of at least nine month's growth, occupying the space between the layers of the Great Omentum. Tapping and Drainage of Cyst.-Recovery.

Dr. E. J. Hawkes, of Ramsgate, referred the patient to me for operative relief in December last. She had recently come under Dr. Hawkes' care for an obvious and increasing abdominal tumour, which had been noticed for some nine months. The patient was a single girl, æt 30, thin, but not emaciated, and with no history of loss of flesh. Examination showed an apparently unilocular cyst, occupying a mid-abdominal area, and dipping into the pelvis on the left side; it gave a dull percussion note over its surface, and an easily elicited thrill in all directions. While its lower limit extended into the pelvis, vaginal and rectal examination did not demonstrate it as of pelvic origin.

Operation showed the growth to be a large cyst, with the transverse colon lying over it in front, and burrowing well up to the ascending and descending colon on either side. On tapping, forty-three ounces of a turbid light brown fluid were removed;* and recognising the character of the growth, the opening in the cyst was stitched to the abdominal wall, and the cyst cavity thus continuously drained. The patient made a good recovery, and six weeks after operation Dr. Hawkes

* Mr. Johnstone's report on this fluid shows that it contained no cholesterine, but a very large number of emulsified fat globules.

reports that the sac, still irrigated and drained, has already contracted to less than half its initial capacity. Mesenteric cysts of this character and size are very rare growths. Grieg Smith states that only fifty recorded cases exist. To endeavour to enucleate them is frequently fatal; and general experience has endorsed the wisdom of compassing the cure by continuous drainage, thus bringing about spontaneous obliteration of the sac. Fibroid Tumour of the Uterus, growing between the layers of the Broad Ligament.-Hysterectomy.-Recovery.

Dr. Neild, of Tunbridge Wells, referred a lady to me in October last for operative treatment of a uterine fibroid. The circumstances were as follow:-Several years previously she had been informed, after local examination, that the uterus was notably enlarged. The period now was continuously becoming more prolonged and more copious; pain during the period was also marked and progressive; bladder symptoms were troublesome; and, to crown all, the patient had for months been the victim of acute and ceaseless anxiety on account of family matters.

Local examination showed a fibroid enlargement of the uterus, the mass reaching nearly up to the umbilicus. Taking all the details into account, operative proceedings were decided upon.

At operation, Dr. Capper anæsthetising, and Dr. Neild with Mr. Dudley Wright assisting, the tumour was found to lie entirely within the left broad ligament, and to be an outgrowth from the uterus in that direction. After tying off the ovarian vessels, the mass was with some difficulty enucleated, and the uterus down to the lower level of the seat of origin, included in the rubber ligature. The patient made a most excellent recovery, convalescence being easy and unbroken.

Fibroid tumours wholly encapsuled by the broad ligament are not common; and their treatment is correspondingly difficult. Enucleation of necessity leaves a large bed of cellular tissue; and this has also to be dealt with; damage to the ureter is very easy. It is taught, on high authority, that fibroids growing within the broad ligament are often accompanied by amenorrhoea. To this, as a general statement, my case was a conspicuous. exception.

Review, March 1, 1897.

Commencing Sarcoma of the Endometrium, with Menorrhagia as the only physical indication.-Vaginal Hysterectomy.-Recovery.

In September last Dr. Purdom, of Croydon, sent to my hospital clinic a middle-aged married woman, with frequent and drenching menorrhagia. This depleting hæmorrhage had been going on for some time, and it proving obstinate to well chosen remedies, she was sent up for further treatment. Taking all circumstances into consideration, I decided to curette; and on doing so, evidences presented themselves of a lesion more suspicious and more extensive than was at first supposed. The curetted fragments were examined by Mr. Johnstone, and pronounced to be sarcomatous. There had hitherto been no loss of flesh, no cachexia, and no notable pain. Anæmia, of course, was pronounced.

Vaginal hysterectomy was performed, under very difficult conditions, on account of the bulk of the uterus; but the entire organ was removed, and without infection of tissues in the locality. The broad ligaments were uninvolved.

The patient made a slow recovery, somewhat hindered by a troublesome vesico-vaginal fistula, for which she is at present under treatment by plastic operation.

The notable features in this case are several.

(1). The detection of the disease in this early stage was accomplished solely by the agency of the curette and microscope.

(2). Constitutional symptoms of malignant disease, other than anæmia, were one and all absent.

(3). Although the uterus was bulky, it was removed before either the deeper muscular layers, or the parametrium became affected.

(4). In all probability, the menorrhagia had existed for some time anterior to the irritation of the malignant growth. The corollary from this is that the cause which determined the earlier hæmorrhage contributed also to the later evolution of sarcomatous growth in situ. Large Pyosalpinx, containing over a pint of pus, and evidently of some years' growth, accompanied by neither pyrexia nor menstrual aberration.-Removal.-Recovery. In the autumn of last year, Dr. Ord, of Bournemouth, asked me to meet him in consultation on the case of a

single girl, æt. 31, who for some time had lived a life of chronic invalidism, and who latterly had been compelled to keep her bed. Backache, persistent and severe, was the most prominent symptom; while the physical counterpart of this was an abdominal tumour of firm. consistence, and reaching from the pelvis nearly up to the umbilicus.

The previous history, in brief, was that the backache had been a source of trouble for a couple of years, and that for eight years, more or less, there had also existed a less severe hypogastric pain, with occasional intermissions. Increasing inability to undertake the duties. of life, but with no record of peritoneal crises or other complications, had characterised the case throughout. The period was of the three-day type, usual in point of quantity and character, and with no special attendant pain.

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The patient came up to the hospital and, after consultation, operative relief measures were recommended and abdominal section accordingly performed. tumour, firm and tense, and about the size of an elongated foetal head, was with much difficulty enucleated from the left broad ligament; the capsular bed was carefully closed by continuous silk suturing, and part of the elongated and hypertrophied Fallopian tube also cut away. The operation lasted two hours.

Convalescence was easy and complete, and the patient was sent home a month after operation, having already greatly improved in general health.

Examination of the tumour by Mr. Johnstone showed it to be a large pyosalpinx, the contents being wholly pus, contained in a cyst wall actually thin, but which was so tense with contained fluid as to convey on manipulation the relative sense of solidity. A distinguished specialist has communicated to the writer another instance of pelvic cyst, similarly tense, and similarly misleading in physical character.

But the striking feature in this case is that the patient should have had for some time so large a collection of pus, with a peritoneal investment, yet without hectic, or rigors, or pyrexia, or even local inflammatory attacks. Here, evidently, the character of the symptoms bore absolutely no corresponding relation to the extreme jeopardy in which the patient's life was placed.

Vol. 41, No. 3.

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