may be at the same rate as normal tissue, and is therefore more frequently observed in adults. The size of dermoid cysts varies. They may be so small as not to be observed, or they may weigh many pounds. Ward reports a dermoid cyst weighing 30 lbs. removed from a woman 32 years of age, and the mother of two children. When a dermoid cyst contains mixed structures from two or more germinal layers, it has more of a tendency to degenerate into a malignant tissue. PERCENTAGE OF DERMOIDS TO OTHER TUMORS. -Olshausen reports about three and one-half per cent of dermoid cysts of all cystic growths of the ovary, and out of 2,275 ovarian tumors under all conditions he found 80 dermoids, or 3.5 per cent. Kelly states: "The relative frequency of dermoid to other ovarian tumors is 1 to 105." McKerron mentions 862 cases of ovarian disease collected, of which 204 were dermoids. PREGNANCY.-Desirues, out of 135 operations on ovarian tumors during pregnancy, found ten on dermoids. McKerron" collected the history of 162 cases of ovarian disease associated with pregnancy, and 204 had dermoid growths. A number of cases. have been reported as shown under report of interesting cases. CAUSE OF THE CYSTIC PORTION.-Pfannenstiel states that while the embryo develops from the ovum, the cystic portion is derived from the Graafian follicle. Jelke and D. Mary Jones' are of the same opinion and believe that the cyst is due to some irritation or stimulus. Klein found 30 per cent of dermoids combined with other types of cysts. AGE.-Meres of Philadelphia reports a dermoid found in a girl six and one-half years old. They have been found from early infancy to old age and may exist for a lifetime. COMPLICATIONS.-There is unquestionably a great danger of dermoid cysts rupturing and infecting the abdominal cavity at the time of labor. By pressure they may become adherent to the contiguous organs, such as bowel, etc. They are liable to become infected with the colon bacillus. DIAGNOSIS. The diagnosis of these tumors is uncertain and impossible in many cases. However, one should remember that they are usually located more anteriorly than other cysts, being frequently situated lateral to the bladder and in front of the horn of the uterus. When they contain solid substances, such as bone and teeth, that may be felt and located in this position, a diagnosis is possible as illustrated in Case No. I. SOME INTERESTING CASES REPORTED.-S. W. Bandler', Wm. F. Jelke, Gould & Pyle, Dudley, Pryor, Jos. F. Fox", Henry D. Beyca", Jelke", and Arnsperger" report dermoid of the ovaries. L. A. Nippert, J. E. Mcore", J. A. Sutcliffe", and J. B. Macauley" report cases of dermoids with extra-uterine pregnancy. J. F. Mitchell" and J. Basil Hall" report dermoids of the mesentery. Chas. F. Adams" reports dermoids of both ovaries. Jacob Block and Frank J. Hall" report a very interesting case on dermoid of the female urinary bladder. Dr. Fieux" reports a case of dermoid of ovary causing dystocia. Barton Cooke Hirst" reports dermoids with gangrene. Paul F. Munde" reports a dermoid ovarian cyst and rudimentary third ovary attached to the other ovary. J. W. Withrow", Watkins", and Miles F. Porter" report double dermoids of the ovaries. Simmerline, Wilms, Klein, and Lindsay Peters" report dermoids with other tumors. Bryce J. Macaulay reports dermoids complicating labor. CASE I Mrs. C——, aged 30, married, has had three children. Patient has complained of a great deal of pain in the back and pelvic region for several months; dysmenorrhea was quite pronounced. A cystic tumor, the size of an orange, pedunculated, movable, lateral, and anterior to the uterus, was discovered. Some portion of the tumor seemed to contain an irregular solid mass. A dermoid was suspected. An anterior vaginal incision into the pelvic cavity revealed the growth. It was quite easily removed, the pedicle being ligated. It was found to contain several teeth, quite a large ball of hair, sebaceous material, and some bony substance resembling the inferior maxilla. Sections were not made of the tumor, therefore we are unable to identify all the struc tures present. The convalescent period of the patient was uneventful. CASE 2 Mrs. S, widow, aged 55, mother of several children, has always been fairly well. The patient began to have symptoms of bloating in November, 1903. The abdomen became somewhat enlarged; this subsided for a time. In February, 1904, a growth was noticed in the abdomen, and pain began to be experienced. She has been declining in flesh and general health since that time. Upon examination, April 25, 1904, a large mass was discovered within the abdomen, which seemed to be cystic in character over the greatest portion of it. To the right and low down in the pelvis was a hard adherent mass. Temperature ranged between normal and 100°; pulse between normal and 85; hemoglobin estimate 85 per cent; white count 10,000. An operation was performed April 29, 1904. A long incision was made. The cystic portion of the tumor was raised out of the abdomen, and removed. The hard mass below, involving the left ovary and the left side of the uterus, was adherent to the bladder in front and the small intestine behind. Adhesions to the bladder covered an area about two inches square. The growth was separated from the adherent organs by a Paquelin cautery. The extent of adhesions to the bowel was about three inches. The bowel was carefully teased away. The peritoneum was stitched over the exposed muscular coat, and the rest of the portion cauterized, where the malignancy existed. The left broad ligament was ligated and the left uterine horn was cut through, with a Paquelin cautery. The cystic portion contained a great deal of brownish fluid, cheesy substance, and a great deal of hair. The soft mass was about eight inches in diameter, and the hard mass about three inches by five inches. The patient took ether, and stood the operation well. The abdomen was closed with through-and-through sutures. The tissue removed was not well preserved, I was therefore unable to secure good slides to identify the various tissues present. It was undoubtedly a dermoid which had existed a long time and which had undergone a malignant degeneration. This patient died about a year later of a recurrence. This case amply illustrates the necessity of recognizing these growths early, and argues for an early and thorough removal. CASE 3 Mrs. H. W, aged 39, colored, weight 1311⁄2 lbs.; occupation, cook. FAMILY HISTORY.-Father and mother are dead; cause unknown. Two sisters and four brothers living; all well so far as patient knows. PREVIOUS AND PRESENT HISTORY.-Had children's diseases. She had pneumonia twelve years ago, and was very ill, and she had pneumonia again six years ago. Menstruated first at 14 years. The menstruation was painless and regular during the younger years. She was married at twenty-one years, and has had five children and one miscarriage. For about a year she has had some trouble in the right inguinal region. The pains at the menstrual periods were A little nausea has attended the trouble. She has vomited considerably during the last two weeks. The local tenderness is pronounced; bowels somewhat constipated; last menstrual flow about as usual; no history of leucorrhea. The patient has had a little bladder trouble. lost some weight, and is very nervous. CHIEF SYMPTOMS.-Local pain, tenderness, and vomiting. severe. She has A physical examination revealed a rounded enlargement, adherent anteriorly in the left inguinal region within the pelvis. It was hard, and resistant, and seemed to be fibrous in nature; palpable both externally and by vaginal examination, but too high up to be well reached by a vaginal examination. An operation was performed February 23, 1905. Leucocyte count 5,000. Eleven ounces of ether was given. A median incision was made. A mass was found on the right side involving omentum, cecum, appendix, and the right tube. The omentum was adherent above and in front of the mass. The tube was enlarged to three times its normal size, and situated within the center of the mass. A dermoid tumor was found in this mass containing some hair and cheesy substance. The appendix was found adherent to the upper portion of this growth, and was entirely surrounded by omentum on one side and tumor and tube posteriorly. The tumor and the tube were separated from the mass and the appendix. The appendix was then dissected out. Some lymphatics, fat tissue, and exudate extended from the appendix into the pelvis, and was dissected out. This patient made a perfect convalescence. PATHOLOGY OF CASE 3 BY DR. MARGARET NICK ERSON A description of gross specimen : GROSS SECTION.-The tumor is an irregularly shaped mass which may be roughly likened to a large moth. The mass is about four inches long, three inches deep and one and one-half inches thick. Near the upper edge of the ventral surface are found the fimbria, which mark the beginning of the Fallopian tube and which furnish considerable aid in locating the tube. About one inch to the left of the fimbria is the first real evidence of a tube, which now assumes form, and projects from the left upper extremity of the mass. The part of tube between the fimbriæ and the projecting portion of the tube is utterly unrecognizable as any anatomical structure, and when incised with a razor shows no lumen, and is involved in the neoplasm. Cheesy material, hair, and degenerated tissue occupy its site. The tube is doubled upon itself, which makes the proximal and distal ends approach each other. From the posterior portion of the upper surface projects a papilla with constricted base. It is about the size of a large pea, and presents to the naked eye the appearance of scalp tissue showing sparse dark-colored hairs about one inch long projecting from its entire surface. The omental fat is adherent over a good portion of the anterior, posterior and inferior surIaces. A deep razor incision about two inches long, extending from the upper to the lower edge, reveals below a mass of sebaceous-like substance containing matted hair. Above this sebaceous mass and on about the same level as the fimbria are two or three white, hard, smooth, resistant bodies resembling teeth in external appearance. The largest is about 4 mm. in length. The appendix, which is apparently involved in the neoplasm, presents a free distal extremity, about three-fourths of an inch in length. A freehand section shows no lumen. transversely 2. Oviduct. Sections taken through the proximal portion show a lumen with stellate outline. The epithelium in places shows. its ordinary ciliated columnar character; in other places it is so modified as to approach the squamous type. The muscular coats are thickened concentrically, being much thicker on one side than on the other. A considerable amount of round-celled infiltration is found both in the submucosa and in the muscular layers. A largenumber of polymorphonuclear leucocytes are also present, especially in the submucosa. 3. The Cyst Wall. The lining is of stratified squamous epithelium and resembles strongly the epithelium covering the body except that papillæ are absent in the subepithelial connective tissue. Eleidin granules are abundantly present in the stratum granulosum, while the deeper portion of the stratum germinativum contains much pigment. The stratum corneum is well developed.. Within the corium are a large number of sebaceous glands and a few hair follicles. Solid epidermal pegs are occasionally found which probably represent the anlagen of new hairs. Deeper still is found a peculiar hollow structure with epithelial linings, the epithelium in some places being simply columnar in type; in others stratified columnar, and in still other places stratified squamous. Hyaline cartilage plates, nerve trunks containing medullated nerve fibres, and groups of large ganglion cells are found still deeper in the wall. A large amount of unstriped muscle is present. In one block a tooth about 2 cm. long was found deeply imbedded in the cyst wall, and proved a serious obstacle to the cutting of good sections. 4. Papilla. The papilla, of which a general description has been given, proved interesting upon section. It was covered with stratified squamous epithelium containing pigment in its deeper layers, and eleidin granules in the stratum granulosum. Hairs and a large number of exceedingly well developed sebaceous glands. were found. In addition there was present a peculiar glandular structure, which in some places resembled sweat glands, in other places the structure of mammary gland. This structure is probably to be regarded as mammary gland tissue. CONCLUSIONS.-From the foregoing reports and a review of the literature, one arrives at the conclusion that dermoid cysts are more common than we are led to believe, some of them being so small at the time of operation that they may be overlooked. A careful analysis of these growths as in Case 3 indicates the presence of a great variety of tissue. The term dermoid cyst is somewhat confusing, as the dermoid proper is usually a solid substance, and the cystic portion is often a cyst of the Graafian follicle, due to irritation. On account of the danger of their becoming adherent to neighboring tissues (see Case 3); because of the possibility of becoming infected; from their liability to rupture and produce peritonitis during labor; because of the tendency toward malignant degeneration (see Case 2), it is essential that all obscure abdominal growths, or all disease within the pelvis, should be carefully studied, and subjected to operation where there is any possible indication of the existence of a dermoid. By this means we avoid many Adams, Post-Graduate, January, 1904. p. 38. 13. Block and Hall, Am. Jour. Med. Sciences, Apr. 1905, p. 651. 14. 15. 16. 17. 18. 19. 20. 21. XIII. Pryor, Gynecology, p. 141. Hall, London Lancet, May 14, 1904. McCauley, London Lancet, November 8, 1902. Porter, Fort Wayne Med. Jour. Magaz., May, 1904. 22. 23. Macauley, London Lancet, Nov. 8, 1902. Klein, Inaug. Diss., Freiburg, Bd. i, 1893. HOSPITAL BULLETIN ST. BARNABAS HOSPITAL MINNEAPOLIS INTERCOSTAL NEURALGIA IN THE SERVICE OF DR. C. H. HUNTER Neuralgias are usually considered medical diseases and are amenable to medical treatment. A case that is obstinate should lead to exact diagnosis of the conditions, for otherwise such words as neuralgia, rheumatism, etc., may come to cover a multitude of negligences. Such surgical procedures as nerve-stretching or resection or an incision to lay bare a tumor or gland, or an encroaching periostitis often reward an exact diagnosis. One reported case, gradually incapacitat ing the patient, with two years of persistent pain, illustrates what is meant. A ready reference to this specific form is found in von Bergmann's Surgery. Soon Mr. R-, colored, aged 40, porter, has had typhoid, also malaria, but no syphilis. Has had frequent attacks of la grippe. In 1903 was in bed a month with "pleurisy stitches." thereafter had pains in left side along the course of the sixth and seventh ribs at angle, and streaming forward. "Feels like tumor inside the chest." chest." Pain severe, cutting off breath; apt to cause vomiting; not brought on specifically by his work as a Pullman porter. Beginning to use morphine. PHYSICAL EXAMINATION.-Chest negative in ternally. Tenderness along 5th and 7th intercostal spaces. Most marked over 6th nerve 3 inches from vertebræ. A four-inch incision. over and parallel to the 6th rib uncovered the ribs and intercostal nerves. A slight protuberance 4 inch high and pointed, was felt at the angle of the 6th rib, not felt at the others, was clipped off. The nerves exposed were stretched. The divided muscles were sutured with silk in layers. The wound healed by first intention. This man had been submitted to various treatments-tonics, iodides, massage, electricity, and Christian Science. He has now been about his work three months without pain. A CASE OF SUDDEN DEATH FOLLOWING OPERATION FOR APPENDICITIS COMPLICATED BY DIABETES IN THE SERVICE OF DR. G. G. EITEL Mr. G———, aged 45, entered the hospital May 18th, with symptoms of gall bladder and appendiceal disease. With the exception of having been at one time a heavy drinker, he had been a man of average health until 1901, when he was first informed that he had diabetes. Since that time sugar has appeared intermittently in the urine, but it has always been amenable to diet, and the amount present has never been excessive. In February, 1901, he had his first acute attack of abdominal pain, which was accompanied by the classical appendicitis symptoms. This was followed by successive attacks of varying severity, the intervening periods becoming steadily of shorter duration. During the spring of this year he has had four such attacks. They have varied somewhat from those preceding, however, in that the pain had become localized higher up in the gall bladder region, and that in the last two he had been very much jaundiced. He has been annoyed with constipation for the last two or three years. The pain became so intense that the patient had taken to using morphine, and it was because of the danger of this habit's growing that it was determined to operate. On examination he proved to be a well-nourished, healthy-appearing man of middle age. The abdomen was somewhat distended and very sensitive to deep pressure on the right side, the most sensitive spot being the region between McBurney's point and the gall-bladder. There was some tympany. Two examinations of the urine for sugar gave negative results. OPERATION.-An incision as for gall-stones was made. Dense fibrous adhesions were found surrounding the cystic and common ducts, and involving the small intestine. These were freed. The appendix was found above its normal position, pointing upward and bound down with adhesions. It was inflamed, and showed evidences of trouble of long standing. It was removed as usual. The wound was closed without drainage. The patient sustained the operation admirably. His pulse was strong throughout, and he was entirely free from any nausea attending the anesthetic. The day following the operation, however, it was noted that the urine contained a considerable amount of sugar. This amount steadily increased with each twenty-four hours' examination. In every other respect his convalescence was all that could be desired until the sev enth day, and he showed no constitutional symptoms from the increased sugar output. The temperature never arose above 100°, and he gave no cause for alarm whatever. On the seventh day, however, he was extremely restless and he was permitted to sit up in a chair. Quieted, he ate an excellent dinner after which he slept. At eight o'clock that evening his temperature had risen to 100°, his pulse to 110. He spent a restless night complaining of headache. The following afternoon his respiration and pulse became accelerated and he complained of pain in his chest. The next morning (the 8th day) his temperature was 100.6°, and I examined his chest. Some dulness and râles were made out below the angle of the right scapula. Calomel was ordered. The temperature subsided and the chest cleared up. But it was apparent that he was not quite so well. His pulse was 120 and weaker. He had no pain. Stimulants were given, and since he complained of some difficulty in breathing he was allowed to sit up. He died suddenly while sitting in his chair on the evening of the 9th day. No post mortem was obtainable, therefore the cause of death can only be surmised. There was nothing to indicate that diabetes was the cause, and the most plausible theory would seem to be that it was due to an embolic process. |