ovarian tumor, its size, mobility, sensitiveness, etc. The prognosis of enterocele, with regard to life, is good; the accompanying symptoms are not usually grave. Since it generally occurs in patients who have repeatedly been delivered, the parts are relaxed and stretched, and symptoms of strangulation are very rare. On the other hand, a radical cure is almost out of the question; the treatment will be palliative, instruments being used to retain in position the parts which were prolapsed. Of 15 cases collected by Hoin, 13 were women who had recently been delivered, and in whom the position of the uterus directly behind the abdominal walls favored the descent into Douglas's cul-de sac. But it also occurs in nulliparæ. Treatment.-An ovariocele may be reduced, when the ovary is wedged into the sac, either in the lateral posture or à la vache, the operation being facilitated by narcosis: this is a necessity in the reduction of the ovary from beneath the pregnant uterus. If reduction be impossible, an attempt to lessen the size of the tumor by removing a part of its contents must be made, and this is best accomplished by puncturing the fluctuating portion with a long, curved trocar passed up the vagina. The modus operandi of this operation will be considered in detail under ovarian affections. Should reduction be impossible after lessening the size of the tumor, or should the latter be also impossible, then ovariotomy or, during labor, the Cæsarian section would come in question. In enterocele the reduction is usually easy, the two cases reported by Landau and Breisky excepted. It is performed with two or four fingers, or the whole hand, in the position à la vache. Retention is secured by a round pessary of suitable size, in a manner similar to that required in vaginal inversion. Petrunti in one case diagnosticated an abscess which threatened to open into the vagina; he therefore made an incision, and, after evacuating a quantity of bloody serum and putrid matter, a large portion of the gangrenous omentum appeared which he excised. In hydrocolpocele which is in free communication with the abdominal cavity, puncture will also evacuate the sac. Puncture through the vagina would be necessary only when the sac is completely closed, when the symptoms demand an operation, or when the other measures adopted fail to reduce the size of the tumor. The operation is to be repeated if the sac refill. But it matters not in what way suspicions of hydrocolpocele arise, no excision of part of the wall, or injection of tincture of iodine. should be made, since the possibility of some slight communication with the peritoneum always exists. The treatment of the original affection causing the hydrocolpocele does not come within the limits of this treatise. In pyocolpocele the question of incision or puncture may also arise. As a rule, the treatment of the diffuse peritonitis will first claim attention, and any therapeutic measures be of avail only when it has subsided. CHAPTER IV. NEOPLASMS OF THE VAGINA. GURLT observed the following tumors of the vagina in 11,140 patients with tumors of all kinds : Of 647 women with fibroma, 1 was situated on ant. vaginal wall. " 4107 carcinoma of the genitals, 114 occurred in the vagina alone; in the vagina with uterus, 3449. In all, 122 in 5029 tumors of the external and internal sexual organs, excepting tumors of the mammary glands, there were 2 to 2.3 per cent. of vulvar tumors. When we study Gurlt's statistics of tumors, we will at once notice the remarkable infrequency of neoplasms of the vagina. On the other hand, compared with the rare appearance of neoplasms, we find congenital tumors and those occurring in early childhood quite common. I wish to call attention to the fact that neoplasms of the vagina must really be much more frequent than these statistics would lead one to believe, for individual authors have observed so many cases. Critical examination of the vagina is often neglected; that is to say, the affections of the uterus receive more attention and are of comparatively greater importance, and hence many affections of the vagina are simply overlooked. Beginning with tumors of the vaginal mucous membrane, the first which will claim our attention are: 1. CYSTS OF THE VAGINA. In my article on vaginal cysts,* in the year 1871, I began with the words: "Cystic formations in the vaginal walls are calculated to awaken a certain interest, not only because they are on the whole very rare, but because their location and their origin are by no means well understood." Twelve years have passed since then, and considerable literature upon this subject may now be obtained; but still the sentence just quoted has its full force. The article referred to had certainly the merit of proving that vaginal cysts are far more common than had hitherto been believed, and that they were the most frequent vaginal neoplasms. Cysts of the vagina will be divided into the simple, compound, single or isolated, and those occurring in masses or groups. As a rule they occur singly (82 per cent.), more rarely two or three at once, or even five (Kiwisch); air cysts, however, always occur by the hundred. The location of cysts is on the anterior or posterior wall, more rarely on the lateral walls, the proportion being 29 21:11 (Graefe). In the anterior wall they are most frequently found in the lower third, or between the lower and middle thirds, and in the posterior wall with like frequency in the lower, and in the middle third. By far the greater number of cysts are therefore situated in that part of the vagina between the middle and the vicinity of the vaginal orifice, 66 per cent. About onefourth of vaginal cysts are as large as a pea or hazelnut, one-half as large as a walnut, and about one-third as large as a pear or the fist; the larger cysts are therefore three times as common as the smaller ones, which is a proof that the latter are often overlooked or not considered worthy of notice. Peters's account of a cyst of the posterior wall as large as a child's head, and which * Archiv für Gynäkol., vol. ii., p. 283. interfered with labor, and from which he evacuated a pound of clear yellowish fluid, at once arouses a suspicion of the tumor having been an ovarian cyst.* The contents of the cysts resemble the fluid from hydrocele― bright and clear with a tinge of yellow; but they may be reddish, brownish, chocolate-colored, or greenish, also similar to synovial fluid, thick and albuminous: those of firm consistence are about as common as the serous. In Nélaton's case, one of a cyst as large as the fist, and which occupied the entire posterior wall, the chemical analysis of the contents was as follows: water 18, albumen 14, and salts part. Microscopical investigation reveals in different cysts, epithelium, granular and pus cells. Graefe found many crystals of cholesterine, débris, nucleated cells, globules of granular matter and lymphoid cells. The character of the cyst wall is very variable. In some cases it is so slight as to rupture from the use of the speculum. It has frequently been noticed that the wall was harder and firmer than would have been expected from the transparency of the cyst. Lisfranc found the walls 7 mm. (4 in.) thick. The wall was hard, fibrous and firm in several cases reported by West, Säxinger, Lisfranc and others. From the above there can be no doubt that cysts must also be divided into superficial and deep. Careful microscopical examination of the cyst wall gives the following results: The external surface is covered with the ordinary pavement epithelium of the vagina; the thickness of the wall varies between 1 mm. and 1 centim. (2 in. and 3 in.), the thinnest portion being formed of connective tissue alone, the thicker with the addition of smooth muscular fibres. The internal surface is usually perfectly smooth, but may show papillæ covered with epithelium which in the majority of cases is cylindrical, more rarely * Monatsschrift, xxxiv., 2, 1869. † Graefe says that my article above referred to has one great defect, namely, that the microscopical examination is given in a few cases only, and then in a very incomplete manner; this charge is preferred against the wrong person, however, for the blame should not be attached to me, but to the authors who cited and published my cases. My own descriptions in this article are very precise, and have since been confirmed by various authors, e. g., Schroeder, Klebs, Hückel, and Lebedeff. simple or stratified pavement epithelium, or still more rarely stratified pavement and cylindrical epithelium in the same cyst.* The original simple cylindrical epithelium may become flattened into pavement epithelium, and this in turn be transformed into stratified pavement epithelium. The original location of these cysts, according to our present information, it will be seen, may vary. In the first place, it cannot be doubted that many vaginal cysts arise in the form of retention cysts of the vaginal glands. The most interesting account of this variety is furnished by von Preuschen. Heitzmann and Hückel have confirmed the observation of von Preuschen as regards the existence of vaginal glands. The coalescing of several cysts which were originally single would explain the occurrence of cylindrical and stratified pavement epithelium in the same cyst. All such cysts would obviously occur in the superficial portions of the vaginal mucous membrane. Secondly, there are cysts whose interior is lined with endothelium, as I have demonstrated and Klebs has confirmed. Such cysts would seem to originate in dilated lymph vessels; they do not appear to be common. Four cases, found in the literature of this subject, tend to show that cysts may also originate in oedema, contusion, or in transudation of blood into the submucous tissues. These will have neither epi- nor endothelial lining. Deep-seated cysts having a muscular wall may arise in one of two ways: From the remains of Wolff's or Gartner's canals, and hence they must be situated in the middle and upper third of the vagina or in the wall of the uterus, particularly at its sides. I excised such a cyst six months ago from the right side near the urethra; it was almost as large as a hen's egg. I have also repeatedly punctured one as large as a pigeon's egg, situated on the left side in the vaginal vault. Secondly, as Freund believes, some such cysts may be considered as rudiments of Müller's ducts, in that some portion of them has not united with the corresponding part, while the spiral course of the double vagina * Three cases by Graefe, one by Kaltenbach and Lebedeff. |