erated exfoliated detritus, fat and VAGINAL CYSTS epithelium, 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 Vaginal cysts 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 cyst, usually painless, occasionally causes a Small cysts in the vagina 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 vaginal epithelium, 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 vaginitis, not uncommon in the young. Such an adhesive vaginitis may result from infections, from a general systemic highly irritating Fig. 2.—On the double uterus 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 duct 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 vaginas, 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 mucus, 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 cervix to the hymen. The ducts may persist as either short Fig. 1.—Relation of epoophoron, pharoophoron, wolffian duct and segments or, as in a few instances, from the paro- Gartner's duct, through their course in the broad ligament, 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 urethra 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.