TUMORS OF THE VAGINA, 
Considered in the Obstetrical Point of View. 
Charles Greene Cumston, M.D., 
BOSTON, MASS., 
Instructor in Clinical Gynaecology, 
Tufts* College. 
Reprinted from Annals of Gyncecology 
and Peediatry. 
BOSTON, 1895. TUMORS OF THE VAGINA, 
Considered in the Obstetrical Point of View. 
A CLINICAL LECTURE DELIVERED AT THE SUFFOLK DISPENSARY 
ON MARCH 16, 1895, 
CHARLES GREENE CUMSTON, B. M. S., M. D., 
Instructor in Clinical Gyncecology, Faculty of ,Medicine, Tufts'1 College; 
Member of La SociStS Franpaise FFlectrotherapie de Paris. 
HARVARD PRINTING COMPANY. 
Cambridge, Mass.: 
*895- TUMORS OF THE VAGINA, 
Considered in tt\e Obstetrical Point of YieW. 
A CLINICAL LECTURE DELIVERED AT THE SUFFOLK DISPENSARY ON MARCH 
16, 1895, BY CHARLES GREENE CUMSTON, B. M. S., M. D., 
Instructor in Clinical G-yncecology, Faculty of Medicine, Tufts’ College; 
Member of La SociStS Frangaise d’ Flectr other apie de Paris. 
Gentlemen :—Some of you will re- 
member the young married woman 
who consulted us for a pregnancy, 
which was about five months along, 
and who presented a cyst in the pos- 
terior wall of the vagina. This cyst 
was the size of a small walnut, and 
when I punctured it, after all due 
antiseptic precautions had been ob- 
served, a rather thick, transparent 
liquid escaped. A simple dry dress- 
ing of europhen and carbolized gauze 
was all that was required to complete 
the operation;' and, let me say in 
passing, that I consider europhen 
one of the best, if not the best, 
powders for dressing the vagina after 
minor or plastic operations that I 
have ever experimented with, and 
well worthy of your attention and 
trial. 
I shall take this case, gentlemen, 
as the text for this lecture, as tumors 
of the vagina are of considerable im- 
portance, especially when the patient 
is pregnant, on account of difficult or 
impossible delivery, and I desire to 
put before you the various growths 
which may be met with in the birth 
canal. They may be divided into 
five groups, as follows : (1) cysts ; 
(2) fibrous tumors and polvpus; (3) 
carcinoma; (4) sarcoma; (4) hsemat- 
oma. * 
Of all the neoplasms in the vagina 
complicating pregnancy, cysts are 
the most common. Their situation, 
as well as their size, are most varied, 
while the difficulty of extracting the 
child during labor is not always in 
proportion to their volume. 
Winckel and von Preuschen have 4 
CHARLES GREENE CUMSTON. 
long since studied the formation and 
aetiology of cysts of the vagina. Winc- 
kel found in fifty cases of cysts, nine- 
teen times the growth was on the 
anterior wall, fourteen on the pos- 
terior, and five times on the lateral 
walls of the vagina. The same writer 
relates five cases in which the cysts 
were present in pregnant women. 
first time at the age of twenty; menses 
were irregular. On examination, a 
small pediculated growth, the size of 
an egg, was found on the posterior 
vaginal wall. The tumor felt quite 
elastic, prolapsed when the patient 
stood up, but returned into the 
vagina when she sat down. The 
patient said that she first noticed 
the tumor at the end of pregnancy, 
and that it was not painful. At 
labor, which was spontaneous, the 
cyst was flattened by the head of 
the child, but was afterwards per- 
ceptible to the touch. The post- 
partum was uneventful, and thirteen 
days later, when the patient left the 
hospital, the cyst was like a flabby, 
withered sac, but did not prolapse. 
In one case it was situated in the 
last third of the anterior vaginal wall 
and was about the size of a walnut. 
The neoplasm was incised, the woman 
having a normal labor thirty-five 
weeks later. 
In two cases the cysts were the 
size of chestnuts and were situated on 
the posterior wall at the entrance of 
the vagina. They were also incised 
and labor took place without any 
complications. Winckel’s third case 
was a IV para, who noticed a dis- 
charge of pus from the vagina at the 
end of pregnancy. The vagina was 
covered, on both anterior and pos- 
terior walls, with small cysts, some 
of which were shaped like and at- 
tained the size of a cherry. Labor 
took place spontaneously, and, six 
weeks after, all the cysts had dis- 
appeared. In the remaining two 
cases the two small cysts had like- 
wise no effect on the labor. 
Case ll. Woman, aged thirty- 
four, 111 para; menstruation, which 
was irregular, began at the age of 
twenty-one. Both preceding labors 
were normal. On the left side, at 
the entrance of the vagina, a cyst 
the size of a hazel-nut was found. 
The cyst was punctured, giving issue 
to a serous fluid, and part of the wall 
removed. Labor occurred several 
days later, and was uneventful. 
Case 111. Woman, aged twenty- 
seven, I para. Menses appeared 
at eighteen; regularly every three 
weeks. On the right side of the 
vagina a cyst the size of a fifty- 
cent piece was found, which, when 
punctured, gave issue to gas. Labor 
uneventful. 
Pregnancy complicated by colpo- 
hyperplasia cystica I will pass over, 
as in this affection the growths are 
so small as not to interfere with 
labor. In the Berlin clinic three 
cases of cysts complicating the prog- 
ress of labor were observed, and I 
would like to give them to you in a 
few words. 
Other cases are reported in which 
labor took place spontaneously, or 
where puncture was performed before 
labor began. In the French edition 
of Churchill’s work, a case of follicu- 
lar mucous cyst is reported, which 
Case I.— Woman, aged twenty- 
five, I para; menstruated for the TUMORS OF THE VAGINA. 
5 
was situated in the vesico-vaginal 
septum, directly behind the urethra, 
and was mistaken for a cystocele. 
Labor took place without complica- 
tion, and several days later the cyst 
was removed by cauterization. 
During the post-partum these 
cysts may suppurate, or, if wounded 
during the passage of the child, may 
slough, and thus produce a focus of 
septic infection leading to dangerous 
accidents. As an illustration of this, 
I would mention Huguier’s case, in 
which he punctured a cyst of the 
vagina. It filled again in two years, 
and the patient at that time was 
pregnant. Daring labor the cyst 
disappeared, and the patient died 
eight days later from metro-peritoni- 
tis. The autopsy showed a cavity 
the size of a nut in the vaginal wall, 
communicating with, the vagina by 
an opening two centimetres in 
length. Suppuration of the cyst was 
produced by the traumatism of labor. 
Puech reports a case in which the 
passage of the foetal head was pre- 
vented by a vaginal cyst. This was 
punctured, resulting in a normal de- 
livery. In a case reported by Mor- 
lanne, the cyst had an elongated 
shape and protruded at the vulva 
with each pain. It burst spontane- 
ously, and the rest of the labor was 
normal. 
McClintock described, under the 
name of cystpolypus, an elongated 
tumor embedded in the posterior vag- 
inal wall, but which did not prevent 
a normal labor. The contents was a 
gelatinous fluid. 
I have now given you examples 
where the neoplasm was no hindrance 
to birth, but there are cases on record 
in which, on account of the consider- 
able size of the cyst, the progress of 
labor was interfered with to such a 
degree as to lead to serious complica- 
tions, and without surgical interfer- 
ence the expulsion of the foetus would 
have been impossible. Peter’s case 
is an excellent example. 
Lever was obliged to puncture a 
cyst, the volume of a child’s head, as 
the pains were not strong enough to 
overcome the resistance offered by 
the tumor. It was situated between 
the vagina and rectum, its contents 
being an oily fluid containing a great 
quantity of cholestearin crystals. 
Hardwick has put on record a case 
of a non-pediculated cyst in the recto- 
vaginal septum which was greatly 
stretched by the passage of the head. 
A pint of clear liquid was removed 
by puncture, the labor ending with- 
out any other complication. I may 
add that Winckel considers this 
tumor rather as a hydrocolpocele 
than a vaginal cyst. 
A woman, aged 34, IV para, who 
had always menstruated irregularly 
and had been confined naturally three 
times, presented a cyst the size of an 
orange, occupying almost the entire 
posterior vaginal wall. The growth 
was soft to the feel, rather movable 
backwards. The pains, which were 
good in quality, were not sufficient 
to overcome the obstacle and even 
traction with the forceps could not 
accomplish delivery. On account 
of the pressure of the head, the tumor 
was pushed against the rectum, and 
Osterloh has also described a case 
in which he incised a cyst during 
labor which ended without any 
further trouble. 6 
CHARLES GREENE CUMSTON. 
by this the anus was considerably 
dilated. Profiting by this condition, 
Peters punctured the cyst per rectum, 
after which he applied the low 
forceps and easily delivered a living 
child. The post-partum was normal. 
The contents of the cyst consisted of 
about a pound of yellowish liquid. 
underlying tissues and a pedunculated, 
dark-colored tumor the size of a 
man’s foot was brought out. The 
contents was liquid. A ligature was 
placed around the base of the tumor 
and the growth was cut off; the child 
was easily delivered. 
Another case, due to Roux, was 
that of an echinococcus cyst in the 
vaginal wall, rendering labor difficult. 
The cyst had, however, no bad effect 
on the outcome of the case. 
Cysts due to the echinococcus are 
met with in the vagina, although I 
am not aware that any case has been 
reported in America. They are 
usually situated in the para-vaginal 
tissues, or in Douglas’ cul-de-sac. 
This variety of cyst is not without 
importance in the obstetrical point of 
view, as the few cases recorded in 
medical literature demonstrate. 
Blot, von Wiener, Park, Porak and 
Birnbaum have reported cases of 
echinococcus cysts in the perivaginal 
tissues, in which various means, such 
as the forceps, perforation, puncture 
of the tumor, etc., were necessary in 
order to bring the child into the 
world. Although these operations 
were done before the days of rigorous 
antisepsis, all the patients recovered, 
with the exception of von Wiener’s 
case, who died from a rupture of the 
uterus. 
Gebhardt describes a case in which 
the anterior pelvic wall was distended 
by a cyst the size of a fist. The 
pains with good contractions caused 
the tumor to burst, and suddenly 
blood and echinococcus vesicles were 
expelled per vaginam. High forceps 
were quickly applied in order to avoid 
collapsus. 
In closing the subject of cysts, I 
will add two more cases in order to 
be a little more complete. Under 
the name of “ urethral cyst,” Hickin- 
botham described a large, soft growth, 
which was situated in the anterior 
vaginal vault, in front of a hypertro- 
phied cervix, and projected from the 
vulva. Labor had already com- 
menced and the patient was so ex- 
hausted that cephalotripsy was done, 
delivery being quickly executed. 
Twelve days after the cyst burst 
spontaneously, as it had been increas- 
ing in size and was painful. It con- 
tained a kind of pus. The patient 
recovered. 
In a case reported by Pauls, the 
patient was pregnant for the third 
time ; the other two labors had been 
normal. A trial with the forceps for 
half an hour was fruitless. When the 
foetal head was pulled on, a pear- 
shaped tumor the size of a large wal- 
nut appeared, situated on the posterior 
vaginal wall, and which, if traction 
with the forceps was stopped, would 
flatten out and was scarcely visible. 
Per rectum, the tumor could be 
distinctly felt, situated in the tissue 
between the rectum and vagina. By 
lightly scratching with the finger- 
nail, it was separated from the 
mucous membrane of the vagina and 
Kiichenmeister has likewise re- 
corded a similar case under the name TUMORS OF THK VAGINA. 
7 
of “ urethral cyst.” He found a 
fluctuating point, parallel to the 
course of the urethra, and quite high 
up on the anterior vaginal wall. The 
forceps were removed and the tumor 
incised, giving issue to about an 
ounce of pus. The ultimate result 
is not given. 
occur as infrequently as cysts, but 
are a most serious complication in 
labor. Glider gives the following 
statistics regarding mother and child 
in eighteen cases taken from the 
literature : 
Lived. Died. Not 
Result 
Given- 
The prognosis of labor complicated 
by a vaginal cyst is, on the whole, not 
bad, especially at the present day, 
when asepsis can be practiced by 
every physician.. As to the treat- 
ment : If you are called to a case 
already in labor, puncture the cyst, 
using all precautions, such as a free 
irrigation of the vagina with a solu- 
tion of lysol, creolin or permanganate 
of potassium. On the other hand, if 
you are consulted for a pregnancy, 
make one seseptic examination of the 
vagina, in order to ascertain the con- 
dition of the pelvic organs, vagina 
etc., and, if a cyst be found, it should 
be opened, the contents emptied and 
the vagina again irrigated and dusted 
with some antiseptic powder and very 
lightly packed with gauze. 
Mother ...... 11 4 8 
Child 4 7 7 
Fibroid neoplasms occur at any age; 
and, according to Glider, they were 
found in larger proportion in I 
para (eight times in primiparse, twice 
in multiparse). This neoplasm may 
have its seat at any part of the 
vagina and is usually noticed after 
labor has commenced. In some cases 
the growth was pedunculated, so that 
it prolapsed from the genital tract, 
and it was consequently detected dur- 
ing pregnancy. In others its presence 
was indicated during pregnancy by a 
profuse white discharge of the vagina. 
Therapeutics in such cases of obstacle 
to birth of the child are naturally 
most varied. The first class of cases 
are those in which delivery takes 
place spontaneously, although the 
growth, on account of its considerable 
size, obstructs the vaginal canal. 
It was with the view of prevent- 
ing any future complications during 
labor, in case the cyst increased in 
size, a fact that should be remem- 
bered, that I performed this simple 
operation, harmless if aseptically 
done, very dangerous if not, on the 
patient who presented herself at my 
clinic. 
The best known case of this kind 
is the one reported by Porro, in 
which quite a large fibro-myoma, situ- 
ated in the vesico-vaginal septum, 
obstructed the vagina. 
there was a spontaneous delivery, the 
tumor being expelled before the head, 
and then remained fixed, so that the 
child’s head came down without any 
difficulty. On the next day the 
growth was enucleated ; the child was 
dead, the mother recovered. 
As regards fibroid tumors, it may 
be said that they come next in fre- 
quency, Giider gives eighteen cases 
in his thesis in which they were com- 
plicated by pregnancy. In this num- 
ber he includes polypi. 
The fibrous and myomatous tumors 
When the tumor does not cause an 8 
CHARLES GREENE CUMSTON. 
absolute obstacle to the passage of 
the foetus, the latter may be delivered 
with the forceps, as is illustrated by 
the following cases: Gensoul, in a 
case of vaginal polypus weighing 22 
ounces, applied the forceps and de- 
livered both tumor and child. 
The treatment in cases of fibroids 
complicating pregnancy is, of course, 
subjected to the circumstances. If 
you should see your case during 
pregnancy I would advise you to 
remove the growth, especially when 
it is large, for my experience has 
been that surgical operations on the 
external genital organs or vagina of 
a pregnant woman are rarely fol- 
lowed by any complications or pre- 
mature labor; but if proper antisepsis 
is not carried out there is great dan- 
ger, and in proof of this 1 may men- 
tion McClintock’s case, which was as 
follows; He removed, by the ecra- 
seur, a fibroid polypus the size of a 
small egg, situated on the posterior 
vaginal wall. The patient was de- 
livered two weeks later, died thirty- 
four hours after from septicaemia. 
In a case reported by Fischer, a 
fibroid tumor the size of a hazel-nut 
was the cause of obstruction, and the 
forceps were applied to overcome it. 
The neoplasm then became larger 
and the patient again became preg- 
nant, and when seven months along 
it was extirpated, resulting in a nor- 
mal labor at term. 
There are other cases on record 
where delivery did not go so easily, 
both mother and child dying on 
account of the severe lesions inflicted. 
Virchow describes a retrovaginal 
tumor nearly the size of a grape-fruit. 
During labor, forcible delivery was 
attempted, resulting in a rupture of 
the vagina and fracture of the des- 
cending branches of the pubis, with 
death of the mother four weeks later. 
We now come to carcinoma of the 
vagina, which is a very rare affection, 
and still more so when complicated 
with pregnancy. There is, however? 
no doubt that this neoplasm may 
primarily attack the vagina—and con- 
siderable valuable evidence has been 
recently given by Hect. 
Three cases are reported in which 
natural delivery could not take place 
and Caesarean section was performed. 
In one of these cases the growth was 
fibro-cartilaginous; its situation is 
not given. In another the woman 
died twenty hours after from collap- 
sus. In all three cases the children 
were dead. 
One reason for the rarity of preg- 
nancy when carcinoma is present is 
that coitus is painful or the tumor is 
an obstacle to the act. Another is 
that the secretions from the neo- 
plasm appear to kill the spermato- 
zoid; and, lastly, the affection is one 
usually occurring at an age when the 
woman is past the fertile period of 
life. However, this is not always the 
case, as Coley has reported a case of 
a woman of twenty-one, and Oliver 
one of a patient twenty-six, who were 
pregnant and had a cancer of the 
genital organs. 
It is easily seen from what I have 
said that fibroid tumors are a most 
dangerous obstacle to the progress of 
labor, especially so if the neoplasm 
be large or immovable; or if, in a 
case of an immovable growth, labor 
has considerably progressed, so that 
one cannot replace or even remove it. TUMORS OF THE VAGINA. 
9 
Carcinoma of the vagina, involving 
the external genitals or the portio 
vaginalis, is the most common form, 
the disease usually attacking the 
vulva and then invading the vagina. 
as illustrations. In two cases perfor- 
ation was necessary. In the first case 
premature labor was induced and 
perforation had to be done on the 
dead foetus, Welponer applied the 
forceps in his case, whereby he de- 
livered a living child, resulting in a 
rectovaginal tear, the mother dying 
twelve days after from sepsis. In a 
case reported by Olshausen he in- 
duced premature labor, while in 
another he first removed the carcin- 
omatous mass with the sharp spoon 
and then induced premature labor. 
Haine extracted a living child by 
laparo-elytrotomy from a woman who 
had a perforation of the rectum due 
to the extension of the carcinoma, the 
vagina being narrowed to only a 
small opening. 
In such cases pregnancy seldom 
remains undisturbed, for often the 
symptoms soon appear which bring 
to notice a disease of the genital 
tract. Either the patient complains 
of lancinating pains, or an exceedingly 
foetid discharge, tinged with blood, 
will appear, and later on haemor- 
rhages of considerable gravity and 
carcinomatous cachexia show only 
too well the real nature of the 
trouble. There is one early symp- 
tom of carcinoma of the genital 
organs that I consider of greatest 
diagnostic value, and which was well 
illustrated in the case I showed you 
a few days ago, and that is a profuse 
and nearly odorless watery discharge. 
You will remember that the patient 
in question only complained of this 
symptom, which was rendered 
slightly bloody by coitus, and that 
on examination I showed you 
through the speculum that the cer- 
vix was well invaded by the neo- 
plasm. 
Caesarean section has been per- 
formed in cases of carcinoma four 
times to my knowledge. Leopold 
did Porro’s operation, saving both 
mother and child, on account of a 
primary carcinoma of the vagina that 
was well advanced; while Cooke, in 
his case, did a Caesarean section and 
saved the mother. In two other bad 
cases both mothers died, but both 
children were saved. 
As in fibroids, the course of labor 
will be very different in different 
cases, always according to the extent 
and malignancy of the tumor. If the 
neoplasm is small, and consequently 
not advanced, spontaneous delivery 
of the child occurs, as in the cases 
reported by Bailly and Schelle. 
This is, however, unusual, as labor is 
the most often difficult, and sometimes 
is even impossible per vias naturalis. 
The prognosis of carcinoma com- 
plicating pregnancy or labor is very 
bad. Most of the patients have died 
in the two weeks following delivery, 
by sepsis, metastasis or exhaustion. 
For the child it is a bit better, the 
mortality being, generally speaking, 
about 65 per cent. 
Surgical measures in this affection 
are of little value, as the affection 
appears to be hastened in its progress 
by the pregnant state, and conse- 
quently when the disease is discov- 
I will give you in a few words 
some cases taken from the literature 10 
CHARLES GREENE CUMSTON. 
ered it is generally too late to inter- 
fere. There is one local application 
that has a certain value in cancer of 
the genital organs, in that it renders 
the secretions odorless, prevents 
haemorrhage to a considerable extent, 
and has a power to clean up the 
ulcerated surfaces. This is terehene. 
It should be diluted one-half its bulk 
with glycerine, and the mixture is 
applied by means of the tampon. 
By its use I have seen some really 
wonderful results in inoperable cases. 
into the birth canal. Its formation 
before labor, and as an obstacle to the 
act, are also infrequent in occurrence, 
but many cases are reported where 
hsematoma was a post-partum com- 
plication. 
Reich speaks of a case of a pedicu- 
lated haematoma of the vagina which 
was found during pregnancy. A 
profuse haemorrhage occurred on 
account of a too great effort that the 
patient made. The tumor was 
opened and the sack put back into 
the vagina. Labor came about four 
weeks later, the tumor being then 
only a small nodule in the vaginal 
wall. 
Sarcoma of the vagina is still more 
infrequent than carcinoma, and I am 
only aware of one case in which the 
affection was complicated by preg- 
nancy that reported by Bajardi. 
The patient, a I para, aged 25, 
had always been in good health. 
The neoplasm, which was situated far 
back on the posterior vaginal wall, 
had attained a considerable volume 
when the patient was eight months 
pregnant. The tumor was removed 
'by the thermocautery snare and labor 
soon took place. The patient died a 
year later from a return of the 
growth. 
Schneider and Yogler have each 
reported a case of pregnancy which 
was complicated by a vaginal haema- 
toma, and interference was necessary. 
Yogler applied the forceps, withdraw- 
ing a dead child; Schneider opened 
the tumor and quickly terminated 
labor. Perregaux opened a hsema- 
toma of the vulva which extended 
into the vagina, and then stuffed the 
cavity with iodoform gauze; the 
child was born on the same day with- 
out any complication before or after 
birth. 
In such cases, where obstruction at 
labor from the size of the tumor is 
forseen, operative interference during 
pregnancy is absolutely indicated in 
order to save the child. The chances 
for the mother by a radical operation 
are so small, as the neoplasm is sure 
to return, that a capital operation is 
out of the question. 
The prognosis of haematoma, in 
general, is not very good. According 
to Deneux, 22 patients died out of 62 
cases of the affection, while for the 
children 41 survived. 
As to treatment, open the tumor 
as soon as discovered, with great 
aseptic precaution, gently curette the 
interior of the sack with the dull spoon 
and pack the cavity with iodoform or 
europhen gauze. 
Haematoma of the vagina is not 
often observed, although this tumor 
is often met with on the external 
genitals, extending more or less up