A clinical lecture on dermoids, ovarian and pelvic : delivered at the Samaritan Free Hospital on Thursday, November 5th, 1903 / by Alban Doran.

  • Doran, Alban H. G. (Alban Henry Griffiths), 1849-1927.
Date:
1904
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Credit: A clinical lecture on dermoids, ovarian and pelvic : delivered at the Samaritan Free Hospital on Thursday, November 5th, 1903 / by Alban Doran. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    The Medical Press. ORIGINAL COMMUNICATIONS. Feb, io, 1904. doubtful, or, more correctly speaking, instances of ovarian dermoids transplanted to the omentum. Returning to genuine ovarian dermoids, the most important question in respect to their characters is, Are they innocent or malignant ? It is now known that true pathological malignant degenera- tion of this kind of tumour is quite exceptional, and occurs late in the development of the growth. But the dermoid tissue not rarely implants itself on the peritoneum outside the cyst wall; this prejudicial change is constant in a form of dermoid mainly solid, named teratoma. Dermoid cyst of the ovary proper is a very common tumour. I have operated in this hospital on five cases during the past summer. The percentage of dermoids in relation to other ovarian tumours is much higher than was once supposed, for mixed adenomatous and dermoid multilocular cysts are quite frequent. Only last month I removed a large cystic tumour, emptying during the operation several pints of typical ovarian fluid, free from dermoid elements, from a cyst larger than its fellows ; afterwards grease and hair were found in some of the lesser cavities. Such an experience is common in ovariotomy. Ovarian dermoids proper are rarely multilocular, and nearly always pedunculated, which is for- tunate, as enucleation would involve risk of escape of septic grease. They are often bilateral, so that it is always necessary to make sure of the condition of the opposite ovary when an ovarian dermoid is removed. This frequency of bilateral dermoid disease is specially important to bear in mind in cases under puberty. Ovarian cysts in children are nearly always dermoid, so when a cyst is diagnosed in a child the possibility that both ovaries may require removal must not be overlooked, and the con- sequences of double ovariotomy must be explained to the patient’s friends. Ovarian dermoids are met with in women of all ages ; children, young girls, parous subjects, elderly virgins, and old women who have borne children. In age they appear sometimes, as in a case which I shall relate, to lie latent, but I have removed large dermoids in an active state of development from old patients. There are four clinical features of special interest in relation to the common ovarian dermoid. (1) If diagnosed early, ovariotomy proves easy and highly successful. (2) Twisting of the pedicle and worse complications are very frequent. (3) Association of an ovarian cyst with pregnancy, labour, and the puerperium is specially serious when the tumour is dermoid. (4) Neglected der- moids cause dangerous and intractable compli- cations. Early diagnosis of an ovarian dermoid is one of the greatest services which a doctor can render to a patient, and if the tumour be successfully removed cure is complete, for a dermoid is not pathologically malignant, so there will be no recurrence in the pedicle. The tumour has not, in such a case, contracted adhesions, its pedicle is rarely broad and usually narrow, and above all, none of the contents have escaped into the peri'-.onfeal cavity, nor has bone or hair worked its wayiinto the bladder or rectum. Even twisted pedicle, so frequent in dermoids, at first facilitates the operation, the ovarian vessels being usually plugged. If operation be delayed serious effects may arise from this complication. An ovarian dermoid forms a tumour of small and moderate size, usually occupying the middle of the abdomen up to or above the umbilicus. A very large dermoid is often compound, the main loculi being freed from dermoid elements, but this is not a matter of much clinical import. There will be resonance in the epigastrium and flanks. Free fluid in the peritoneal cavity is very unusual, just as in uterine fibroid disease. In cases of glandular ovarian cyst this condition is not rare ; in fibroma of the ovary (which has been taken for a dermoid when very soft) it is frequent, and in free papilloma or malignant disease of the ovary constant. A dermoid ovarian tumour may fluctuate quite distinctly, but as a rule fluctuation is obscure, and there is a doughy feeling on palpation. Above all, irregular degrees of consistence in differs., c parts of the tumour are very characteristic in most dermoids. It may feel tense high up, hard on one side, almost spongy on the other, doughy below, and so forth. When a mass of bone can be felt, diagnosis is practically certain. A true included monstrous foetus never lies in a movable cyst and well up in the abdomen; a retained extra-uterine foetus in a sac is associated with conditions in the pelvis and disturbances of the catamenia which are not to be detected in a case of uncomplicated dermoid, whilst a normal uterine foetus should never be taken for bone in a dermoid cyst. As a rule, I find that bony plates in ovarian dermoids are not to be detected by palpation, even though plenty may be found in the tumour after or during its removal. An ovarian dermoid is quite movable at first, and on pelvic exploration the uterus is nearly always far back, behind the lowest part of the tumour, which comes down to the level of the pelvic brim, if not lower. These relations are, however, by no means constant. Occasionally, as in a case where I operated here last month, the entire uterus lies forward, pushed upwards by the dermoid which comes down into Douglas’s pouch. When very small, a dermoid not rarely lies altogether in the pelvis, and occasionally remains there even after attaining a considerable size. Diagnosis is not always easy, but occasionally the doughy feeling is very evident on bimanual palpation. A pelvic dermoid is a distinct source of danger in young married women, as it will obstruct labour, and may rupture, especially should obstetrical operations be necessary. But complications often set in early. Ovarian dermoids are particularly liable to torsion of the pedicle, intra-cystic haemorrhage (very rarely serious), adhesions due to irritation and inflam- mation of neighbouring peritoneum, septic in- fection of the contents and escape of the contents from the cyst cavity, either through rupture of the cyst wall or by processes which allow hair or bone to grow through the wall. Even very early in its history a dermoid is often tender to touch, a fact which aids in diagnosis. A history of a very sharp attack of pain is not rare, while very often the patient complains that she has suffered from dull pain for several days. The sharp pain means acute torsion of the pedicle ; the dull pain, if observed by a medical attendant to be free from rise of temperature, signifies slow torsion. The latter complication, much the more frequent, is, however, often associated with local