Possibly certain deep-seated cysts in the urethro-vaginal septum, which being sub-mucous, may attain considerable size, may originate from par tial dilatation of the urethra (urethrocele). This possibility implies that the entrance into the diverticulum has narrowed and closed, and this has not been seen to occur. Still, 'I will relate an incompletely observed case which suggests this possibility to my mind, although it does not prove it. A specially strong woman, who had been married for four months, had had for two months a tumor hanging from the genitals which rendered walking difficult and caused dysuria. I saw her in November, 1875, and I found a slight prolapse of the anterior vaginal wall. The catheter en tered the prolapse without difficulty, and the wall intervening between it and the finger in the vagina seemed very thin. I saw the patient sgain in April, 1876. The prolapse of the anterior vaginal wall still existed, but the catheter no longer enterel it, passing over it into the bladder. There now existed a cystic sac, filled with pus, the size of a hen's egg, which was discharging into the vagina from an opening the size of a pin's head. I incised this opening to the extent of three-quarters of an inch, made a counter opening and passed a drainage tube. Under injections of carbolic the sac shrank, and in three weeks it was cured. Such a sac as this might readily be mistaken for cystocele. Sc,anzoni has recorded two cases very similar to mine.
There is but little to be said in regard to etiology. Huguier's supposi tion that pregnancy and labor had an influence has been disproved by Winckel, seeing that of fifty cases which he collected, only eight had borne children. Their dependence on catarrh can scarcely be granted, although the presence of catarrh near these cysts is noted, and, owing to the slight symptoms caused by these cysts, the time of their development generally cannot be stated. The cases are few in number when an exami nation was made before their presence and then afterwards. Knowledge of the etiology is yielded in those caies where the cysts formed after traumatism, and generally then they follow on hemorrhage.
Only larger vaginal cysts cause symptoms by rolling down the vaginal walls into the lumen of the vagina, and outside of the genitals. They may then cause vaginal catarrh, bearing down, pain in walking and in sitting, dysuria, dyspareunia, and prove serious obstacles to labor. Hard wicke recorded an instance of impediment to delivery, and cited similar cases from Ashwell, Langley, Lever, Peters, Mind& Mund6's case is the only one of these which affected the anterior vaginal wall. Catarrh of the vagina is frequently found near the cysts. We have already referred to the possibility of a catarrh favoring the develop ment of these cysts.
We need not say much in regard to diagnosis, since their fluctuation and their seat in the vaginal wall are sufficiently characteristic. Mis takin`g them for a cyst of the Bartholinian gland is hardly likely, owing to the site of the latter. Retention tumors in semi-atresia of the vagina are chamterized by their longitudinal shape and their relation to the uterus; peri-vaginal hematomata and abscesses are suggested by the his tory, the great pain they cause, the infiltration of the borders, the irregu lar form, and when superficial by the color.
In treatment simple puncture will not suffice. In a few cases after puncture and cauterization with lunar caustic or iodine, cure resulted, but this method is uncertain. The preferable method is incision and cauterization, or through drainage. The best way of all is extirpation, and this has the advantage that we can suture the surface and obtain union by prima intentio, as in Horder's case. Sometimes total extirpa tion fails, and then we must be content with partial (Lee, Muncie). Schroeder has lately advocated cutting off the projecting part of the cyst with the scisssors, and sewing its edges to the mucous membrane of the vagina. The inner wall of the cyst, which according to Ruge is covered with cylindrical epithelium, soon cannot be distinguished from the rest of the vaginal mucous membrane.