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Maps, plataa. charts, etc.. may be filmad at different reduction ratioa. Thoaa too larga to be entirely included in one expoaura ara filmed beginning in the upper left hand comer, left to right and top to bottom, aa many framea aa required. The following diagrama iiluatrata tha method: Laa carten. planches, tableaux, etc., pauvent Atra film^a i dee taux de rMuction diffirents. Lorsque le document eat trop grand pour dtra reproduit en un saul cliche, il eat fiimA A partir da Tangle supArieur gauche, de gauche i droite, et da haut an baa. en prenant le nombre d'lmagaa nAcaaaaira. Laa diagrammes suivants illuatrent la m^thodo. 1 2 3 1 2 3 4 5 6 4 DERMOID CYST OF THE OVARY. By J AS. A. GRANT, M.D., RR.C.S., EDIN. Consulting Physician Geneual Protestant Hospital, OTTAWA. JtE-PRINTED FROM THE CANADA MEDICAL & SURGICAL JOURNAL. DERMOID CYST OF THE OVARY. By Jas. a. Grant, M.D., F.R.C.S., Ed. Consulting Physician Genoml Protcstimt Hospital, Ottawa. [From Proceedings Canada Medical Aanociafion.] The brief report of the following case of ovarian dermoid cyst, which presents some points of interest, I thought well to bring under the notice of the Association, and more especially as the subject of dermoid tumors is one in which there is still considerable diversity of opinion and is the chief apoiogy I offer for occupying your valuable time, fully aware of what Bryant has so well stated, " That the publication of isolated " cases^ hoivever good^ proves nothing^ whereas the ivith-holding " of the ivhole suggests much.'''' Ann M., aet. 47, married, native of Galashields, Scotland, arrived in Canada 1st May, 1878. Father and mother healthy, the former died at 60 and the latter at 80. According to her own statement she has usually enjoyed good health. Married about 20 years, and had one child, aged 18 years. Labor was very severe and lasted 48 hours, in consequence of which she was obliged to keep her bed for a period of fully three months. On recovery she experienced no bad effects, excepting a con- siderable degree of irregiilarity as to menstruation. About seven years ago she observed that the abdomen wrs enlarging, but no pain in particular was experienced. AboLt five years ago, her family physician diagnosed a tumor, and advised her to enter the Royal Infirmary, Edinburgh, which slie did in Oc er, 1877, under the charge of Dr. Simpson. At this date the tumor had increased to a very considerable size. She remained in Edin- burgh until March, 1878, at which date she returned home. While in the Infirmary, the tumor discharged a quantity of serous fluid twice, from an opening at the umbilicus, from which spontaneous result she experienced considerable relief. The quantity of fluid which escaped during the first discharge was about six quarts, and the second, fully four quarts. Shortly after leaving the Infirmary there was a third discharge of about four quarts. August 25th, 1878, in consequence of consider- able inconvenience and moderate suffering and at the earnest solicitation of Mrs. M., she was admitted as a patient into the Ottawa General Protestant Hospital. I examined the case most carefully, as from the history, it presented unusual features of interest. She was much larger than a person at the full period of pregnancy, and the abdomen presented no enlarged or dark-colored veins, such as frequently observed in fibro-cystic uterine tumors. There was a dull percussion sound generally, but no solid deposit anywhere in particular. The abdomen was moderately soft and elastic in its entire extent, and fluctuation could be detected without any difficulty. On examination, per vaginam, the uterus and bladder presented no abnormality, beyond Avhat was the result of an unusual degree of pressure. The rectum was healthy, and in the pelvic viscera, no indication of malignant disease, thus supporting strongly the outward signs, as to the absence of organic cancerous change of structure being in progress in any part of the system. The results from a careful examination of the heart, liver and kidneys, were quite satisfactory. After consultation of the hospital staff, the 29th was appoint- ed for operation, which was decided upon at the request of the patient. Chloroform being Administered, the usual incision was made through the abdominal walls, which were quite thick and fatty, and the structure of the tumor in the mesian line suffi- ciently exposed to define in a degree its character. The large trocar of " Spencer Wells *' was used ineffectually, the contents of the cyst being too viscid and dense to flow through the canula, which being removed at once gave forcible exit to the chief liijuid contents of the tumor. The cavity of the cyst being well exposed by a free incision, was entered by the hand and the contents removed down to either side of the uterus, no perceptible tumor being observed during the entire explora- tion. The sac or cyst was attached by its entire posterior surface to intestines, abdominal walls, pelvic surfaces, and in fact to all the contiguous structures, no portion of intestine being at any time visible. The entire contents, weighing fully 25 lbs., and having somewhat the feel of hran mash, were carefully removed with the hand and the cavity sponged out with warm carbolized water ; the incision closed with silk sutures, and over the adhesive plaster, a compress, saturated in carbolized water, protected by a thick layer of cotton batting, the whole held in position by a firm flannel roller. The opera- tion was not in any way complicated by either bleeding or vomiting, and owing to the peculiar character of the case, occupied a shorter time than previously anticipated. A large- sized india-rubber drainage tube was passed deep into the cavity of the sac, and free vent given to its external end by an opening through the entire dressing, thus affording escape to any accumulating secretion, and an opportunity for repeated washings, which were found to be of great importance, through- out the treatment. The quantity of purulent fluid which escaped from time to time was very considerable, but by regulated pressure over the abdominal walls, the frequent injection. of warm carbolized water into the drainage tube, and supporting the system by milk diet, beef tea, quinine and iron, and occa- sional stimulants, the discharge lessened gradually, and the constitution gained in strength as it changed from the serous character to that of laudable pus. For fully two weeks prior to leaving hospital, very little discharge was observed, beyond what would moisten the Hght dressing at the time. The india- rubber tube was gradually shortened as the sac closed, and at the end of the fourth week was entirely removed. The inci- sion healed throughout the greater part by first intention, and the left side of the sac was the chief source of difficulty, the right affording very little discharge indeed. Returned to her home 28th October, 1878, since which date enjoyed very good health and performed her usual household duties with compara- tive comfort and freedom. The contents of the tumor presented a dark grayish appear- ance, quite thick, and having long black hairs scattered throughout in various directions, but not any bone structure or teeth. 0x1 Closer examination it presented the usual constitu- ents : free fat, pavement epithelium, fatty cells, and crystals of 6 cholestearine, having u glittering appearance, the v/hole satu- rated in a thick quasi-gelatinous fluid, quite devoid of odor. Remarks. — During the progress of this case but two import- ant complications took place : septici\3mic symptoms and dysentery. Sejjtember 23rd, on entering the hospital ward there was an unpleasant odor from the discharge, which was of a dark brown fluid character, ami more copious than usual. During the night of the 2r)th September, there was also an attack simulating unilateral mumps. Tcm])uraturc lOn*^ ; pulse 9(> ; all of which pointed to aeptio pohonim/. On careful examination, moderate bulging was observed below the left hypochondriac region, and on firm pressure over this space, (juite a (juantity of fojtid, thin, dark-colored matter escaped, both through the tube and the opening, the patient at the same time being turned upon her side, so as to make the drainage as efficient as possible. At this stage of the case the stomach was very irritable, and even the milk diet was retained with considerable difliculty. By constant care and frequent dressing, the se jticaemic symptoms yielded and the swelling in the neck gradually subsided by the application of warm poultices. The dysenteric attack, wh'ch took place on the 18th October, was only of short duration and gradually yielded to treatment. The daily register of the House Surgeon, Dr. McKinnon, conveys more than I could otherwise express. The history of this case, from the fact that on three separate occasions a quantity of fluid escaped, by a communication established through the abdominal walls, evidently pointed towards " dermoid cj/st " of the ovary. This, however, I had not anticipated, and having been taken unawares, had recourse to the method of treatment adopted under the circumstances. Barnes' Clinical History (Diseases of Women,) p. 338, says : " So long as the fluid is confined in the ovarian cyst it is beyond the influence of absorption." The converse, however, is not unlikely, when suppuration takes place after operation, as in the present instance. The transmission of septic influence to distant parts, such as the glands of the neck, (the peritoneum, on which the very sac rests, being thus passed over,) is a point of much interest, and more especially so, when we consider the rapidity with which the poison of scarlet fever or other zymotic influ- ence, centres on the parturient i)eritoneum. The power of accommodation may here be at work and the very strain the result of contiguous abnormal adhesion, so have modified sus- ceptibilities as to render the parts less liable under these cir'^um- stances to direct inflammatory action. Gross (System of Surgery, p. 931,vol. 4,) remarks : " One of the great obstacles to success in ovariotomy, grows out of the difficulty, if not utter impossi- bility, in many cases in arrivhig at a correct diagnosis, no matter what pains may be taken ni the investigation, hence it is not surprising that in at least three-tenths of the cases subjected to the knife, the operation had to be abandoned, while in quite a number of others no ovarian tumor of any kind was found." Again, p. Ool, he states : " I should con- sider an operation as unjustifiable when the tumor, ivhatever be its structure, is strongly and extensively adherent." Thomas (Diseases of Women, p. 700) states : " Although such tumors are innocuous, and not likely to increase rapidly or attain any great development, they sometimes set up very serious and even fatal disturbance — the case in point being one of the three varieties defined, viz., the cyst which contained the histoid elements, secreting fluid and changing its character to that of a fluid or rather semi-fluid charact u-. In such cases, he is of opinion, no treatment is required, since none would be at all effectual except extirpation. This would be eminently inadmis- sible, since there are not sufficient dangers attendant upon the tumor to warrant a resort to so hazardous a procedure. Dr. Graily Hewitt records a case in which Dr. Alexander Simpson injected Avith iodine, l)ut not with a favorable result. Dr. Atlee, on Ovarian Tumuis, p. 18'), records a case of Dermoid Cyst, in which, by passing a sound into the cavity of the cyst through an umbilical ()})eiiing, the diagnosis was determined, and an operation for the extirpation of the tumor was pronounced im- practicable, and consequently abandoned. Subsec^uently iodine was injected by Dr. Hayes, however, with no favorable result. Page 180, a second case of dermoid cyst is recorded by Dr. Atlee, which being diagnosed by paracentesis, all idea of extir- 8 pation was abandoned, death taking place shortly afterwards. In the former, fost-mortevi examination demonstrated very extensive adiiesions ; in the latter, no after examinatior, was made. Barnes (Clinical History of the Diseases of Women, p. 334) says, " These tumors are exceedingly apt to contract intimate adhesions with the viscera amongst which they are imbedded," And again, p. 340, two cases of much pathological interest are recorded from Guy's Hospital Museum, in which the possibility of an " ovarian cyst " healing after rupture was most carefully demonstrated, thus clearly supplying 2l post-mor- tem verification of vast importance. 'Tis true, these were ordinary ovarian cysts, not of the dermoid character ; still, the manner in which, in these cases, s[)ontaneou3 rupture and sub- sequent cicatricial power effected a cure is marvellous evidence <" the method in which nature heals, and a stimulus to carry out in practice the lessons deduced from, such spontaneous efforts. Bryant, p. 07 0, records a case from Guy's Hospital Reports for 1808, in which a woman act. 34 was successfully treated in a case of extensive adhesion, by turning out a con- siderable portion of the parent cyst, and the remaining part stitched to the margins of the wound, a drainage tube used, and the suppurating cavity washed twice daily. This was an ordinary ovarian cyst, with partial evacuation of the contents. Byford, in the Transactions of the American Gynecological Society for 1878, records four cases of recovery after operation in Dermoid Ovarian Tumors, in all of which there was no re- corded complication from adhesions ; and Dr. Hingston, of Montreal, has informed me that such was his experience in some cases of dermoid tumor that came under his observation. From these various facts, we observe, there is considerable diversity of opinion even with the master minds of the profession, and in those cases of doubt and uncertainty, we must be guided by surrounding circumstances. As to the histology of dermoid cysts, the i)rofession is much indebted to Dr. Julius Pauly, of Zduny, Prussia, and Dr. Byford, of Chicago, for their recent contributions, which may be considered as valuable additions to the writings of the various authors who have already achieved a well known celebrity.