In April, 1873, I saw an analogous case in a healthy seven weeks old, breast-reared infant. A cyst, the size of a hazel-nut, with relaxed walls and furrowed surface, sprea,ding from the anterior vaginal wall backward and to the left of the meatus urethrie, was prolapsed through the widely dilated hymeneal orifice. The little finger could be passed into the vagina behind the tumor, and the atta,chment of the cyst as well as the normal state of the posterior vaginal wall and of the cervix could be determined. There was no disturbance of micturition, and the cyst did not trouble the patient Artificial opening was not allowed by the parents. It probably broke spontaneously, since the family physician reported later that it had shrunk.
In neither of these cases was there an anatomical examination, and therefore no definite statement can be made in regard to the source. The site, the thickness, the vascular wall, and the nature of the contents in Winckel's case, speak for their having been due to a closure of a rudi mentary segment of the anterior vaginal. wall. This is more likely than the belief in their origin from a crypt near the meatus urinarius, since in the new-born, when they are developed at all, these crypts are very shallow.
In favor of the derivation of these cysts from rudiments of Milller's duct, the following points speak: They are simple or multiple cysts, arranged longitudinally, and never extending above the fornix towards the broad ligament, they are usually in the axis of the vagina, in the mid dle or to one side; the base of the cyst wall consists of developed mucous membrane (muscularis, papillte, with pavement epithelium); the wall is thick; there is no connection with the urethra; there is occasionally also present a uterus unicornis (Freund).
As regards the bloody and the purulent contents of such vaginal rudi ments, Kleinwitchter point,s, with reason, to the influence of pregnancy and of labor, and even in Freund's c,ase traumatism of labor must be considered the cause of the blood in the cyst, although he thought it was depetident on menstrual separation of the vaginal mucosa. Such rudi ments may exist for years without symptoms, until the appearance of hypersecretion or hemorrhage, or else of prolapse.
In regard to the origin frog' persistent remnants of Wolff's or Gartner's ducts, to which G. Veit first called attention, two instances have recently been recorded where this seemed to be the case.
In one case (Robert Watts) the woman was forty-one years old, had borne eight children, and for three years a cyst, the size of a hen's egg, attached to the anterior vaginal wall, had prolapsed, and it spread upwards into a slender duct, in which a sound could be passed without difficulty towards the left side for a number of inches, so that the point of the sound could be felt through the abdominal wall at the level of the umbi licus, between it and the ant. sup. spine of the ilium. Only the lower
cystic portion could be loosened from its bed, and it was removed after ligature of the upper and neck-like extension. The point of removal was knit above the reflexion of the vagina from the cervix, and the lower end of the cyst was about one half an inch behind the urinary meatus. Fre quent examinations with the catheter proved that it hal no connection with the bladder. The contents of the cyst was about two ounces of a sero-purulent fluid.
Garrigues examined the extirpated cyst and found the smooth inner surface covered with pavement epithelium, and about a dozen recesses, the smaller of which were round. while the larger were transverse. Un derneath the epithelium of the thick wall there was a thin layer of con nective tissue containing round cells and many capillaries, and externally there was a normal muscularis.
During and after the operation there was hemorrhage from the upper part of the.wound which required the tamponade. During two days the urine was bloody, but it then became clear, and the cavity gradually closed. Watts states that analogically the site was that of the vas deferens, and he finally reaches the conclusion that it was a cyst of Gartner's duct. If his supposition be correct, then the bloody urine must be considered the result of exe,oriation of the mucous membrane of the bladder by the repeated catheterization.
A second very uncommon case is considered by the reporter, J. Veit, to be an instance of cystic development of a persistent Wolffian duct. In a woman of forty-seven, who had borne a number of children, there had existed a prolapse for a number of years, which it was difficult to rectify and which caused retention of mine. Veit found the prolapse only from the right side of the vagina, and the size of a child's head. The urethra was entirely dislocated downwards; the left wall of the urethral projection was normal; to the right, where there was no cul:cle-sac, the urethra spread over the prolapse. To the left the finger penetrated into the compressed vagina, and reached the cervix, which was unchanged, as also the anteriorly flexed uterus. The uterine adnexa could not be felt with out anEesthesia, but the uterus was greatly pushed to the left by a swelling in the right broad ligament. There was no rectocele. The catheter could not be inserted into the prolapse. Examination under anEesthesia revealed a tense tumor in the broad ligament, which was in connection with the cyst in the vagina. Above the tumor the ovary could be felt, and on the left side the adnexa were normal. Veit incised 'the prolapsed portion as freely as he could without injury to the vessels, and then sewed the edges to the vaginal mucous membrane.