A DERMOID CYST 
OF THE 
LEFT OVARY. 
BY 
WILLIAM WARREN POTTER, M. D„ 
Buffalo, N. Y. 
With a Pathological Demonstration 
By William C. Krauss, M. D., 
of Niagara University. 
RHPRINT FROM THE 
JBuffafo iBQedicaf ariD Journal, 
December, 1889. A Dermoid Cyst of the Left Ovary. 
OPERATION—RECOVERY. 
By WILLIAM WARREN POTTER, M. D., Buffalo, N. Y. 
With a Pathological Demonstration 
By William C. Krauss, M. D., 
of Niagara University. 
Dermoid Cysts, though not infrequent, are not sufficiently com- 
mon, nor is their pathogenesis so well established as to render reports 
of isolated cases uninteresting or without value. The clinical ante- 
section history of the following case is kindly furnished by the attend- 
ing physician, Dr. J. D. Macpherson, of Akron, N. Y. : 
Mrs. R , aged 53, mother of two children, has had several miscarriages, and 
menstruates regularly. I saw this patient first, Oct. 16, 1888, when I found her 
suffering from severe pain in the cecal region, associated with marked tenderness 
at that point, together with tympanites and localized swelling. I made a diagnosis 
of obstruction of bowels, Dr. Lapp, of Clarence, in attendance at the time as consulting 
physician, coinciding in this opinion. The patient was kept under opium for twelve 
days, when her bowels moved naturally and she made a rapid and apparently full 
recovery. She summoned me again, April 1, 1889, when I found her suffering from 
severe pain in the lower part of her abdomen, temperature 104°. Under treatment 
for pelvic peritonitis these symptoms subsided and I discharged her from care the 
second time. April 14th, a week later, I was again summoned with the information 
that her abdomen was swelling. Upon examination I discovered a tumor rising 
from the pelvis which I surmised at once to be a distended bladder, as the patient 
informed me she had passed but a small amount of urine for some time. A catheter 
was introduced, but no urine was obtained. I saw the case the following day with 
Dr. Lapp, and upon the supposition that the tumor contained pus, a hypodermic 
needle was introduced, and enough fluid drawn to satisfy ourselves of the nature of its 
contents. We aspirated a week later, (as patient was menstruating profusely at 
that time), and drew off two quarts of healthy pus. The sac filled up again in about 
two months, and aspiration was again resorted to, with a similar result, though this 
time aspiration was followed by a chill and subsequent peritonitis. This time the 
sac filled even more rapidly than before. From the position of tumor, its inclining 
more to the left side, we now concluded it to be a cyst of the broad ligament, and 
recommended an operation to the patient and friends. Consent having been obtained 
the date of operation was set for August 24, 1889, and Dr. W. W. Potter, of Buffalo, 
N. Y., summoned to make it. 4 
DERMOID CYST OF LEFT OVARY. 
With only this meager history to guide me, and as the patient was 
in a markedly septic condition, I concluded that I had a suppurating 
cyst of the broad ligament to deal with, though a positive diagnosis 
was not ventured The only thing to do was to open the abdomen, 
with a view to a removal of whatever might be found. 
Abdominal section, August 24, 1889, at 8.30 a. m. Potter, opera- 
tor. Present, Dr. J. D. Macpherson, of Akron, and Dr. Henry 
Lapp, of Clarence, the attending and consulting physicians; also Dr. 
B. H. Daggett and Dr. Edward Clark, of Buffalo; Dr. A. N. Moore, 
of Rapids Bridge, and Dr. Martin, of Clarence. 
The short median incision quickly disclosed the cyst, that was found 
strongly adherent in all directions. It was tapped with an ovarian 
trocar, and something over four quarts of pus, flocculent towards the 
DERMOID CYST. VARIETY—PROLIFERATIVE, DENTIGEROUS.1 
last, were drawn. Some time was consumed in shelling out the cyst, 
from its stoutly adherent attachments to all the adjacent viscera, and 
the operation was necessarily a very dirty one. The patient seemed 
well-nigh collapsed by the time the cyst was released, but a free irri- 
gation with quite hot water rallied her promptly. The abdomen was 
closed with a drainage-tube left in the lower angle of the wound, and 
the usual dressings applied. In the evening, after the operation, her tem- 
perature rose to 100*4° F., with the pulse at 130. Next morning, the 
temperature fell to 990 F., with the pulse below 90. The temperature 
i. The walls have been opened sufficiently, allowing the edges to be everted so as to show the 
interior of the cyst. The presence of teeth, three in number, can be easily recognized. Photo by 
W. C. K. DERMOID CYST OF LEFT OVARY. 
5 
lurked in the vicinity of normal, being slightly subnormal at times, 
during the following week. The drainage-tube was removed on the 
fourth day, and the patient made a rapid and uninterrupted recovery. 
To the excellent after-treatment by the attending and consulting 
physicians, belongs much of the credit of the cure. 
Upon enlarging the opening in the cyst five teeth were found, and 
the remains of what seemed to be a maxillary bone. The cut which 
appears on page four shows three of the teeth very clearly, the others 
being now in possession of one of the physicians in more immediate 
attendance. I leave to Dr. Krauss the histological description of the 
tumor. 
William Warren Potter. 
HISTOLOGICAL AND PATHOLOGICAL DEMONSTRATION, BY DR. KRAUSS. 
Dermoid cysts have been classified under the teratomas by Vir- 
chow, in view of the number of different tissues which enter into 
their structure. They also come under the head of congenital or 
developmental cysts, taking their origin, in all probability, at some 
early intrauterine period. 
The exact nature of the genesis of these cysts is still shrouded in 
mystery. The most plausible theory yet offered, and the one prone 
to be accepted, is that they result from a misplacement, or involution 
of the epi- and mesoblast of the embryo, at an early period of devel- 
opment. The misplaced epithelial elements, contained in the stroma 
of the ovary or other organ, in developing produce a neoplasm, whose 
inner walls assume the character of the epidermis, with its structure, 
appendages, and, in part, its functions. 
The theory, once held in good repute, that they result from some 
ectopic gestation, has long been discarded ; the character of their 
contents and mode of development preclude all possibility of their 
being the remains of an undeveloped fetus. 
The favorite seat of these cysts appears to be in the ovaries, as 
two-thirds of all known cases have been found in these organs. Next 
to the ovaries, they are most frequently encountered in the testicles, 
and have even been found in the mediastinum, lungs, and cranial 
cavity. 
Structure.—The walls of dermoid cysts are composed of an exter- 
nal or muscular, and an internal or epidermal layer. All interest, 
however, is centered in the latter, which consists of a corium and an 
epidermis of flattened epithelial cells, simulating closely the structure 
of the skin. This layer may vary considerably in structure and 
appearance. Sometimes it is of a smooth epidermoidal character, or 6 
DERMOID CYST OF LEFT OVARY. 
it may be nodular, with hypertrophy of the corium and epithelial cells, 
resembling warty excrescences. Cartilaginous tissue, irregular-shaped 
bony structures, as bony plates, misformed maxillary bones with 
alveoli set with teeth and structures corresponding to the nails, have all 
been met with complicating this inner layer. It may also, at times, 
possess the appendages and structures of the normal skin, developed 
to a high degree of perfection. Sebaceous glands, with secretory 
power, sweat glands and hair follicles, capable of performing their 
functions, have been found in the walls of these cysts. Nerve 
elements, brain tissue and unstriated muscular fibers have occasionally 
been observed. Cysts, with this variety of contents, have been called 
proliferative. 
Lebert found, in half the cases of dermoid cysts, the presence of 
teeth, while Pauly found them in only one-sixth of the cases. They 
may be set in alveolar cavities, or may be attached to the walls by 
connective tissue bands. The number of teeth found in these cysts 
varies from 1-300. (Cases reported by Plocquet and Autenrieth 1807, 
and by Schnabel 1844). The variety may include incisors, canines, 
bicuspids, molars, or wisdom, perfectly developed with fang, neck, 
crown, enamel, tartar and cement. In the majority of cases, however, 
they are imperfectly developed, being irregular in shape, and incapable 
of being classified. Those cases of dermoid cysts in which teeth com- 
plicate the structure are designated as dentigerous. 
A close histological examination of the heterogeneous elements 
found in the walls of dermoid cysts, discovers nothing to distinguish 
them from the same tissues which occur normally in the human 
structure. 
The size of these cysts may range from that of a walnut to a man’s 
head, depending, of course, upon their contents, which is the result of 
continuous activity of the glandular structures. Large masses of fatty 
matter, epidermal scales, cholesterine crystals, leucocytes, bunches of 
hair, etc., have been found enclosed within their walls. 
This short sketch of the development and structure of dermoid 
cysts may aid somewhat in a better comprehension of the description 
which is to follow. It may also serve to remind the reader of the great 
variety of anatomical elements present in such a neoplasm, and to show 
how far the development of this cyst has advanced. 
DESCRIPTION OF DR. POTTER’S SPECIMEN. 
The cyst is slightly globular in form, with a transverse diameter of 
four and a half inches, and a longitudinal diameter of five 
and a half inches. (In the fresh state, these figures were undoubt- DERMOID CYST OF LEFT OVARY. 
7 
edly much increased, the action of alcohol tending to con- 
tract the tissues.) The external surface presents a ragged, uneven 
appearance, with long irregular shreds of connective tissue, having 
once served as attachments to the neighboring organs. The cyst does 
not appear to have had a pedicle, as no remnant of one is recogniz- 
able. A small fragment of the Fallopian tube, much distended, is 
found attached to the external surface. 
The external or muscular coat is variable in thickness. In some 
places nothing but a broad aponeurotic structure is present, which 
soon expands into dense, muscular layers, from one-sixteenth to one- 
quarter inch in thickness. These muscular fibers have a more or less 
circular arrangement, and are of the plain non-striated variety. 
Masses of adipose tissue, blood-vessels of different sizes, and several 
nodules of cartilage, the size and form of a small bean, were found 
imbedded in this muscular coat. 
The internal, or epidermal, layer claims most of our attention. It 
is smooth, soft, velvety at places; then it takes on a rugged nodular 
appearance. In some places, small cauliflower-like excrescences, of 
considerable area, are present. The thickness of this layer is also vari- 
able, depending upon the condition of the corium and epithelial cells, 
whether in state of hypertrophy or not. Scrapings from the surface 
of this layer, examined microscopically, show flattened epithelial cells, 
fat globules, leucocytes, and detritus. 
Near the original opening of the cyst are grouped a number of 
well-formed teeth, some set in alveolar cavities, others joined to the 
wall of the cyst by connective tissue fibers. The number of teeth 
originally present was five ; subsequent to the operation, two became 
detached, and were removed. In the walls of the cyst, a flattened 
triangular bony plate, with sharp edges, is found, projecting through 
the soft structure. Leading down to this bony plate are two alveolar 
cavities, whose corresponding teeth, as has just been stated, were 
removed after the operation. A probe inserted into these cavities 
shows that the bone contains rather shallow but well-marked depres- 
sions, which served for their lodgment. The free edges at the open- 
ing of these cavities have a ragged fringed appearance, indicating the 
ruptured attachments between the soft tissues and the teeth. 
The remaining teeth now to be described are well shown in the 
illustration. 
Tooth No. i is asecond bicuspid, three-quarters of an inch long, with 
crown and fang complete. The masticating surface of the crown is 
about three-sixteenths of an inch in diameter, and possesses two cusps, 
of unequal length. The fang tapers to a point, and is half an 8 
DERMOID CYST OF LEFT OVARY. 
inch in length. This tooth is of normal color, and is supplied with 
enamel, tartar, and cement, making it a perfectly developed tooth in 
every particular. It is firmly attached to the walls of the cyst by broad 
bands of connective tissue. 
Tooth No. 2 is a wisdom tooth three-quarters of an inch long. Its 
crown possesses four cusps separated by a crucial depression. The fang 
is five-eighths of an inch long, transversely flattened, wedge shaped 
with no tendency to bifurcate. It also is attached to the wall of the 
cyst by connective tissue fibers. 
Tooth No. 3 is a distinct cuspid, or canine. Its crown is conical, 
convex externally, concave internally, tapering to a blunted point. 
The neck is surrounded by a tissue resembling the normal gum. Its 
fang is firmly set into an irregular shaped mass, calcareous in color 
and appearance, but lacking the hardness and brittleness of calcareous 
structure. This mass, which is about five-eighths of an inch in diam- 
ter, is attached to the wall of the cyst by a short, thick, fleshy, 
pedicle. Small pieces of this calcareous-like substance are scattered 
about the epidermal layer. 
Hair follicles, sweat glands, nails, etc., were not found in connec- 
tion with the inner layer. 
From the description of its contents, this cyst is to be classified as 
dermoid, proliferative, dentigerous. 
Interesting points about this cyst are the perfectly developed teeth 
which permit of classification, its large size, and the length of time it 
remained dormant in the system. 
William C. KrAuss.