erated exfoliated detritus, fat and VAGINAL , droplets cholesterin crystals. If large, the contents may be a from 2 to 4 mm. are of CLARENCE B. INGRAHAM, M.D. clear fluid. Their walls, thick, fibrous tissue lined from two to of DENVER by thirty layers squamous epithelium, usually thicker at one point than have received frequent consideration at another. The superficial cells are often devoid of in medical literature. Stokes, Cullen,1 Breisky,2 nuclei and filled with vacuoles. The deepest layer is Winkel,3 Freund,4 Veit,5 Gebhard6 and Bandler7 most often cuboidal. have written important articles on this subject. Such a , usually painless, occasionally causes a Small cysts in the are unusual; a large cyst disagreeable irritation or vaginismus. The treatment is rare. One large cyst and two small ones having is enucleation. come under my observation, I take this opportunity to report them. Vaginal cysts undoubtedly originate from different sources; from inclusions of , from vaginal glands, persistent embryonic structures, pos- sibly from urethral epithelium. It is often difficult or impossible to determine their origin. A cyst, originally lined by squamous epithelium, may undergo changes, many layers of cells being reduced to a single layer with the characteristics of a cuboidal cell. A probable form of vaginal cyst is one that develops from inclusions of vaginal epithelium, crypts or folds adhering as a result of , not uncommon in the young. Such an adhesive vaginitis may result from , from a general systemic highly irritating Fig. 2.—On the double with cervices with or a left, communicating discharge, from the ulcération of foreign body. a fully developed vagina, and a rudimentary vagina. The blind vagina The commonest form of is the inclusion is converted into a cyst by the accumulation of menstrual secretion. cyst cyst On the left, the small rudimentary uterus has no communication with found near the introitus. are small and result its corresponding vagina which through accumulation of secretion has They formed a müllerian or vaginal cyst. from the inclusion of islands of squamous epithelium in the of lacerations or the healing perineal during repair It is believed that there are no of a relaxed outlet. generally normally vaginal in the in Such occur in the or lower lateral glands vagina. Preuschen,8 1877, however, cysts posterior made sections of and wall, often in scar tissue. are small, carefully thirty-six , They relatively found definite in four. The necks of the varying in size from that of a pea to that of a hazel- vaginal glands glands were of squamous epithelium ; the deeper por¬ ß were Left UterinetuW or Mulliría"!, Uteri-ne tu.tr* mehr tions lined by cylindric epithelium in which cilia Mullirían Butt were detected. Hennig had described similar glands in 1870. Meyer9 found glandular formations in new¬ -i born infants, which on consolidation of the excretory ducts could develop into small cysts. Cullen ascribed as source of and a t*~ vaginal glands the three possibly "iH^datid. fourth in his series of cases. His careful of MorqaQnl cyst histologie »'Hiidatids of UJ^e«" seems to substantiate this origin. They are small VV. study Ulev'infc |> 1 /- ! pert of Qod^ lined a cuboidal or almost flat The of £jo.rtneri T>ucf /Po-rOofahorcrt, fragments cysts by epithelium. i of IuUaUs aoovqlomoleruli cavity is partly filled with , with no evidence of / of tower port of W. Q degenerative changes. Vo-qiwa·' portion, £ loo o|i h or orv CR.V ft^nxWv} as their fetal Gartner's of q'&rrter's Du.ct,/ Ubvlts oj u+t>*r port of Cysts having origin remains, Wolff ion. <1« - duct, may assume quite large proportions. They have been described as being as large as the fetal head. Klein 10 was able to follow the wolffian ducts in a new¬ born infant and in an older child from the to the . The ducts may persist as either short Fig. 1.—Relation of , pharoophoron, wolffian duct and segments or, as in a few instances, from the paro- Gartner's duct, through their course in the broad , cervix and vagina. varium to the uterus, running alongside, or through the masculature of, the uterus in the substance of the cer¬ vix and the lateral or in the anterior nut, usually single, and yellowish, or whitish, if larger. along vaginal wall, on either side of the to the They are filled with a friable, sebaceous material portion hymen. and masses of Some observers believe Skene's glands to be the ends resembling pus, representing degen- of Gartner's ducts. 1. Cullen: Vaginal Cysts, Bull. Johns Hopkins Hosp., June, 1905. Gartner's duct has an inner of one of 2. Breisky: Cysten der Scheide, Stuttgart, Pittra and Billroth 55: lining layer 131, 1879. cuboidal or cylindric epithelium. Its outer covering is 3. Winkel: Die Scheidencysten, Lehrbuch der Frauenkrankheiten, of fibrous tissue with a middle zone of mus¬ Leipzig, 1886, p. 153; Ueber die Cysten der Scheide, Arch. f. Gyn\l=a"\k. nonstriped 2: 383-413, 1871. cle, arranged longitudinally, transversely or running in 4. Freund: Beitr\l=a"\gezur Pathologie des doppelten Genitalkanals, both directions. Ztschr. f. Geburtsh. u. Gyn\l=a"\k.1: 231, 1877. Echinococci, Gyn\l=a"\k.Klin., Strassbourg 1: 321, 1885. 5. Veit: Handbuch der Gyn\l=a"\kologie 1, 1897. 8. Preuschen: Ueber Cystenbildung in der Vagina, Virchows Arch. 6. Gebhard, C.: Cysten der Vagina. Pathologische Anatomie der f. path. Anat. 70: 111, 1877. weiblichen Sexualorgane, Leipzig, 1899, p. 535. 9. Meyer, R.: Atlas der normalen Histologie, der weiblichen 7. Bandler; S. W.: Gynecological Pathology, Abel and Bandler, 1901, Geschlectsorgane, Leipzig, J. A. Barth, 1912, p. 97. p. 206. 10. Klein: Lehrbuch der Gyn\l=a"\kologie,Otto K\l=u"\stner,1910, p. 98.

Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/01/2015 Cysts arising from Gartner's duct are most common accumulates fluid and forms a cystic tumor in the along the anterior vaginal wall just to one side of the lateral wall of the normal vagina. urethra, or on the lateral vaginal wall. They are ses¬ In the other type, there is the well-developed horn sile, rarely pedunculated, usually oblong. They may communicating with its corresponding vagina, while the show at one end rudiments of the undilated duct; they rudimentary horn is sufficiently well developed to give are single, or there may be two or more following the off menstrual fluid which communicates with a rudi¬ course of the duct. The cyst may be small or like the mentary vagina below. This vagina has no communi¬ one here reported, it may extend from the introitus to cation with the normal vagina or with the exterior. It the vault of the vagina. Cysts have been reported becomes filled with a chocolate colored fluid. It is not which dissect upward between the layers of the broad a true cyst. Tension may cause it to break into the well ligament, or a parovarian cyst may dissect its way formed vagina, or becoming infected, it may form a downward and encroach on the lumen of the vagina large abscess. (vaginoparovarial cysts). The removal of such cysts occasionally causes serious Gartner's duct cysts grow slowly, as in my case, and surgical difficulty. They are often treated by incision as -reported by others, pregnancy has a stimulating and removal of the intervening septum, incorporating effect on their growth. Often they are first noticed the cyst into the vagina. during gestation. Graves 12 reports a case in which the septum between Like the duct, they are lined by a single layer of the two vaginae had become the seat of a great plexus cuboidal epithelial cells, occasionally cylindric or almost of vaginal veins, so that an attempt to remove the sep¬ flat (Cullen). Robert T. Frank lx reported a case in a tum and connect the two vaginae into a single canal multiparous patient in whom four large cysts developed could not be carried out, hysterectomy with drainage of along one side of the vagina, reaching from the skin the infected cyst through the abdomen and vagina deeply into the broad liga¬ eventually dried up the cav¬ ment, and necessitated a ity. cesarean section. The lining Cullen considers the possi¬ of these cysts varied from bility of vaginal cysts de¬ low cuboidal, ciliated colum¬ veloping from the urethral nar, to a stratified transi¬ (Littré's) glands. Such tional epithelium. The large cysts are rare, if they ever cysts showed no epithelium ; occur. In two of his cases, the smaller ones showed the the similar histologie picture variations reported. No der¬ led to the belief that such ivation,' excepting the wolf- might be their origin. fian duct, he states, is plausi¬ The urethra and vagina ble, and so he makes the are intimately associated. statement that different types The posterior wall of the of epithelium from a colum¬ urethra is firmly attached to nar to stratified epithelium the anterior vaginal wall exist in Gartner's duct cysts. throughout its entire length. Meyer9 states that "Gart¬ The mucosa of the urethra ner's duct in the vagina is longitudinally folded with the club and and hymen shows a varied formation of epithelium, single layers, or tubular depressions. Some Fig. 3.—Low power photomicrograph, showing columnar epi¬ are lacunae, others double and multiple layers ; thelial lining of cyst. The muscle belongs to a portion of anterior simple cylindrical, cuboidal, and vaginal wall removed with the cyst. are glandular in nature and large squamous cells are occa- secrete a colloid material. sionally found." The cysts may have squamous epi¬ Lacunae form the entire length of the urethra. While thelium with stretches of cylindric epithelium between. some are broad based and open by a narrow channel Gartner's duct cysts contain a mucinous material, into the urethra, others are large, tubular, push into the either colorless or straw colored, or after injury, brown¬ propria, and often branch and run parallel to the a cf ish or reddened semifluid material, from blood pigment. urethra. The cysts described by Cullen had lining the cells The walls are thin/usually not more than 0.5 mm. from three to eight layers, superficial being on of flattened in thickness, and are composed of fibrous tissue with cylindric and resting underlying layers muscle cells intermingled. These are diffi¬ and deeply staining cells, the general arrangement being nonstriped that the cult to make out in the larger cysts. of the lining of urethra. Freund,4 in 1877, first described the type of vaginal Dilatations arising from the urethra should not be confused with most of cyst resulting from an accumulation of fluid in a rudi¬ vaginal cysts. Probably cysts mentary vagina or Müller's duct. It is remembered this type originate as periurethral abscesses, and pres¬ that in fetal life, Müller's ducts fuse to form the sure will usually cause such a cyst to empty itself urethra. uterus and vagina. Fusion may fail to occur and a through the a small be met double uterus and double vagina result. "Occasionally, cystic prominence may with in the lateral on which there Two forms of defective development occur which vaginal wall, opening is an of urine with a resultant fistula. may give rise to Müllerian duct cysts. In the first, a escape urinary This is an Brodel and others well-developed horn communicates with an apparently embryologie abnormality. normal vagina; the other horn is rudimentary, takes have pointed out that when there is a double kidney on one the ureter from the lower is no part in menstruation and has no communication side, kidney ordinarily with its corresponding vagina. This incomplete vagina implanted into the normal site, while that of the upper 12. Graves, W. P.: Text Book of Gynecology, Ed. 2, Philadelphia, 11. Frank, R. T.: Am. J. Obst. 72: 467, 1915. W. B. Saunders Company, 1918, p. 299.

Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/01/2015 kidney is carried down further by the wolffian duct, and during a pregnancy, when they fill rapidly. This cyst by inserted more medialward and nearer the urethral the seventh month was the size of a goose egg, extended the vault of the was with the anterior orifice. Were this ureter carried a little lower, the into vagina, sessile, blind described in the would be accounted vaginal wall rather lax over the cyst. pouch vagina When the patient went into labor at term, the cyst was for." Such an should be in mind abnormality kept tapped, and so collapsed as not to interfere with the birth, when a small cystic protrusion is encountered in the which was normal. lateral part of the vagina. About six weeks after labor, the cyst had refilled, was not so large as during pregnancy, but protruded on walking, was annoying and for temporary relief was aspirated. When the child was 4 months old, I removed the cyst. It extended from the up into the left and was the size of a goose egg. The cyst, thin walled, was attached between the anterior vaginal wall, urethra and bladder throughout the length of the vagina. It dissected away easily. The anterior vaginal wall was brought together after removing some of its redundancy, as in a operation. Its description follows. The vaginal cyst was elliptic and measured 5.5 by 3 by 3 cm. (the dimensions here given are smaller than the size in situ, as the cyst had been partly aspirated and preserved in liquid formaldehyde. The wall was 1 mm. thick and had a smooth inner surface. Its contents were a colorless mucoid substance. Microscopic Examination: The outside of the wall is lined by the vaginal squamous epithelium under which is a layer of loose with a fairly rich blood supply, and a well developed layer of muscular tissue. The cyst, has a thin capsule made up of fibrous tissue; no muscle cells are seen. The lining of the cyst is a single layer of columnar epithelium; no cilia are demonstrated (Dr. Philip Hillkowitz). Metropolitan Building.

INJURIOUS COMBINED EFFECT OF ROENTGEN RAYS OR RADIUM, AND TOPICAL REMEDIES Fig. 4.—Gartner's duct cyst (author's case). GEORGE M. MacKEE, M.D. in Dermoid cysts have been encountered developing AND the rectovaginal septum. In countries where the GEORGE C. ANDREWS, M.D. cases echinococcus is prevalent, of echinococcus cysts NEW YORK of the vagina are reported.4 Cysts arising from Skene's glands must be considered under vaginal cysts. Now that roentgen rays are widely employed in A rare condition is colpohyperplasia cystica, diagnosis and therapy and radium is used exten- described first by Winckel.3 Small cavities filled with sively as a remedial agent, it is essential that physi- clear fluid or gas, and forming elevations, appear on the vaginal mucosa. Lindenthal13 states that it is a condition due to with Bacillus aerogenes- capsulatus. Others have demonstrated this organism, while Jaeger 14 has produced the cysts experimentally in animals. Though not amenable to treatment during pregnancy, when the disease usually makes its appear¬ ance, it usually disappears spontaneously after child¬ birth. REPORT OF CASES The two small cysts were both inclusion cysts, and followed perineal lacerations. They occurred in scar tissue near the vaginal orifice. One measured 1 by 1 cm. and was encoun¬ tered while doing a perineal repair. The other was removed under cocain in the office. It was described as the size and shape of a bean. The description of both corresponds to that given for inclusion cysts, and they were filled with white sebaceous Fig. 1 (Case 2).—Scars resulting from application of solid carbon material. dioxid following roentgen-ray treatment for keloid. The large cyst occurred in a primipara, 23 years of age. In the fifth month of pregnancy, there was a feeling of pres¬ cians, even those who do not employ these agents, be sure in the vagina, and a month later a protrusion, resem¬ of the associated with the a cognizant dangers topical bling large cystocele, appeared. in of remedies to It has been said that vaginal cysts grow slowly, and it is application strength irritating parts are often the case that they do not make their appearance until that have been or to be irradiated. The injurious of such combined treatment does not 13. Lindenthal: Aetiologie der Kolpohyperplasia cystica, Wien. med. possibilities Wchnschr., 1897, Nos. 1, 2 appear to be by the of the medical 14. Jaeger: Das Intestinalemphysem der Suiden, Arch. f. Tierheilk. appreciated majority 32: 425, 1906. profession. Want of knowledge and judgment in this

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