COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00063924 llllllllllllllllllllllllll! RECAP i i in tfje Cttp of J&eto Jiorfc °f ^ College of IJ&ptffcfon* anfc gmrgeons V Reference Htbrarp / v—- X 7 4^a_ ^ y r? 1 f 9 o£ b Gi^^^Cc^^ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/adenomyomaofuterOOcull ADENOMYOMA OF THE UTERUS i^ THOMAS STEPHEN CULLEN ASSOCIATE PROFESSOR OF GYNECOLOGY IN THE IOHNS HOPKINS UNIVERSITY ASSOCIATE IN GYNECOLOGY IN THE IOHNS HOPKINS HOSPITAL ILLUSTRATED BY HERMANN BECKER and AUGUSf HORN rilll API 1 I'lll A \M> LONDON W. B. SAUNDERS COMPANY i wo8 Copyright, 1908, by W. B. Saunders Company PRINTED IN AMERICA TO THE MEMORY OF MY FATHER XBi)t Urtorrcnu gliomas Cullrn WHO WAS BORN IN THE COUNTY OF FERMANAGH, IRELAND. IN 1S36. AND DIED IN LONDON, CANADA, IN 1895, THIS BOOK IS AFFECTIONATELY DEDICATED PREFACE One afternoon in October, 1N94, while making the routine examination of the material from the operating room I found a uniformly enlarged uterus about four times the natural size. On opening it I found that the increase in size was due to a diffuse thickening of the anterior wall. Professor William II. Welch, when consulted, said that the condition was evidently a most un- usual one and surest ed that sections be made from the entire thickness of the uterine wall. Examination of these sections showed that the increase in thickness was due to the presence of a diffuse myomatous tumor occupying the inner portion of the uterine wall, and that the uterine mucosa was at many points flowing into the diffuse myomatous tissue. A few months later a second adeno- myoma was met with. Both of these cases were reported at the Johns Hopkins Hospital Medical Society in March, 1S95, and pub- lished in the Johns Hopkins Hospital Reports, Vol. 6, 1896. Since that time we have carefully inspected all our material for adenomyoma and have encountered over ninety adenomyomata of various kinds in the uterus. v Our material has been obtained chiefly from the Gynecolog- ical Department of the Johns Hopkins Hospital, from Dr. Kelly's private sanatarium and from my cases at the Church Home and Infirmary and elsewhere. The exact source 1 in each case is given in tin 1 tables of cases at the end of the book, from which also the reader can find at a glance the page number o^i any gynecological or pathological number mentioned in the book. After the publication of von Recklinghausen's work on A.deno- myoma in 1896 considerable controversy arose :is to the origin VI PREFACE of the gland elements in adenomyomata. Our first cases had clearly shown that the glands in the diffuse myoma owed their origin to a flowing outward of the normal uterine mucosa. In all subsequent cases these tumors were examined most carefully from this standpoint. Sometimes the mucous membrane origin was easily proved, but in many cases not only were numerous sections necessary, but in some instances a clear idea of the con- dition was obtainable only after an examination of very large sec- tions embracing the entire uterine wall. This labor yielded fruit, as in nearly every case in which diffuse adenomyoma existed we have been able to trace the mucous membrane origin of the glands. Much credit for the large and beautiful sections is due to our labora- tory assistant, Mr. Benjamin O. McCleary. While endeavoring to ascertain the method of development of adenomyomata I have likewise been trying to determine how these growths can be recognized clinically. I cannot help feeling that any one who reads the chapter on symptoms will agree with us that diffuse adenomyoma has a fairly definite clinical history of its own and that in the majority of cases it can be diagnosed with a relative degree of certainty. This definite gain in our know- ledge certainly emphasizes the fact that any morbid process should be studied carefully both from its histological and also from its clinical aspects and shows the importance, for all those who do surgical work, of a thorough familiarity with the histological appear- ances of the pathological processes they are dealing with. In this book the publishers have deemed it wise to use a larger type than usual. At the beginning of each case an epitome is given and in the succeeding paragraphs the essential features are emphasized by the employment of spaced type. This arrangement will permit those who wish to obtain the gist of the book to do so in a few hours, without going into all the minor details, provided that their reading is supplemented by a careful study of the illus- trations. I wish to express my thanks to Dr. Henry M. Hurd for his ad- vice on numerous occasions, to my brother, Dr. Ernest K. Cullen, PREFA( l. Vll for the manifold details lie has looked after for me, and to Miss ('or;, Reik, my secretary, for the continued interesl she has taken in the preparal ion of this volume. I am under especial obligation to Dr. Frank R. Smith for his revision of the manuscript, and for correcting the proof-sheets. To my friends Mr. Hermann Becker and Mr. August Horn I am deeply indebted for their excellenl and faithful illusl ral ions. With the publishers. \Y. B. Saunders Company, my relations have been most cordial and I am especially mindful of the many kindnesses shown by Mr. R. W. Greene, one of the vice-presidents of the company. Thomas S. Cullen. Baltimore, May 1. L908 CONTENTS ( 'll VPTER I pAGK Adenomyoma of the Uterus 1 ( 'll VPTER I I Cases of Adenomyoma in which the Uterus R et vins a Rel \ ti\ ely Normal ( lONTOUR I". I Chapter III Cases of Adenomyoma i\ which the Uterus Retains a Relatively Normal ( !l (NTOUR 52 Chapter IV Cases of Adenomyoma i\ which the Uterus Retains a Relatively Normal Contour ^ Chapter V Subperitoneal vnd [ntralig what vry Adenomyomata 125 Chapter VI Si bmucous Adenomyom \ta 156 Chapter VII Cervical Adenomyomata L65 Chapter VI 1 1 Condition of the Tubes and Ovaries \\hi:\ Adenomyoma of the Uteri - Exists 171 cr vpter i x The Clinical Picture inC vses <>f Adenomyoma of the Uterus 17^ ( 'll VPTER X Differential Diagnosis in C vses of Adenomyoma of the Uterus 177 ( 'll VPTER X I Treatment of Adenomyomata of the Uteri - 186 Ch VPTER XI I Prognosis in Cases of Adenomyoma of the Uterus L87 X CONTEXTS Chapter XIII p AGE Origix of Adenomyomata of the Uterus 193 Chapter XIV Causes of Adenomyoma of the Uterus 199 Chapter XV Hypertrophy of the Cervix axd Diffuse Adenomyoma of the Body of the Uterus 200 Chapter XVI Adenomyoma in oxe Horx of a Bicorxate Uterus 203 Chapter XVII Diffuse Adenomyoma of the Body of the Uterus Occurrixg in Cases of Squamous-cell Carcinoma of the Cervix : 206 Chapter XVIII Adexocarctxoma axd Adexomyoma Occurrixg Ixdepexdextly ix the Body of the Same Uterus 218 Chapter XIX Adexocarctxoma of the Body of the Uterus Developixg from ax Adeno- myoma 222 Chapter XX A .Multiplicity of Pathological Chaxges ix the Pelvis 228 Chapter XXI Diffuse Myomatous Thickexixg of the Uterus but xo Glaxdular Inva- sion 230 Chapter XXII Adenomyoma of the Uterixe Horx 235 Chapter XXIII Pregxaxcy ix the Left Fallopiax Tube; Discrete Uterixe Myomata; Diffuse Adexomyoma ix the Right Uterixe Horx with the Develop- mext of Decidual Cells arouxd the Glaxds ix the Adexomyoma 246 Chapter XXIV Adexomyoma of the Rouxd Ligamext 250 Summary. ..'. 260 Ixdex of Cases Arraxged According to their Gynecological Xumbers. . . 263 Index of Gyxecological-Pathological Numbers 265 Ixdex 267 LIST OF ILLUSTRATIONS I 1... PAGE 1. Diffuse Ad enomyoma of the Posterior Wall of the Uterus lo 2. 1 Diffuse Adenomyom \ of the l'< isterior Uterine Wali 12 3. Diffuse Aden* >my< m \ i >f the P< isterk ih Uterine W \i.i L9 I. Diffuse Adenomyomatous Thickening i\ the Fundus \\i> Posterior Uterine Wall with Extension < n muss, of the Mucosa into a Lar(;k Cki.\ m; between Myomatous Masses 26 5. Diffuse Adenomyoma Forming a Complete Zone around the Uterine (' W ITY 35 6. Diffuse Adenomyoma of the Uterine Wall with Marked Extension of the Mucosa into the Growth 37 7. Extension of the Mucosa into a Diffuse .Myoma of the Uteres 38 8. Diffuse Adenomyoma of the Anterior Uterine Wali 42 9. Diffuse Adenomyoma of the Anterior Uterine W w.i 43 K). Mode of Extension of Uterine ( Ilands into a Diffuse Adenomyoma .... 44 1 1. Diffuse Adenomyoma of the Uterus with Sever \i. I Discrete Myomata . . 48 12. Diffuse Adenomyoma of the Posterior Uterine Wali 49 13. Diffuse Adenomyoma of the Uteris Involving the Anterior and I 'i isterior Walls and Fundus 55 14. Diffuse Adenomyoma of the Anterior and Posterior Uterine Walls . 56 15. Method of Penetration of the Mucosa in a Diffuse Adenomyoma of the Uterine Wall 57 lti. Extension of Uterine Glands into the Diffuse Myomatous Tissue «>f an Adenomyoma 59 17. Interstitial and Subperitoneal Uterine Myomata. Interstitial Adenomyoma 65 18. Small Adenomyoma of the Fundus of the Uterus 66 10. Diffuse Adenomyoma of the Uterus ('»'.' 20. Diffuse Adenomyoma of the Uterine Wall 70 21. Cyst-like Spaces Just Beneath the Peritoneum in Diffuse Adeno- myoma of the Uterus 72 22. The Mucos \ Lining One of the Cyst-like Sp v.ces Situated Just Beneath the Peritoneum in a Diffuse Adenomyom \ of the Uterus 7 1 23. Diffuse Adenomyoma of the Anterior Uterine Wali 77 24. Diffuse Adenomyoma of the Anterior Uterine W\li 7^ 25. Cross-section of \ ( }land Taken fr< m Fig. 2 1 vr d 80 26. A Branching Gland from a Glandular Area in \\ Adenomyom \ 81 27. Dd?fuse Adenomyoma of the Body of the Uterus 90 28. Extension of the Mucosa ento the Muscle in vCaseof Diffuse Adeno- myom \ of the Uterus 91 Xll LIST OF ILLUSTRATIONS FIG. PAGE 29. Method of Penetration of a Single Uterine Gland into the Diffuse Myomatous Growth of an Adenomyoma 92 30. Diffuse Adenomyoma of the Body of the Uterus 96 31. Discrete Uterine Myomata. Diffuse Adenomyoma with the Glands Originating from the Mucosa. Adenomyoma of the Left Uter- ine Horn 101 32. Longitudinal Section of Discrete Myomata; Discrete Adenomyoma Near the Left L t terine Horn 102 33. Subperitoneal, Interstitial and Submucous Uterine Myomata; Dif- fuse Adenomyoma of the Entire Fundus 107 34. Discrete Myoma of the Cervix; Diffuse Adenomyoma of the Body of the Uterus HI 35. Diffuse Adenomyoma. of the Body of the Uterus 116 36. Diffuse Adenomyoma of the Fundus with Cystic Spaces in the Left Uterine Horn 120 37. A Cystic Subperitoneal Adenomyoma of the Uterus 130 38. A Cystic Subperitoneal Adenomyoma of the Uterus 131 39. A Subperitoneal Cystic Adenomyoma Occurring in the Case of a Large Myomatous Uterus 134 40. Cystic Subperitoneal Adenomyoma of the Uterus 136 41. Subperitoneal and Interstitial Uterine Myomata. Adenomyoma of the Body of the Uterus. Adenomyoma Springing from the Left Utero-oyarian Ligament 142 42. Cross-section Through a Pedunculated Subperitoneal Adenomyoma . . 1 44 43. An Intraligamentary and also Partly Submucous Cystic Adenomyoma of the Uterus 151 44. A Cystic Intraligamentary and Partly Submucous Adenomyoma of the Uterus 152 45. The Submucous Portion of a Cystic Adenomyoma of the Uterus 154 46. Submucous Adenomyoma of the Uterus 159 47. Submucous Adenomyoma of the Uterus, the Myomatous Muscle Being Riddled with Miniature Uterine Cavities 162 48. Interstitial Uterine Myomata with a Small Diffuse Adenomyoma in the Cervix 168 49. Adenomyoma in the Outer Portion of the Cervix Near the Broad Ligament Attachment 169 50. A Cystic Myoma Macroscopically Simulating a Cystic Adenomyoma .... 176 51 . A Small Uterine Polyp 178 52. Large Venous Sinuses in the Uterine Mucosa Causing Severe Hem- orrhages 179 53. Thickening of the Uterine Mucosa. Marked Dilatation of Some of the Glands without any Atrophy of their Epithelium; very Dense Stroma 181 54. A Portion of a Diffuse Adenomyoma of the Posterior Wall of the Uterus 188 55. Diffuse Adenomyoma 189 LIST OF ILLUSTRATIONS .Mil 56. Very Extensive Hypertrophy of the Cervix. Discrete Myoma and DlFFl SE ADENOMYOMA 01 THE BODI OF THE UTERI 8 . 200 57. ADENOMYOMA l\ ONE HORN OF \ BlCORN \'l l. UTERUS 204 58. DlFFl BE ADENOMYOMA l\ THE BODI I IF THE I ITERUS '_'l»7 59. Squamous-cell Carcinoma of the Cervix; Discrete Subperitoneal wo Interstitial Myomata; Diffuse Adenomyoma of the Pos- terior Uterine Wali 209 60. Commencing Diffi be Adenomyoma of the Bodi of the Uteri s Abso- Cl \l 'ED Willi Al)\ ANCED SQUAMOUS-CELL CARCINOMA OF THE CERVIX _' 1 5 61. Adenocarcinoma of the Body of the Uterus Associated with a Small Subperit< ineal Adenomyoma 219 ()■_'. Adenocarcinoma Developing from a Dilated Gland in an Adeno- my< ima oh' the Uterus _''_' l 63. .Myoma, Aden* imyoma and Primary Adenocarcinoma ok the Body ok the Uterus; Pyosalpinx and Primary Adenocarcinom \ ok the Ovary. . 228 (I I. Adenomyoma of the Uterine Horn 237 65. Adenomyomata ok Both Uterine Horns; Discrete Myomata; Diffi se Adenomyoma ok the Uterus _' l.'i (id. Left Tubal Pregnancy; Discrete Uterine .Myomata; Adenomyoma ok the Right Uterine Horn with Decidual Formation in the Stroma Surrounding the Glands 247 67. Adenomyoma ok the Round Ligament 256 68. Adenomyoma of the Round Ligament _'.">7 ADENOMYOMA OF THE UTERUS CHAPTER I ADENOMYOMA OF THE UTERUS In 190.']. in a review of the literature published in a supplemenl to Orth's Festschrift, I reported 22 cases of adenomyoma examined by me up to that date. 1 Since then I have paid especial attention to these growths and have been astonished at the striking frequency with which they occur. Out of a total of 1283 cases of myoma examined from April 1, 1893, until July 1, 1906, 73 a that is. about 5.7 per cent. — were instances of adenomyoma." I have included only interstitial, subperitoneal and submucous adenomyomata and large adenomyomata of the uterine horns. The smaller nodules so frequently present in the cornua have been purposely omitted. Glandular elements have from time to time been noted in myo- mata, and according to Breus,' Schroeder, Ilerr and Grosskopf had been able to collect a total of one hundred cases up to 1884. But not until the appearance of the masterly work of von Reckling- 1 Cnllen, Thomas S.: Adeno-Myoma des Uterus, Verlag von Augusl Birsch- wald. Berlin, 1003. 2 The following adenomyoma cases have been operated upon between July 1st, L906, and Dec.31st, 1907: Path.Nos. 10,109, 10,499, 10,560, 10,596, 10,617, L0,669, 10,677 (Gyn. 13,423), 10.707. L0,844(Gyn. 13,590), 10,972, Ll,078(Gyn. 13,679), 11,120, 11,140.11.101, 11.10."), 11,849, 11,859, 1 1,863, 12,007, making a total of 19 cases; showing beyond peradventure thai this disease is particularly prevalent. We have had in all 92 cases of at lenomyoma. 3 In some of the cases no microscopic examination was made. 1" positively exclude the presence of adenomyoma it would have been necessary t<> take sections from many parts of i he uterine wall. This would have entailed an enormouf penditure of labor that was often impossible. It will thus he seen that a certain number ^( cases o( adenomyoma have probably been overlooked. * Breus, Carl: Qeber wahre epithelfiihrende Cystenbildung in Uterus-Myomen. Leipzig und Wien, is*) 1. i 2 ADENOMYOMA OF THE UTERUS. hausen, 1 published in 1896, had this subject received much atten- tion. 2 These growths, as their name implies, consist of gland ele- ments and myomatous tissue. They form a distinct class of their own, and on microscopic examination their recognition is eas} r . Even in the gross specimens it is often possible to render a positive diagnosis. For the use of clinicians we divided these growths into three classes, although it will be readily seen that one class may merge imperceptibly into the other. The divisions are : (1) Adenomyomata, the uterus preserving a relatively 3 normal contour. (2) Subperitoneal or intraligamentary adenonryomata. (3) Submucous adenomyomata. ADENOMYOMA IN WHICH THE UTERUS PRESERVES A RELATIVELY NORMAL CONTOUR The uterus may be nearly normal in size, as in Fig. 5 (p. 35), or it may be two or three times the natural size, as noted in Fig. 13 (p. 55) and in Fig. 23 (p. 77). When the organ is considerably en- larged, it is frequently partly covered with adhesions. In these uteri there is a myomatous transformation of the muscle; the thickening extends from the mucosa outward, sometimes involving the wall in half its thickness, or at other times reaching even as far as the peritoneum (Fig. 13, p. 55). Sometimes it is limited to the anterior or posterior wall (Fig. 1, p. 10, and Fig. 23, p. 77), but may 1 A T on Recklinghausen, Frieclrich: Die Adenomyome unci Cystadenome der Uterus und Tubenwandung, ihre Abkunft von Resten des Wolff'schen Korpers. Berlin, 1896. (I wish to express my deep sense of obligation to Professor v. Reck- linghausen for his kindness in examining sections from several of the cases and for his valuable criticism of the same.) 2 Probably the best article written in this country on adenomyoma of the uterus was that by Dr. J. M. Baldy and Dr. W. T. Longcope, presented to the Philadelphia Obstetrical Society and published in the American Journal of Obstetrics, 1902, vol. xlv, p. 788. 3 1 use the word "relatively" because if operative interference be long delayed some of the discrete myomata so frequently found may assume large proportions and almost completely overshadow the adenomyoma, while at the same time greatly altering the contour of the uterus. DIFFUSE .\l)i;\o.M Vo.MA OF Till. CJTERUS 3 involve both (Fig. ">, p. 35). Where such is the case, we have a uterine cavity lined with a mucosa which is surrounded by a thick zone of myomatous muscle and covered externally with a mantle of normal muscle of variable thickness. The myomatous thickening is diffuse in character, consists of bundles of fibres running in all directions and along the advancing margin gradually merging into the normal muscle, in contradistinction to the condition found in simple myomata, which are sharply circumscribed, (liven such thickenings of the uterine wall, we may always suspect the presence of "land elements. On examining the uterine cavity it is usually found thai the mucosa at one or more points extends into the diffuse myomatous tissue beneath (Fig. 1, p. 10). This point is more readily verified by examining with a loup, when a careful scrutiny of the diffuse myomatous growth will discover small, round, irregular, triangular or oblong areas, composed of a waxy, fairly homogeneous tissue, lying between myomatous bundles. These areas correspond closely in appearance with the uterine mucosa, and with the glass one can make out punctiform openings, which are cross-sections of glands. Frequently such areas contain cyst-like spaces varying from .5 to 5 mm. or more in diameter (Fig. 5, p. 35, Fig. 19, p. 69). Other and larger cyst-like spaces are occasionally found. These have smooth inner surfaces and a lining of mucosa often 1 mm. in thick- ness. They are in reality miniature uterine cavities. Main- of these cyst-like spaces contain fresh blood or yellowish blood pigment, the remains of old hemorrhages. The small cyst spaces may readily be mistaken for blood-vessels, but the larger ones are easily rcc..-- nized. Among the most instructive cases reported are those of Lockstaedt. 1 In his Case 5 there was a diffuse myomatous thick- ening invading the posterior and part of the anterior wall. At several points the myoma had penetrated the outer muscular cover- ing and sent prolongations as far as the peritoneum. On section 1 Lockstaedt, Paul: Ueber Vbrkommen und Bedeutung von Drusenschlauchen in don Myoraen dos Uterus. Monatsschrifl t'- Geburtshulfe und Gynaekologie, 1898, Bd. vii, p. 1SS. 4 ADENOMYOMA OF THE UTERUS of the tumor numerous round lumina were seen. These had a diameter of 2 mm. In the fundus were six roundish depressions of the mucosa, into all of which one could easily pass a metallic sound, and a bristle could be inserted for a distance of from 1 to 1.8 cm. into the myomatous tissue. These canals branched with one another and also with those in the middle of the tumor. All were lined with a clear membrane which was easily loosened from the underlying myomatous tissue. In short, the small canals in the myomatous tissue were channels from the uterine cavity and had a lining of uterine mucosa. In his Case 7 Lockstaedt found a diffuse myomatous thickening of the posterior wall and of the right side of the uterus. Near the fundus he saw five roundish depressions of the mucosa, and from these it was possible to pass into the myoma for a distance of 1.5 cm. One of the canals was broad enough to be easily opened with the scissors, and here one could see that the mucous membrane was directly continuous with that of the uterine cavity. Scattered throughout the diffuse growth were many cyst spaces, most of them filled with reddish-brown or chocolate-colored fluid. In order to determine whether these also communicated with the uterine cavity, Lockstaedt introduced a solution of Berlin blue into all of them, and was thus enabled to show that isolated cyst spaces were indirectly connected with the uterine cavity. From such cases we see that the uterine mucosa penetrates the diffuse myoma at several points and that these down-growths branch in all directions. In Fig. 4, p. 26, we see just the earliest stage of such a condition as was found by Lockstaedt. Here in the fundus coarse myomatous masses are welling into the cavity and a large area of mucosa is passing down into the crevice between. With the continued growth of the myoma a portion of the uterine cavity would soon be drawn into the depth, and in all probability would eventually lose its continuity with the parent uterine cavity. Rarely, if ever, do we find the slightest trace of glands in the outer covering of normal muscle. In the majority of these cases besides the diffuse myomatous growth a few circumscribed myomata DIKFl'SK ADKXO.MYO.MA OF THE DTER1 - 5 are present. These are irregularly scattered, being submucous, interstitial, or subperitoneal. They are usually only a few centi- metres in diameter, hut many attain to 1") cm. or more before the uterus is removed. When the uterus is not enlarged, the uterine cavity generally presents the usual appearance and is in no way altered, as the diffuse myoma does not usually press inward, as a submucous myoma invariably does. Case 27.~)4, however, is an exception (Fig. 8, p. 42). Here there is a considerable bulging into the cavity. The uterine mucosa is usually smooth, save for the occasional depressions as noted in Lockstaedt's eases; it is of the usual breadth or may reach a thickness of from 7 to 8 mm., as is seen in Fig. 1, p. 10, and Fig. 23, p. 77. Polypi, so common in cases of discrete myomata, are usually absent. Histological Appear a nces . — The surface of the mucosa is usually smooth and has an intact surface epithelium I Fig. 6, p. 37, Fig. 14, p. 56, and Fig-. 24, p. 78). The glands present the normal appearance as seen in Fig. 3, p. 19, and Fig. 7, p. 38. The stroma of the mucosa just beneath the surface epithelium is often slightly edematous or rarefied. The diffuse thickening in the uterine walls consists of characteristic myomatous tissue, the muscle bundles, however, showing much more interlacing than is found in the ordinary discrete myomata. Along the outer or advancing margin of the growth the myomatous cells gradually and imper- ceptibly merge into the normal muscle cells. The myomatous tissue, as was noted macroscopically, extends up to but usually does not encroach upon the mucosa. In most cases the mucosa can be seen dipping down into the diffuse myomatous growth, and at such points the muscle bundles run at right angles to the mucosa, thus allowing the latter to dip down between them. Sometimes a single gland penetrates the myoma. Such a gland presents a perfectly norma] appearance (Fig. 20, p. 92), and is usually accom- panied by the stroma of the mucosa which separates it from the muscle. In favorable sections such a gland can be traced far into the myomatous tissue. If it meets a barrier in the form of a muscle 6 ADENOMYOMA OF THE UTERUS bundle running parallel with, instead of at right angles to, the uterine mucosa, it is deflected along the surface of this until other muscular bundles are encountered that are again at right angles to the uterine cavity. It then passes still further outward between them. In other words, the gland follows the path of least resistance, winding in and out in all directions like a rivulet, but always making toward the peritoneal surface. While single glands sometimes penetrate, larger portions of the mucosa, as a rule, find their way into the muscle ; for example, in Fig. 16, p. 58, three glands, accompanied by their stroma, can be seen extending into the muscle and spreading out in the depth, where more room is met with. In other words, they form a funnel with its smaller calibre directed toward the mucosa. In Case 3136 the mucosa (Fig. 24, p. 78) invades en masse, while in Fig. 6, p. 37, and in Fig. 7, p. 38, the mucosa is seen penetrating as the roots of a tree, there being a main trunk with many rootlets piercing the myoma in all directions. These glands retain their normal appearance and, as can be noted from the drawings, are invari- ably surrounded by the normal stroma of the mucosa. These exten- sions of the normal mucosa in many cases can be traced by direct con- tinuity for at least 1 cm. In Fig. 6, p. 37, they can be followed for over 1.5 cm. Of course, with the windings in and out of the down- growths of the mucosa the continuity will be lost in the depth. Nevertheless, serial sections and injection in favorable cases, as carried out by Lockstaedt, show that the bunches of glands found in the depth are direct extensions from the mucosa. In the out- lying portions of the diffuse myoma round, oval, triangular, or irregular islands of glandular tissue are encountered. These consist, as a rule, of essentially normal uterine glands (Fig. 14, p. 56), lined with one layer of cylindrical ciliated epithelium and surrounded by the normal stroma of the mucosa. Not infrequently these glands become cystic, the dilatation varying from 1 to 9 or more millimetres in diameter. Such dilata- tions are easily explained by the kinking and bending to which the glands are subjected by the surrounding and ever-growing myoma- tous tissue. The epithelium of the dilated glands is usually pale- DIFFUSE A I) i:\o.\lYo.\I A OF THE I TER1 - / staining and somewhal flattened. The cysl Bpaces frequently contain desquamated epithelium, sometimes are partially filled with blood pigmenl and also contain a varying quantity of blood. In several instances we have noted round giant cells containing from four to eight nuclei in their centres and probably originating from the coalescence of degenerated epithelial cells. Some of the large spaces are not dilated glands, but represent cross-sections of the deep depressions from the mucosa, as noted in Lockstaedi 's cases. Here the entire mucosa is carried into the myoma, and on cross-section we have a space lined with one layer of surface epithelium and surrounded by typical uterine mucosa. Of course, the mucosa on one side may be thinned out on account of the irregular stretching of the myomatous tissue, and then we have a picture corresponding to the chief canal — the Hauptkanal of von Recklinghausen. The miniature uterine cavit}^ seen in Fig. 21, p. 72, although situated near the peritoneal surface, is probably similar in origin. From the pathological description it is seen that the uterine glands were found extending into the diffuse myoma; and again, a reference to Fig. 22, p. 74, w 7 hich is an enlargement of a portion of Fig. 21, shows a mucous membrane indistinguishable from that lining the uterine cavity — a mucosa that is peculiar to the uterus and never found elsewhere. The glands in the diffuse myoma occasionally show some branching, as noted in Fig. 16, p. 58, Fig. 22. p. 74, Fig. 26, p. 81. This finding is sometimes noted in a normal uterus, and here, where the mucosa has such free play and where the glands are so long, we would naturally expect some branching. On the whole, however, they are remarkable for their regular shape. The glands are naturally most abundant in the vicinity of the mucosa; they gradually diminish in number in the outer myomatous zone and are completely wanting in the normal outer muscular capsule. In short, where the myoma ends they cease. This is well shown in Fig 3, p. 19, Fig. 6, p. 37, Fig. 9, p. 43. and Fig. 24. p. 78. In some cases, although the glands in the diffuse myoma are identical with uterine glands, their origin from the mucosa cannot be clearly proved. In the majority of these cases, however, careful 8 ADENOMYOMA OF THE UTERUS examination of serial sections will show that at several points at least the glands of the mucosa are continuous with those in the depth. CASES OF DIFFUSE ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELATIVELY NORMAL CONTOUR Had we been told several years ago that in an examination of 1283 myomatous uteri diffuse adenomyomata were found 73 times, that is, in about 5.7 per cent., we should certainly have been tempted to doubt the veracity of the author. Nor can such a statement even now be accepted without ample proof. Accordingly it has been deemed advisable to give the essential features of each of the cases. In the brief description which we have just given of this disease only the salient points were discussed. Many other inter- esting data may be gleaned from a careful perusal of the individual records. Gyn. No. 3418. Path. No. 661. Diffuse adenomyoma of the posterior uterine wall (Figs. 1 and 2). K. B. N., married, aged forty, white. Admitted April 3, 1895. Complaint on admission: Painful and profuse menstruation. The patient began to menstruate when fourteen years of age. The periods occurred at intervals of from three to four weeks, were profuse, but not accompanied by much pain. She has been married seventeen years; had one difficult, but non-instrumental, labor sixteen years ago, after which she was confined to bed for six weeks on account of chills and fever, which were followed by ab- dominal pains. Eleven years ago she had a miscarriage. Immedi- ately after the birth of the child the menses became profuse and there was a discharge of dark, clotted blood. Pain was felt in the lower abdomen, also in the back. It commenced a few hours before the flow and lasted until the menses were over. The patient has never been strong; when twelve years of age she had malaria, and when fifteen, pneumonia. Her family history on both sides is decidedly tuberculous, both grandfathers, her mother, one aunt, and two cousins having died of phthisis. DIFFUSE \l)i;\o\n mm \ OF Till: UTERUS '.» Present Condition. The patient is ,-i well-nourished but rather anaemic woman, weighing llo pounds. Her tongue is coated; appetite good. She has an occasional headache; ex- periences do difficult y in locomol ion ; her feel and ankles occasionally swell; urine normal; the last menses ceased two weeks ago after a duration of ten days. On vaginal examination myoma uteri was diagnosed. April 6, 1 cS 9 5 . Operation. An incision L5 cm. long was made in the median line, and the tumor lifted out of the pelvis. The ovarian vessels, round ligaments, and uterine vessels were tied and the uterus was amputated low down. The cervical lips were then brought together, and the peritoneum from the posterior pelvic wall was united with that from the anterior. The patient was discharged May 3d feeling perfectly well. Gyn.-Path. X o . 6 6 1 . — The specimen consists of the enlarged uterus with its appendages intact. The uterus is pear- shaped and measures 12 cm. in length, 10 cm. in breadth, and 8 cm. in thickness. It is pinkish in color, smooth and glistening. A portion of the cervical canal measuring 2 cm. in length is present ; its mucosa is pearly white in color, smooth and glistening, and has almost entirely lost its rugous appearance. The uterine cavity measures 4.5 cm. in length and is 5.5 cm. in breadth in its upper portion. The posterior wall bulges slightly into the cavity. The mucous membrane is smooth, but presents a mottled appearance, being the seat of extensive hemorrhage. It is S mm. in thickness. The anterior uterine wall averages 2.5 mm. in thickness. The posterior wall is 5 cm. thick an d maybe d i - v i d e d into two portions: a n i n n e r a n d t h i c k - e n e d , w h i c h is coarsely striate d a n d which looks ver y m u c h 1 i k e m y o m a t o u s tissue, a n d a n outer, r e s e m b 1 i n g n o r m a 1 u 1 e r i n e m u s c 1 e (Fig. 1). The contrast is much sharper after the specimen has been hardened in Midler's fluid, the coarsely striated portion staining lightly, the normal muscle deeply. On careful examination of the hardened specimen, grayish- 10 ADENOMYOMA OF THE UTERUS brown granular areas are seen scattered portion of the wall. These are round Fig. 1. — Diffuse adenomtoma of the posterior wall of the uterus. (Natural size.) Gyn.-Path. No. 661. The uterus has been amputated through the cervix. The anterior uterine wall is unaltered. The posterior wall from cervix to fundus is greatly thickened, owing to the presence of a diffuse myomatous growth lying between the mucosa and the outer covering of normal muscle. This diffuse growth consists of fibres forming whorls but also passing in all conceivable directions. It encroaches to a slight extent on the uterine cavity. At a is seen the junction between the diffuse myoma and the normal muscle. The fibres of the one, however, blend imperceptibly with the other, and it would be impossible to shell this growth out, as can be done with discrete myomata. Near the internal os is a small polyp. The uterine cavity is somewhat lengthened. The mucosa lining the anterior wall is of the normal depth, but that covering the posterior wall is considerably thickened, and at two points indicated by b it can be traced for a considerable distance into the myoma. At c, just along the lower margin of the growth, the mucosa can be seen penetrating into the uterine wall for fully 1.5 cm. (For the histological appearance of the posterior wall see Fig. 2.) throughout the thickened or irregular in contour, and as one approaches the uterine cavity are seen to merge directly into the mucosa. Even on macroscopic examina- tion it is evident that at least in the superficial areas are portions of the mucosa that dip down into the tumor. Scattered here and there throughout the tumor are cavities, the largest of which is about 5 mm. in diameter. They have a smooth, glisten- ing inner surface. Some of them are filled with blood. Along one mar- gin of the tumor is a myomatous nodule 1 cm. in diameter. The outer portion of the uterine wall, which corresponds to the uterine muscle, averages 1 cm. in thick- ness. Right side : The tube is 9 cm. long, 6 mm. in diameter. It is free from adhesions and has a patent fimbriated ex- tremity. The parovarium lUHTSK ADKXOMVO.MA OF THE UTERI - 11 is intact. The ovary is 3.5 by 2.5 by L.8cm. It is free from adhe- sions, and on its under surface contains two slightly dilated Graafian follicles. Left side: The tube is 7 cm. long and .8 cm. in diameter. It is free from adhesions and has a patent fimbriated extremity. The parovarium is intact. The ovary is 3.5 by 2.5 by .5 cm. and is slightly cirrhotic. On its under surface is a corpus luteum, 2.5 by 1 cm. Histological E x a m i n a t io n . — The cervical glands are in most places normal, but here and there have proliferated. The epithelium covering; the surface of the cervical mucosa is of the high cylindrical variety; near the junction of the internal os, how- ever, it suddenly changes and the mucosa is covered with several layers of squamous epithelium. Above this point the typical cervical epithelium is again found. The mucosa covering the pos- terior wall of the uterus has an intact surface epithelium. Here and there little knob-like masses of the mucosa project into the uterine cavity. The uterine glands in the superficial portion are moderate in number and are small and round on cross-section. In the deeper portions they show considerable branching, and in some places it looks as if one gland gave off three or four branches; this appearance is probably due to a marked convolution of the glands. In several places the glands are seen extend- ing down into the underlyi n g t n m o r . T h i s is most noticeable near the upper p a i' t of the uterine cavity, where Ion g i t u d i n a 1 sections of two or three glands can be seen p a s s i n g b e t w een m u s c 1 e bundles into t h e d e p t h o f t h e tumor. This is clearly demonstrable to the naked eye. The stroma is rarefied (Fig. 2). The individual stroma cells have oval vesicular nuclei and are slightly swollen. Scattered here and there throughout the stroma are small round cells occurring either singly or in clumps. The superficial portions of the mucosa show considerable hemorrhage. The coarsely striated thickening in the posterior wall is composed 12 ADENOMYOMA OF THE UTERUS A. Horn-, Fig. 2. — Diffuse adenomyoma of the posterior uterine wall. (3 diameters.) Gyn.-Path. No. 661. The section represents the upper half of the posterior wall of the uterus seen in Fig. 1. The wall is divided into three distinct zones, an inner, a, consisting of the uterine mucosa; a middle zone, b. thick and coarse, made up of diffuse myomatous tissue; and an outer zone, c, composed of normal muscle. The mucosa, although increased in thickness, is normal. The surface epithelium is intact and the glands present the usual appearance. The diffuse myomatous growth has many islands of glands scattered throughout it. These consist of practically normal uterine glands and are surrounded by the characteristic stroma of the mucosa. Some of the glands are much dilated. Occasionally a gland occurs singly and lies in direct contact with muscle. At e the gland has retracted from the surrounding stroma. The origin of the gland elements in this diffuse myoma is clear, as at d we see the uterine mucosa extending directly into the myoma. DIFFUSE AI)i;.\o.MV().MA OF THE UTERI - 13 of non-striped muscle fibres, which are cul Longitudinally and trans- versely. This tissue is denser than normal uterine muscle, but otherwise closely resembles it. Between the bundles of muscle fibres, and also between the individual fibres, there is considerable infiltration with small round cells. Scattered freely throughoul the tumor are glands. The majority of these are found in groups; some, however, occur singly. In many places they are seen on cross-section, where they appear as rows of oval or round glands. Some have been cut longitudinally and are cylindrical; others are curved. A few appear to have secondary glands opening into them. The glands as a whole are lined with one layer of cylindrical epithe- lium, on which it is possible in many places to make out cilia. A few of them are dilated. The epithelium of some is intact ; in others it has become flattened or has disappeared. Some of the dilated glands are empty, others contain desquamated epithelium and granular material. Some of the desquamated cells are swollen and their protoplasm contains yellowish-brown, granular pigment. The largest gland is filled with blood. In many of the glands the epithelium has become desquamated, and the gland is only recognized as a space partially or completely filled with desquamated cells. The groups of glands, and also most of those occurring singly. are surrounded by stroma which separates them from the muscle. This stroma is similar to that of the normal uterine mucosa. Here and there cross-sections of three or four glands are seen where the epithelial cells lie directly in contact with the muscle. In a good many places stroma cells contain brown, granular pigment. At one or two points a very curious picture is noted. At one end of a space between muscle bundles it is possible to make out a gland undergoing degeneration; on tracing this a little further, we see three oval spaces forming a chain; these are almost completely filled with small, round cells and cells having oval vesicular nuclei. which look a little like those of epithelioid cells. Each of these masses of cells contains one or more giant cells, which are round. oval, or elongated-oval; their nuclei are vesicular and situated in the centre of the cell or around the periphery. They remind one 14 ADENOMYOMA OF THE UTERUS somewhat of tubercles, but we believe them to be degenerated glands. No tubercle bacilli could be detected in these areas; nor was there any caseation. There is no definite arrangement of the muscle around the bunches of glands. It looks as if the glands just filled in the spaces between muscle bundles. At one side of this new growth is a typical myomatous nodule, 1 cm. in diameter; this is entirely devoid of gland elements. The outer zone of the posterior wall, consisting of uterine muscle, is normal. The mucosa covering the anterior uterine wall is normal. Both tubes and ovaries are normal. Gyn. No. 12,681. Path. No. 9517. Diffuse myomatous thickening of both anterior and posterior uterine walls; large polyp in the body of the uterus; diffuse adeno- myoma of the posterior wall; slight adeno- myomatous tendency in the anterior wall. F. Y., married, aged fifty-nine, white. Admitted Feb. 7, 1906; discharged March 12, 1906. The menses commenced at fourteen and were regular until ten years ago. At this time the periods became irregular and were from three to seven weeks apart. The flow is now more profuse and there is flooding. The patient has had pain in the region of the uterus for some time. The last period came on three weeks ago. The patient has been married thirty- nine years, has had eight children and two miscarriages. The oldest child is thirty-eight, the youngest twenty. Two years ago she consulted a physician, who removed several small polypi from the cervical canal. The bleeding diminished somewhat after this, but has been increasing again of late, and is now as abundant as before the operation. The patient has had no pain except a feeling of dull aching about the bladder. She is constipated. There is shortness of breath and a slight increase in frequency of micturition. Protruding from the os is a polyp 5 mm. in diameter. The fundus is not definitely outlined. Operation . — Removal of small cj^st from the left labium DIFFUSE ADENOMYOMA OF THE UTERUS LO tnajus; hysterectomy; double salpingo-oophorectomy. The pa- tient's highest temperature was L00.8 1". She made an uneventful recovery except for a superficial breaking down of the incision. P a 1 h . X o . 9 51 7. — The specimen consists of a myomatous uterus 10 cm. in length, 9 cm. in breadth, and 8 cm. in its antero- posterior diameter. It is smooth and glistening. The anterior wall varies from 3.5 to 4 cm. in thickness and presents a coarse striated appearance. In the fundus is a discrete myoma 3 mm. in diameter. The posterior wall varies from 2.3 to ?> cm. in thickness. It also presents a rather coarse striation. Just to the left of the cervix is a myoma 2.5 cm. in diameter, and below the cervix i> a myoma approximately 6 cm. in diameter. The right tube offers nothing of interest. The ovary is covered with a few adhesions. It is very small. The left tube is normal. The ovary is somewhat mutilated. The mucosa varies from 2 to 4 mm. in thickness, and projecting from the left side is a polyp 2 cm. in length, 1 cm. in thickness. Sections taken from the posterior wall show an intact surface epithelium. The glands are normal. The stroma presents the usual appearance. The most striking point ob- served with the dissecting microscope is t h a t a t m any p o i n t s the g 1 a n d s c a n b e trace d into the depth. At one point the y can 1 > e followed by continuity for 3 mm. In other places several glands run down in the form of a funnel. Scattered throughout the thickened diffuse myomatous wall are glands and islands of uterine mucosa. Some of them contain only a single gland, others cross-sections of eight or more. Very few of these glands show dilatation. Sections from the anterior wall also show a great deal of diffuse thickening. We have an intact surface epithelium, normal glands, and a stroma which in its superficial portion shows considerable hemorrhage. At several points far down in the depth we have a few isolated glands. There is here an adenomyomatous ten- dency, which is not. however, very marked. In the anterior wall 16 ADENOMYOMA OF THE UTERUS we have several discrete myomata, the largest being 1.5 cm. in diameter. Diagnosis . — Diffuse myomatous thickening of both anterior and posterior uterine walls with marked extension of the mucosa into the posterior wall and slight penetration of the uterine mucosa into the anterior wall; discrete myomata chiefly in the cervical tissue; normal appendages. Gyn. No? 11,850. Path. No. 8197. Diagnosis: Interstitial and subperitoneal uterine myomata. Diffuse adenomyoma in the uterine walls, the glands originating in the mucosa. C. B., aged thirty-nine, white, married. Admitted January 30, 1905. Complaint: abdominal tumor. The patient had one child, eight years ago; no miscarriages. Menses at sixteen. Were regular every four weeks. Flow lasted four days, but lately has been of only one day's duration. Flow very scant, with clots. The pain was formerly cramp-like, but lately only slight. There has been no bleeding since the last period. After the birth of the child, eight years ago, she had what was supposed to be an abscess of the uterus. This opened spontaneously. She made a satis- factory recovery, and in 1900 she had a second abscess, which opened spontaneously. Operation . — Hystero-myomectomy. The uterus was small. On its anterior surface was an irregular myomatous tumor about 18 by 5 cm. The tubes and ovaries on each side were very much adherent from a chronic inflammatory process. The myoma was first bisected and loosened from the bladder. The uterus was removed and later the appendages. The left ovary was firmly adherent to the rectum. In cutting it away a small piece of ovarian tissue was left behind. Convalescence was not complicated. The highest temperature was 100.4° F., twenty- four hours after operation. DIFFUSE A.DEN0MY0MA OF THE [JTERUS 1< Path. No. 8 1 9 7. The specimen consists of the uterus amputated above the cervix. It has been bisected. Attached to the anterior wall is a large interstitial myoma. Both tubes and a pari of the left and of the righl ovary are present. The uterus is normal in size. Its cavity measures 4 cm. in Length. Springing from the anterior wall of the uterus is a myomatous growth, is by 5 cm. The tumor does not encroach at all upon the uterine cavity. There are several small myomatous nodules scattered throughout the uterine wall. These are interstitial. There are dense adhesions over the surface of the tumor. The right tube and ovary are ad- herent. The fimbriated end is lost in the tubo-ovarian mass. The left ovary is cystic. The left tube is normal. Only a portion of the left ovary has been removed. Sections from the endometrium show that the glands are perfectly normal except that here and there there is a dilatation. At some points there is a distinct tendency for the glands to extend into the depth, and at one point we h a v e definite islands of mucosa at least 4 mm. from the surface. A direct connection between these and the surface mucosa can be traced. Around these islands the muscle show r s a definite myomatous tendency. Sections from one of the myomata yield the usual appearance. There is some hyaline transformation. D i a g n o s i s . — Interstitial and subperitoneal uterine myomata : definite adenomyoma with the glands originating from the mucosa. Gyn. No. 2573. Path. No. 163. Diffuse a d e n o m y o m a c c u p y i n <;■ both the anterior a n d post e r i o r u t e r i n e w alls I Fig. 3 : discrete subperitoneal, interstitial and s 11 1 > - m u c o u s m y o m a t a . H y s t e r e c t in y . R e c v e r y . M. B., married, aged fifty, white. Admitted Feb. 7. discharged March 10. 1894. The patient has been married twenty-eighl years and has had five children, the youngesl of whom is now sixteen. Flow usually 18 ADENOMYOMA OF THE UTERUS returned in ten months. One miscarriage, thirteen years ago, at six weeks. Menses irregular until marriage, with profuse flow and some pain; periods regular after marriage. Last spring the menses began to decrease gradually, the pain also became less. The last period occurred in June. 1893 (menopause?). After the cessation of the flow in June. 1893. the patient felt very well. In August, 1893. she had a slight flow at about the menstrual period, and at this time commenced to feel weak and to have a profuse yellowish leucorrhoeal discharge. Since November, 1893, she has had constant hemorrhages. Examination . — Douglas' cul-de-sac is filled with a hard, immovable mass, from which the uterus cannot be differen- tiated. Operation . Feb. 10, 1894. Dilatation and curettage. Double salpingo-oophorectomy. Hystero-myomectomy. Uterus dilated and curetted with removal of a large quantity of mushy endometrial tissue. Retroflexed adherent myomatous uterus re- moved. Maxi m um temperature 100.8° F. on eleventh day. Varied between 98.6° and 100.5° F. for over three weeks. Recovery. Gyn.-Path. N o . 16 3 . — The specimen consists of the uterus, tubes, and ovaries. The uterus is uniformly enlarged, being 8 cm. in length, 7 in breadth, and about 7.5 in its antero-posterior diameter. It is smooth and glistening, but situated on the posterior surface are two small, hard nodules about 5 mm. in diameter. These are myomata. The anterior uterine wall varies from 2 to 3 cm. in thickness. Its muscular tissue is rather coarse, especially in its inner half, and scattered throughout it are numerous myomata, some reaching 1.5 cm. in diameter. The posterior uterine wall varies from 2 to 3.5 cm. in thickness. Its muscular tissue near the uterine cavity is coarse in texture. Scattered throughout it are several small myomata. Some of these encroach to a slight extent on the uterine cavity. The uterine cavity is 7 cm. in length and 7.5 cm. in breadth at the fundus. A description of the mucosa can DIFFUSE A.DENOMYOMA OF THE I TER1 - 19 - Jf £eckes>. —A Fig. 3. — Diffuse adenomyoma of the posterioh uterine wall. (3 J diameters. Gyn.-Pal h. N o . 163. The section is taken from the upper pari of the uterine cavity, as shown by the position of ". which denotes the fundus. The uterine walls with the higher power show a slight myomatous transformation. There is considerable encroachment of the growth on the uterine cavity. At b the mucosa is of the usual thickness and is normal in appearance. At the fundus as seen al c it is thickened, but mechanically injure, 1. At <1 t he mucosa penetrates the diffuse growth torn short distance and at d' can be traced far into the muscle. At the latter point there is also a direct communicat ion bel ween the two down-growths, e is a cystic uterine gland. Scattered throughout the inner half *<\ the uterine wall are numerous islands of uterine glands surrounded by deeply stained areas the normal stroma of the mucosa. Here and there is a small gland lying in direct contact with the muscle. There are also numerous deeply stained areas, as represented by /. These consist of stroma of the mucosa devoid of gland elements. That the glands of this growth are derivatives of the uterine glands i- evident. 20 ADENOMYOMA OF THE UTERUS be of little value, as the greater portion of it had been removed with the curette prior to operation. Histological Examination . — Sections from pro- tected portions show that the surface epithelium is intact. The uterine glands present the usual appearance ; some of them, however, are considerably dilated. The stroma of the mucosa presents the usual appearance. On the whole, we should consider the mucosa normal. At one point, however, near the fundus the glands show a peculiar branching and the epithelium is somewhat flattened, but the individual cells show no suspicious changes. The diffuse thickening in both the anterior and posterior walls is due to a myo- matous transformation of the muscle. In some places this is very pronounced, but it is to a great extent limited to the inner half of the uterine walls. In many places the mucosa has penetrated the diffuse myoma for a distance of 1.5 cm. and in several places the direct extension into the depth can be traced for a distance of 6 mm. (Fig. 3). In the depth these down- growths of the mucosa are recognized as islands of mucous membrane surrounded by myomatous tissue. These islands sometimes contain a dozen or more glands, normal in appearance and surrounded by the characteristic stroma. Some of the glands are much dilated, and occasionally an isolated gland is found lying between muscle bundles, but even then it is usually separated from the muscle by the stroma of the mucosa. The diffuse adenomyomatous condition, although present in both the anterior and posterior walls, is more pronounced in the posterior. Both tubes and ovaries are normal. Diagnosis . — Diffuse adenomyoma occupying both the anterior and posterior uterine walls; discrete subperitoneal, in- terstitial, and submucous myomata; normal appendages. H. A. K. Sanitarium No. 193 1. Path. No. 9367. Subperitoneal, interstitial, and submu- cous uterine myomata; commencing adeno- myoma. DIFFUSE ADEN0MY0MA OF THE UTERUS -1 J. H., aged forty-nine, white. Admitted May LI, L905. The patient complains of an excessive flow. In L893 a myoma was diagnosed. This has apparently not increased in size. The patient now suffers chiefly from pressure on the bladder. There is a great deal of pain in the region of the left ovary and in the lower pari of the abdomen. On May 12, 1905, with a pair of forceps, a myoma was drawn down out of the body of the uterus. Examination per rectum showed that the tumor was the size of a cocoanut and that there were several others. She soon left the hospital, hut returned on October 6th. The last menstrual flow had been very severe. Operation Nov. 18, 1905 . — Hystero-myomectomy, right salpingo-oophorectomy. The patient made a very satisfactory recovery. Path. No. 936 7. — The specimen consists of the uterus, which is rather uniformly enlarged, and which lias been amputated through the cervix. It is 11 cm. in length, 12 cm. in breadth, and 12 cm. in its antero-posterior diameter. Occupying the anterior wall is an oval mass, 8 by 6 cm., presenting a typical myomatous appearance. Scattered throughout the uterine walls are numerous interstitial myomata, and there are also two submucous nodules, the larger 2.5 cm. in diameter. The uterine mucosa is apparently very thin. The right tube and ovary look normal. Histological examination shows the endometrium to be perfectly normal. Over the surface of a submucous myoma from the fundus, there is a distinct myomatous thickening, and covering its surface is an intact surface epithelium. R i d d 1 i n g t h e m y o m a for a short d i s t a n c e a r e n o r m a 1 u t e r i n e g lands, some of w h i c h s h o w a d i r e C I conn e c t i o n w i t h the ut e r i n e m u c o s a . A little further on are two small myomata projecting into the cavity, and on either side of them is normal mucosa. This is rather remarkable, as there is really no encroachment upon the uterine cavity, the myomata just taking the place of the normal uterine mucosa. Diagnosis. — Subperitoneal, interstitial, and submucous uterine myomata; commencing adenomyoma. 22 ADENOMYOMA OF THE UTERUS Gyn. No. 12,599. Path. No. 9366. Slight grade of endometritis, diffuse thick- ening of both the anterior and posterior uterine walls; diffuse adenomyoma of the anterior wall with the glands originating in the mucosa. S. A. B., married, aged forty -three, white. Admitted January 10, 1906; discharged January 31, 1906. Complaint: uterine hemorrhages. The menses commenced at eleven and occurred every three or four weeks until a year ago. Since then the periods have been irregular and prolonged, with flooding, at times accom- panied by cramps, which, however, have not been severe. Flow normal, lasting from six to eight days. The last period began one month ago and has persisted up to the present time. The patient has been married twenty-one years, has had three children and two miscarriages. The oldest child is twenty, the youngest fourteen. For fourteen years the patient has noticed that ten days after the menses the abdomen would swell markedly and she would have the sensation as if everything were falling out of the abdomen. Six months ago she had her menstrual period and the bleeding per- sisted for one month; it could not be controlled with medicine. Three days before admission the bleeding became so marked that the uterus was packed. Operation . — Hysterectomy, amputation through the cer- vix. The history was somewhat suggestive of carcinoma, and as the uterus had been recently curetted we prepared to do an abdominal hysterectomy, if necessary, but on opening the abdomen noted the coarse striated appearance of the uterus and consequently amputated through the cervix. The patient made a satisfactorj^ recovery. The highest post-operative temperature was 100° F. Path. No. 9366 . — The specimen consists of the uterus amputated through the cervix and of the appendages on both sides. The portion of the uterus present is 7 cm. in length, 8 cm. in breadth, and 6.5 cm. in its antero-posterior diameter. Anteriorly it is smooth and glistening. Posteriorly it is covered with a few adhe- sions. The uterine walls are firm. The posterior wall varies from 2.5 DIFFUSE ADENOMYOMA OF THE UTERI - 23 to 3 cm. in thickness. The anterior also reaches 3 cm. in diameter. The mucosa is apparently thin on the posterior wall and on the anterior reaches 2.5 mm. in thickness. Therighl tube is covered with a few adhesions. Its fimbriated end is patent. The righl ovary, apart from a few adhesions, is normal. The left tube is normal. The left ovary is slightly adherent. S e c t i o n s f r o m 1 h e a n t e r i o r u t e r i n e w a 1 1 show t h a t it is r i d d 1 e d w i 1 h is] ;i n d s o f n I e r i n e mucosa. In a good many places these islands are irregular and are surrounded by a zone of muscle fibres lying parallel with the islands. External to this parallel zone is a circular zone. In a good many places the glands occurring in the muscle are dilated and at numerous points are seen miniature cavities. These are lined with one layer of epithelium resting on the underlying stroma, in which typical uterine glands are situated. The myomatous tissue forming this diffuse growth is not very sharply differentiated from normal uterine muscle. Some of the glands have two layers of cells which stain palely, and the appearances are rather suggestive of pathological changes. It will be noted that the glands in such an adenomyoma might very readily have undergone carcinomatous changes. On examining further sections it is found t h a t the mucosa of the a n t e r i o r w all can 1 > e traced into the depth for 1.5 cm. Here it ends abruptly. The endometrium shows numerous polymorphonuclear leucocytes. The posterior wall show r s diffuse myomatous thickening but contains no glands. D i a gnosis . — A mild grade of endometritis; diffuse myoma- tous thickening of the anterior and posterior uterine walls; definite adenomyoma of the anterior wall with the glands originating from the mucosa. Gyn. No. 3614. Path. No. 788. Diffuse 4 m y in atous t h i c k e n i n g of t h e uterine walls w it li extension f a 1 a r c e are a 24 ADBNOMTOMA OF THE UTERUS of mucosa into the depth between the myo- ma t a ( Fig. 4) . Interstitial uterine myomata; hemorrhage into and thickening of the mucosa; general pelvic peritonitis. Mrs. D. G., aged forty-three. Admitted June 29, 1895. Com- plaint : pain in the lower part of the abdomen and profuse, painful menstruation. She has been married twenty-five years, but has never been pregnant. Menstruation began during the sixteenth year and continued to be regular until five years ago. It has always been free and at times painful. Her family history is nega- tive. At seventeen she had typhoid fever with meningeal symptoms, and since then her health has been poor. The present illness dates back five years. At this time she passed several dark, tarry and red masses from the vagina. These appeared to be covered with a thin membrane and their passage was accompanied b} r paroxysms of pain. After this, menstruation became irregular and very profuse, sometimes lasting two weeks. The discharge was very dark in color and frequently clotted. About the second day of menstrua- tion severe pain would commence. This would last throughout the period, and has at times been so severe that it was necessary to keep her under the influence of chloroform. The last period came on four weeks ago, the one before that six months previously. Four weeks ago she noticed a tumor in the lower part of the abdomen. This was freely movable. In January, 1894, an exploratory section was made. Nothing- was done, as the tumor was supposed to be malignant. After the operation the pain diminished and the patient left improved. Present Condition . — The patient is emaciated and anaemic, the tongue is clean, the bowels are constipated. She has had a watery discharge which has persisted for the last four years. This is slightly offensive and varies considerably in color; at times it is yellow; at other times it has a greenish tinge. It is often tinged with blood, and is profuse. Menstruation is frequent and at times painful, and during recent years there have been sensations of weight and pain in the region of the rectum. Locomotion and exercise DIFFUSE A.DEN0MY0MA OF THE [JTER1 - 25 occasion a greal deal of pain in the lower abdomen. Abdominal pressure, however, does not cause any discomfort. Operation July 1, L 8 9 5 . After breaking up numerous adhesions to the anterior abdominal wall the uterus could be lifted up. It was amputated from left to righl in the usual manner and a drain was broughi out through the vagina. On the second day the temperature rose to 100.6° F. For several days it ranged be- tween 100° and 101° F. On July 15th the cervix was dilated, and aboul 70 c.c. of pus escaped. On the twenty-fifth day the tempera- ture reached normal, and on August 12th the patient was discharged feeling perfectly well. The abdominal wound in this case broke down and discharged for a few days, but on July 20th had healed completely. Path. X o . 788 . — The specimen consists of the uterus with intact appendages. The uterus is 11 by 9 by 9 cm. Anteriorly and posteriorly it is covered with dense adhesions. It is soft and yielding on pressure. The uterine cavity measures 6 cm. in length and 6 cm. in breadth. At the fundus the mucosa is bluish-red in color, very irregular, and presents numerous nodules which vary from 1 to 3.8 cm. in diameter. The surface of the mucosa over some of these nodules is smooth and glistening, but for the mosl part it presents a rough appearance. Over the fundus are numer- ous adhesions passing from the anterior to the posterior surface. The mucosa varies from 1 to 7 mm. in thickness. The uterine muscle averages 3 cm. in thickness. Situated in the anterior wall is a firm nodule, 1.5 cm. in diameter, presenting the typical myoma- tous appearance (Fig. 4). The fundus is occupied by a tumor approximately 9 cm. in diameter. On section the central portion of this tumor over an area 6.5 cm. in diameter has undergone degen- eration. It consists of a soft, yielding, whitish tissue held in posi- tion by delicate bands. Plight side: The tube is S cm. in length. It is covered with dense adhesions. Its fimbriated end is patent. The ovary is 2.5 by 2.5 by 1 cm. and shows a dilated follicle. Left side: The tube is 7 cm. in length and averages 5 mm. in 26 ADENOMYOMA OF THE UTERUS diameter. It is free from adhesions. The ovary is small and covered with delicate vascular adhesions. Fig. i. — Diffuse adexomtomatofs thickening in the fundus and posterior uterine ay all WITH EXTENSION EX MASSE OF THE MUCOSA IXTO A LARGE CREVICE BETWEEN MYOMATOUS masses. Natural size.; Gyn.-Path. X o . 7 8 8. The myoma is welling into the uterine cavity, and into the space between myomatous masses a large area of mucosa is flowing. With the continued growth of the myomatous tissue this mucosa would in all probability be nipped off and carried outward, thus forming a large island of mucosa surrounded by myomatous tissue. On section of the specimen after hardening in Mtiller's fluid, the uterine walls are found to be divided into two distinct kiyers. DIFFUSE A.DENOMYOMA OF THE [JTERUS 21 In the anterior wall the inner layer is 2 cm. in breadth. This differs from the outer layers and docs not stain as deeply. In a few places small myomata ;ire seen scattered throughout the thickened pari of the wall. Eighl mm. beneath the mucosa is an area of mucous membrane 8 nun. in diameter. In some places the u t e r i n e m u c o s a c an l> e s e e n f 1 o w i n g i n t o I h e m y o m a tons g r o w t h . The outer muscular covering looks like normal muscle. The posterior wall varies from 4 to 5 cm. in thickness. It is also divisible into two layers, bu1 the coarse myo- matous arrangement occupies nearly the entire wall. The uterine mucosa extends out for a distance of fully 2 cm. and is invading the myoma. Histological E x a m i n a t i o n . — The epithelium cov- ering the cervical mucosa is intact and the cervical glands are normal. In the vicinity of the broad ligament are a couple of glands lined with cylindrical epithelium. They resemble uterine glands and are surrounded by a small amount of stroma similar to that of the uterine mucosa. The uterine mucosa has an intact surface epithe- lium. Its "lands are very abundant. In its superficial portions they are for the most part small and round; and on cross-section, in the vicinity of the muscle considerably dilated. In favorable sections one can trace the gland, which is narrowed in its upper portion, downward until it becomes dilated. The gland cavities are either empty or contain swollen desquamated cells or blood; in a few are polymorphonuclear leucocytes. The stroma of the mucosa is, on the whole, denser than usual. Scattered throughout the superficial portion of the stroma are a few small round cells and a few polymorphonuclear leucocytes. Here and there the glands are seen to extend a short distance into the muscle. Where the muscle is gathered up into folds its surface is covered by cylindrical epithelium. Here and there i n d i v i d u a 1 g 1 a n d s are seen e x t e n d i n g d o w n i n t o t h e m u s C 1 e , b ut at so m e points g 1 a n d s can be t r a c e d d o w n b y d i r e C t cod t inuit y f o r a d i s t a n c e o f 2 c m . T his a p p e a r a n c e is f o u n d to r e p r e sent n o t h - 28 ADENOMYOMA OF THE UTERUS ing more than a dipping down of the normal glands. They are accompanied by characteristic stroma, and many of the glands are dilated. The epithelium lining those lying- in the muscle has in many places fallen off and is lying free in the cavity of the glands. It looks as if the glands in the deeper portion were being forced out of existence and in the myomatous portion only fine remnants are visible. The stroma of the mucosa, however, in such areas still persists. The thickened portions of the uterine walls are composed of irregular bunches of non-striped muscle fibres cut longitudinally and transversely. They have a rich blood- supply and present the usual appearance. The large nodule situated in the fundus is composed of non-striated muscle fibres cut longi- tudinally and transversely. In many places this tissue has under- gone complete hyaline degeneration, and at some points this hyaline material has completely melted away, leaving small cavities. Diagnosis . — Diffuse myomatous thickening of the uterine walls; definite adenomyoma; general pelvic adhesions. CHAPTER II CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELATIVELY NORMAL CONTOUR 'Continued) Gyn. No. 2706. Path. No. 245. Multiple uterine m y m a t a , co m m e n c i n g diffuse adenomyom a . A d e 11 m y m a of the left uterine horn. Right h y d r salpinx; left tubo-ovarian c y s t . M. A., white, aged forty-seven, married. Admitted April 6, 1894; discharged May 12, 1894. The patient has been married twenty years. She has had no children and no miscarriages. The menses are regular, with a free flow and severe pain the first day. Since marriage the flow has lasted twice as long, is more profuse, and the pain is more severe. Moderate leucorrhcea at times. For over two years she has had pain in the left ovarian region, only constant for the past month. During that time there has been a continuous hemorrhage from the uterus, profuse at first, now less. Operation. — Hystero-myomectomy. Part of the growth was submucous and was removed through the vagina. After the operation the patient had persistent nausea and vomiting until the fourth day, when, after the vomiting of an ascaris lumbricoides, 14 cm. long, the nausea and vomiting ceased. The maximum temperature was 100.5° F., on the third day. The patienl made a satisfactory recovery . P a t h . No. 245 . — The specimen consists of the uterus, the dilated tube from the right side, and an ovarian cyst, together with the left tube and ovary. The uterus is 7 by 9 by 5.5 cm. It has been amputated through the cervix. The peritoneal surface is smooth. On the right side about the middle oi the fundus is a myomatous nodule. 1.5 em. in diameter. At the junction of the left tube with the uterus is a myomatous nodule 1.5 em. in diameter. 29 30 ADENOMYOMA OF THE UTERUS The uterine walls average 3 cm. in thickness. They contain three or four myomata, the largest 2 cm. in diameter. The uterine mucosa averages 2 mm. in thickness. Right side : The tube is 21 cm. long, .8 cm. in breadth, and dilated at the uterine end. After passing outward 6 cm. it becomes con- voluted and occluded. Behind this it forms a sac 5 by 6 cm. This somewhat resembles a pipe-bowl. On the surface are numerous adhesions. The ovary is 4 by 4 by 1 cm. The lower extremity is occupied by a cyst, 2 by 3 cm. The left side is for the most part occupied by a cyst, 13 by 12 by 11 cm. It is smooth and glistening and traversed by numerous small vessels. Posteriorly there are many adhesions and a distinct sensation of fluctuation is perceptible. The tube is 17 cm. long, 1.5 cm. broad. After passing outward 6 cm. it spreads over the surface of the tumor and finally merges into the tumor itself. The ovary is 5 by 3 by 1 cm. Histological Examination . — The cervical glands are normal. In the body of the uterus the mucosa is somewhat edematous. Some of the glands run parallel with, instead of at right angles to, the underlying muscle. As one approaches the fundus the mucosa reaches 5 mm. in thickness. The glands are very long. Their epithelium is intact. Some of the glands have extended down into the muscular layer. The stroma in places is infiltrated with small round cells, and in the deeper portions of the mucosa are a few lymphoid cells. The blood-vessels of the mucosa appear to be more numerous than usual and in places are dilated. The right cornu is normal. The left contains numerous cyst- like spaces, some of them situated on the side of the tube, others lying 2 to 4 mm. beneath the peritoneal surface. These glands are small and round or are irregular and dilated. They are lined with one layer of cylindrical epithelium, which in some places rises directly from the muscle. In other places it is surrounded by a faint amount of stroma similar to that of the uterine mucosa. The glands are dilated. The muscular tissue around these glands DIFFUSE ADENOMYOMA OF THE UTERI - 31 presents a distinct myomatous appearance. One of the glands contains a little finger-like ingrowth. Diagnosis. Multiple uterine myomata. Commencing dif- fuse adenomyoma; adenomyoma of the left uterine horn; right hydrosalpinx; left tubo-ovarian cyst. Gyn. No. 3809. Path. No. 881. Discrete s u b p e r i t o n e a 1 and interstitial uterine m y in a t a . Co m m e n c i n g d i f f u s e a d e n o - in y o m a t o u s for m a t i o 11 w i t li t h e g 1 a n d s o r i g - i n a 1 i n g f r o m the mucosa. General pelvic ad- hesions, probable remains of the Wolffian b o d y in the left o v a r y. S. F., aged thirty-six, white. Admitted September 21, 1895; discharged October 19, 1895. The last period appeared two weeks ago; the flow was somewhat free and there was much pain. The bowels are constipated, defecation is painful. Micturition is scant and painful and at times it is necessary to catheterize. p e r a t i o n . — Hystero-salpingo-oophorectomy. Considerable difficulty was experienced owing to the omental adhesions to the abdominal wall. The uterus was everywhere adherent. It was removed entirely. The highest temperature was lnn.fr I\. four days after the operation. The patient made an uninterrupted recovery. Path. No. 8 8 1 . — The specimen consists of the uterus with the appendages intact. The uterus is 7 by 6.5 by 6.5 cm.; it is covered by dense adhesions. On the posterior surface are two flat pedunculated nodules, l.S cm. in diameter. These are covered by adhesions. The uterine cavity is 4.5 cm. in length and 4 cm. in breadth. At the fundus the mucosa presents a slightly roughened, granular appearance, and projecting into the cavity from the lower third of the posterior wall is a myomatous nodule. ."> by 3 cm. The uterine mucosa averages 1 mm. or more in thickness. The uterine muscle averages 2.5 cm. in thickness. It contains several firm nodules averaging 1 cm. in diameter. On the right side the tube 32 ADEXOMYOMA OF THE UTERUS is 5.5 cm. in length and varies from 5 to 8 mm. in thickness. Its surface is covered by a few adhesions and it contains a cyst 1.5 cm. in diameter, near the fimbriated end. The fimbriated extremity is patent and measures .8 cm. in diameter. It is also covered by adhesions. On pressure pus exudes from the fimbriated extremity. The ovary is normal in size, much mutilated, and covered by adhesions. Histological Examination . — The uterine mucosa has not been well preserved. The glands, where present, are normal and have an intact epithelium. The stroma of the mucosa shows a moderate amount of small round-cell infiltration and the uterine glands exhibit a peculiar tendency to extend a short distance into the muscle. Most of these are surrounded by normal stroma, but a few lie in direct continuity with the muscle. Sections through the nodules present a typical myomatous appearance. Right side: The tube presents the usual appearance, but the tube lumen contains a moderate amount of blood. Sections through the left cornu show that the epithelium in places is slightly swollen and that it has here and there cyst-like spaces which contain a few polymorphonuclear leucocytes and apparently some desquamated epithelial cells. Situated apparently in the hilum of the left ovary is an irregular, deeply staining area composed of irregular spindle- shaped cells which suggest connective tissue ; and scattered through this tissue are irregular gland-like spaces, each of which is lined with one layer of cylindrical epithelium. The spindle-shaped cells are arranged in layers around the gland-like spaces. They are probably remains of the Wolffian body. In further sections through the adhesions on the posterior surface of the uterus, the uterine muscle just beneath the mucosa is seen to contain in some places one, in others three or four gland-like spaces. These are, however, slit-like in contour. They are lined with one layer of cylindrical epithelium in which cilia are in many places visible. These cavities are either empty or contain granular de- tritus, and here and there some desquamated epithelium. Some of DIFFUSE ADENOMYOMA OF THE UTERUS 33 the glands lie in direct contact with the muscle. Others have a definite stroma surrounding them. This stroma is similar to thai of the uterine mucosa. Around one of the glands the muscle is arranged in a circular manner. It looks as if it were forming a definite coat. D i a g n o s i s . — General pelvic adhesions. I Mscrete sub- peritoneal and interstitial nryomata. Commencing diffuse adeno- myoma; probable remains of the Wolffian body in the left ovary. Gyn. No. 9069. Path. No. 5229. C o m m e n c i n g diffuse a d e n o m y m a of the uterus; slight pelvic peritonitis. M. M., aged thirty-five, white, married. Admitted September 17, 1901; discharged October 2, 1901. Father, brother, and grand- father died of pulmonary tuberculosis. The patient has always been rather delicate and has had pneumonia three times. Her menses began at twelve, were regular, lasting two or three days; the flow was scant and painful. She has had a leueorrhoeal discharge since childhood. In 1897 the uterus was suspended. In 1899 she returned with a retroversion. This time she complained of more severe pain than she had had before the suspension was done. The most prominent symptoms were backache and frequency of urina- tion. There is no history of any severe hemorrhage. Operation . — Hystero-salpingo-oophorectomy. The patient made an uninterrupted recovery. Path. X o . 5229 . — The specimen consists of the uterus, tubes, and ovaries. The uterus, including the cervix, is 5.5 by 4.5 by 2.5 cm. Its peritoneum is smooth and glistening. At the fundus is a tag of tissue the result of the suspension of two years ago. The cervical canal appears as a transverse slit 5 mm. broad. The muc< >sa is exceedingly thin in the upper part of the cavity; it is granular and much congested. The appendages on both sides are covered with adhesions. The cervical mucosa is normal. Many of the glands, however, are much dilated. 3 34 ADENOMYOMA OF THE UTERUS Sections from the endometrium show the mucosa in places to be very ragged, possibly the result of curettage. In other places the surface epithelium is intact. The stroma is slightly edematous. At some points the underlying muscle shows a distinct myomatous tendency and we have a direct extension of the glands into the un- derlying tissue, the picture presented being typical of adenomyoma. Diagnosis . — Pelvic peritonitis ; commencing adenomyoma ; small cyst of the ovary. Gyn. No. 7153. Path. No. 3429. Diffuse adenomyoma occupying the an- terior, posterior, and lateral uterine walls; in short, forming a mantle around the uterine cavity (Figs. 5, 6, 7). Slight pelvic peritonitis. Hysterectomy. Recovery. S. W., aged fifty-six, white, married. Admitted August 24, 1899; discharged September 26, 1899. Complaint: pelvic tumor and hemorrhages from the uterus. The patient has been married thirty-four years, has had thirteen children; the youngest is thir- teen years of age. She has had one miscarriage. The menses commenced at thirteen, were regular, and lasted a week. For the last ten years they have been very profuse. Sometimes recently she would lose as much as a quart of blood. There has been a slight leucorrhceal discharge. The patient is very anaemic and presents a blanched appearance. She has a slightly intermittent pulse. The outlet is markedly relaxed and the vaginal walls are redundant. The cervix is in the axis of the vagina and points slightly to the right. It is about four or five times the normal size. The cervical lips are thin and rigid. The uterus is somewhat enlarged and irregular in outline. The lateral structures cannot be palpated. Operation August 28, 1899. — Hystero-salpingo- oophorectomy. The patient made a satisfactory recovery. DIFFUSE ADENOMYOM V OF THE I TER1 - 35 Gyn.-Path. No. 3 429. The specimen consists of the uterus with the appendages intact. The uterus is slightly enlarged. It has been amputated a1 the cervix. The body is 6 cm. in length, 6 cm. in breadth, and 4.5 cm. in its anteroposterior di- ameter. The outer sur- face is covered with ad- hesions. These are especi- ally abundant over the fundus and posterior sur- face of the uterus. Both the a n t e r i o r a n d posterior walls average 2.5 c m . in thickness a n d a r e r e a d i 1 y di- visible into two zones. The inner consists of dense muscular tissue; the fibres run in and out in all di- rections an d for m definite whorls (Fig. 5). Situated in this diffuse growth are also a few small circum- scribed myomata. The coarse myomatous tissue extends directly to the mucosa, but apparently does not encroach upon it. At one or two points brownish areas, rather porous in appearance and faintly resembling uterine mucosa, are found in the myomatous tissue some distance from the mucosa. The outer portion of the uterine wall consists of normal muscle. This forms a Fig. 5. — Diffuse adenomyoma forming a complete ZONE AROl'XD THE UTERINE CAVITY. i Natural size.) G y n . No. 3429. The figure represents an anteroposterior section through the entire uterus which has been amputated through the cervix. The uterine cavity is of the normal length and appearance and the mucosa is probably thinner than usual. The inner two- thirds of the muscular wall have been completely trans- formed into a diffuse myomatous tissue which extends to, hut dues not encroach upon, the uterine cavity. At a is a small cyst with a smooth inner lining. The outer portion of the uterine wall consists of perfectly normal muscle. Scattered throughout it are many cross-sections of small blood-vessels, well shown at /». Although the myomatous muscle sharply contrasts with the normal muscle, the two gradually merge into one another and are intimately blended. For the histological appearance see Figs. <> and 7. 36 ADENOMYOMA OF THE UTERUS covering varying from 3 to 5 mm. in thickness and is sharply dif- ferentiated from the diffuse myoma. The uterine cavity is 5 cm. in length and at the fundus 4 cm. broad. The mucosa is perfectly smooth and is apparently not over 1 mm. in thickness. Just within the internal os, however, is a polypoid outgrowth, 1.2 by .6 by .4 cm. Right side: The tube is 10 cm. long and varies from 4 to 11 mm. in diameter. It is covered with vascular adhesions and its fimbriated extremity is occluded and adherent to the ovary. The ovary is senile in character; it measures 2.5 by 1.8 by 1.5 cm. and is covered with adhesions. Left side: The tube is 10 cm. in length and 5 mm. in diameter. Its fimbriated extremity is patent, but the fimbriae have here and there become agglutinated; the ovary is senile; it measures 3 by 1.8 by 1.3 cm. Histological Examination . — Sections through the polyp near the internal os show that it is composed almost entirely of cervical tissue. The glands are abundant, and apart from being dilated offer little of interest. The mucosa lining the uterine cavity has for the most part an intact surface epithelium. This epithelium is low cylindrical in type. The uterine glands present the usual appearance and are lined with one layer of cylindri- cal epithelium. At numerous points the mucous membrane ex- tends directly into the underlying myomatous tissue (Figs. 6 and 7). Sometimes it is possible to trace it for a distance of 6 or 7 mm. The extension into the muscle varies in different places. At some points prolongations 4 or 5 mm. broad extend from the mucosa into the depth. At other points a large area of mucosa in the depth will communicate with the surface by an actual isthmus. The thickening of the anterior and posterior uterine walls is due to the presence of myomatous tissue. As was noted macroscopically, this forms a broad zone between the mucosa and the outer covering of normal muscle. The fibres of this myomatous tissue are particularly well preserved and wind in and out in all directions. Scattered everywhere throughout the myomatous zone are islands of mucous membrane identical DIFFUSE ADENOMYOMA OF THE UTERI S 37 ! '"V 1 *«& ^ i f ~-**Vjv*.-'' Fig. 6. — Diffuse adeno.myo.ma of the uterine wall with marked extension of the mucosa into the growth. (4 diameters.) Gyn.-Path. No. 3429. This is a section through the entire uterine wall in Fig. 5. a indicates the uterine mucosa; b, the outer covering of normal muscle. The intervening portion, comprising the major part of the uterine wall, consists of diffuse myomatous tissue. The uterine mucosa at a is of the normal thickness and presents the usual appearance. It i- immediately noticeable that the surface is perfectly even, there being no tendency toward the formation of outgrowths. At C there is a wholesale extension of mucosa into the diffuse myoma. At & and c" the mucosa can be traced for a considerable distance, but at <■'" a most instructive picture is seen. Here we are able to follow the extension of the mucosa fully two-thirds of the way through the uterine wall and almost to the point where the diffuse growth end- and the normal muscle begins. It will be noted that the usual stroma accompanies the glands. At numerous other points, indicated by*/, the mucosa is seen penetrating the myoma. Scattered throughout the diffuse growth are many islands of uterine mucosa containing anywhere from one to a dozen or more sections of glands embedded in the characteristic stroma. A few of the glands are dilated as shown at c. Here and there there are islands of stroma (/) devoid of glands. The glandular invasion in this case is remarkable, but it will lie noted thai DO epithelial elements are found in the normal muscle. 38 ADENOMYOMA OF THE UTERUS with that lining the uterine cavity. Some of these are not more than 1 mm. in diameter; others much larger. Frequently they are cut lengthwise and can be traced for a distance *%& ^* c c Fig. 7. — Extension of the mucosa into a diffuse myoma of the uterus. (12 diameters.) Gyn.-Path. No. 3429. The section is from the body of the uterus represented in Fig. 5. A very low-power picture of this is seen in Fig. 6. a represents the thickness of the normal mucosa. The surface epithelium is intact and the surface of the mucosa is comparatively smooth. At b we have an angle where the lateral wall joins the top of the uterine cavity. The greater number of the uterine glands are normal in size, but a few are dilated. The normal mucosa is everywhere extending into the diffuse myoma, as indicated by c. The mucosa in the down-growths differs in no way from that lining the uterine cavity save for the fact that some of the glands, as seen at d, are dilated. This is another example of what we have many times reiterated, namely, that the mere extension of uterine glands into the muscle is not necessarily indicative of a malignant growth. of at least 1 cm. and, as was said before, near the mucosa t h e i r direct connection with the mucous membrane is established. The glands forming these islands can in DIFFUSE A.DENOMYOMA OF THE I TER1 - 39 no way be differentiated from those of the mucous membrane. They are similar in shape and are lined with one layer of the char- acteristic cylindrical ciliated epithelium. Surrounding ili<--<- glands is the typical si roma of the mucosa. Some of the glands are dilated, and at least three or four of them reach a diameter of 2 nun. The epithelium of the dilated glands is somewhat flattened, stains palely, and the gland cavities contain desquamated epithelium. In one of the cavities two ill-defined gianl cells are present, produced apparently by a coalescence of desquamated epithelium. Not infrequently are seen little islands of stroma staining deeply and having the characteristics of that of the uterine mucosa, lying in between muscle bundles. The outer covering of uterine muscle is perfectly normal. In this case it is possible to trace a definite relation between the islands of the mucosa and myomatous muscle. AVhere the mucosa is seen extending into the depth the myomatous fibres run parallel with the penetrating mucosa. Where this penetrating mucous membrane is cut transversely, we accordingly find the islands of mucous membrane surrounded by bundles of myomatous tissue also cut transversely. External to this zone we usually find a second in which the fibres run at right angles to the projection. This case is certainly a most interesting one. We have a fairly large uterine cavity and the inner two-thirds of the anterior, pos- terior and lateral walls are replaced by a diffuse myomatous growth. The underlying layers of the mucosa have penetrated this diffuse myoma in all directions, exactly in the same manner as roots enter the soil. Accordingly, at favorable points where we have obtained longitudinal sections we are able to trace a direct extension into the depth. At many points, however, these rootlets in the depth have been cut transversely, and are then recognized as isolated islands of mucous membrane surrounded by myomatous tissue. Where the diffuse myoma ends, this extension of the mucosa into the depth ceases and the entire myoma is covered with a layer of normal uterine muscle. This growth is without a doubt benign in character. The appendages offer nothing of interest. 40 ADENOMYOMA OF THE UTERUS Diagnosis . — Diffuse adenomyoma occupying the anterior, posterior, and lateral uterine walls; slight pelvic peritonitis. Path. No. 8760. Diffuse adenomyoma of the body of the uterus with the glands originating from the uterine mucosa. A. H. Operated upon at the Church Home on June 9, 1905. Operation: complete hysterectomy. The specimen consists of the entire uterus with the tubes and ovaries attached, and there is also a portion of the vaginal mucosa. The uterus measures 9 by 5 by 4 cm. Its anterior surface is normal; its posterior slightly irregular, owing to the presence of two small myomatous nodules averaging 1 cm. in diameter. These project a few millimetres from the surface. The uterine walls vary from 1.5 to 2.5 cm. in thickness. The uterine mucosa appears normal except for the presence of a polyp, which for .3 cm. projects into the cavity from the posterior wall. Right side: The tube contains two ostia. The right ovary con- tains a small cyst. The left appendages are normal. Histological Examination . — Sections from the uterine mucosa show an intact surface epithelium. Many of the glands are dilated and the stroma generally appears normal. I n numerous places the glands with their ac- companying stroma can be traced directly into the muscular tissue. The muscle shows diffuse myomatous transformation. Some of the glands in the myomatous areas are markedly dilated. Isolated gland spaces are found scat- tered throughout the diffuse myomatous tissue, but none are visible in the neighborhood of the peritoneal surface. Diagnosis . — Diffuse adenomyoma of the body of the uterus; normal tubes and ovaries. H. A. K. Sanitarium No. 2144. Path. No. 9705. Diffuse adenomyoma involving the entire body of the uterus with the glands distinctly DIFFUSE ADENOMYOM \ OF THE UTERI - 11 r i s i 11 g I' r o m I li e m u c o s n : s 1 i g li I e n d o in <• I r i I i a : (1 i s c r etc L n t e r S t i 1 i ;i 1 in y in ;i 1 a . V. M. R., white, aged thirty-nine, married. Admitted April 6, L906; discharged May 22, L906. The patienl has had do children, no miscarriages. She entered complaining of dysmenorrhea, free uterine hemorrhage, and some leucorrhcea. Ob admission her haemoglobin was 70 per cent. O p e r a t i o n . — Hystero-myomectomy. The patienl made an uneventful recovery. Her highest post-operative temperature was 101.6° F., twenty-four hours after operation. Path. X o . 9705 . — The specimen consists of the uterus, considerably enlarged, which has been amputated through the cervix. It is 10 cm. in length, 10 cm. in breadth, and 17 cm. in its antero- posterior diameter. Situated in the anterior wall is a myoma 3 cm. in diameter. The posterior wall varies from 2.5 to 4.5 cm. in thick- ness; the anterior wall from 2 to 2.5 cm. The increase in thickness is due to a diffuse myomatous transformation of the posterior wall, which is also present in the anterior wall. Sections from the endometrium show that the surface epithelium is intact. The mucosa in the superficial portion shows typical gland hypertrophy and there is a great deal of small round-cell and polymorphonuclear cell infiltration, giving a picture of subacute endometritis. The mucosa in the deeper layers is perfectly normal and can be followed directly into the myomatous tissue. Scat- tered t h r o u g h o u t the a n t e r i o r a n d p o s t e r i o r walls every w here are 1 a r g e a n d small islands of uterine mucosa. The glands are normal. The diffuse myomatous tissue is everywhere riddled with islands of mucosa, some of them 2 mm. in length, and in one section it is sometimes possible to make out thirty or more islands of mucosa scattered throughout the myoma. Diagnosis. — Diffuse adenomyoma involving the entire body of the uterus with the glands distinctly arising from the mucosa ; slight endometritis. Discrete interstitial myomata. 42 ADENOMYOMA OF THE UTERUS Gyn. No. 2754. Path. No Diffuse a d e n o m y o m a of t Fig. 8. — Diffuse adenomyoma of the anterior uterine wall. (Natural size.) Gyn. -Path. No. 290. This is an antero-pos- terior section of the uterus. The organ has been amputated through the cervix. The anterior lip of the cervix is consider- ably thickened. The anterior uterine wall is increased in thick- ness. It is covered externally with a zone of normal mus- cle, but the major portion of the thickening is composed of a diffuse myomatous growth which has encroached to a marked degree on the uterine cavity. In this diffuse myoma several small discrete myomata are visible. A few of the cervical glands are dilated and lying in the cervical canal is a polyp. The uterine cavity is considerably lengthened. The mucosa of the anterior wall is of the usual thickness, but at numerous points it can be seen penetrating the diffuse myoma for a short distance. The posterior wall is relatively normal, but at a contains a submucous myoma. Attached to the uterus is the proximal end of the right tube. For the histological picture of the diffuse growth in the anterior wall see Figs. 9 and 10. 290. he uterine wall (Figs. 8, 9, and 10). Hysterectomy ; Recovery. R.M., married, aged fifty-four. Admitted May 2, discharged June 5, 1894. The menses commenced at eigh- teen, were regular, pro- fuse but painless. Five months ago the men- strual flow became pro- fuse and lasted much longer, with flooding each month. The patient has been married thirty- two years and has had ten children and one miscarriage. After the third labor there was puerperal fever. At present she complains of a dull aching pain in the right lower abdo- men. On examination the left side of the pel- vis is found filled with a mass which cannot be differentiated from the uterus. It is firm, sensitive, and immo- bile. DIFFUSE A.DENOMYOMA OF THE UTERUS 43 Operation. Vaginal hystero-myomectomy. Double sal- pingo-oophorectomy. The base of the bladder was opened for a-- c b Fig. 9. — Diffuse adenomyoma of the anterior uterine wall. r_'\ diameters. G y n . - P a t h . No. 290. This is a section through the anterior uterine wall in Fig. 8. Almost the entire wall consists of diffuse myomatous tissue, but at the points indicated by " three discrete nodules are visible, and between these and the mucosa is a fourth one. h represents the usual thickness of the mucosa, and it will be seen that it is normal. In many places, a- indi- cated by c. the mucosa is seen extending into the myoma and there sending off numerous secondary branches. At _4§b^ ,,- i .'.. - U.B*cKe&yj>. -d. Fig. 10. — Mode of extension of uterine GLANDS INTO A (10 diameters.) Gy n .-Path. DIFFUSE ADENOMYOMA. No. 290. The sec- tion is from the diffuse adenomyoma in the an- terior wall of the uterus in Fig. 8. a is a por- tion of the normal uterine mucosa. The super- ficial layers have accidentally been removed by mechanical injury. The mucosa can be traced by direct continuity to a'. It will be seen that the glands, apart from some dilatation, are per- fectly normal, and that they are accompanied by the stroma of the mucosa, b is an island of stroma containing one uterine gland. This stroma can be traced upward nearly to the sur- face, downward as far as c. The irregularity in its course is undoubtedly due to the unequal pressure of the ever-growing diffuse myoma. d is an island of stroma devoid of glands; e, an- other point where the mucosa is penetrating the myoma. uterus, tubes, and ovaries intact. The uterus is 12 cm. long, 7 cm. broad, and 6.5 cm. in the antero- posterior diameter. Both ante- riorly and posteriorly it is smooth and glistening. The cervix is 4 cm. in diameter. The posterior uterine wall is about 2.5 cm. in thickness and somewhat striated. It contains a submucous myoma, 2.5 cm. in diameter. The an- terior wall near the cervix is 2 cm. in thickness, but rapidly be- comes thicker and forms a diffuse growth 3.5 cm. thick (Fig. 8). This encroaches to a consider- able extent on the uterine cavity. It presents a very coarse striation resembling a diffuse myoma, and scattered throughout it are sev- eral well-defined myoma ta, vary- ing from 2 to 6 mm. in diameter. The cervical mucosa presents the usual appearance. The uterine cavity is 6.5 cm. long and its mucosa, which is intact, is ap- parently 1 mm. in thickness. Right side: The tube is normal in size but covered by numerous adhesions. The ovary is unaltered. Left side : The tube and ovary seem to be normal. Histological Exam- i n a t i o n . — The cervical glands DIFFUSE A.DEN0MY0MA OF THE CJTER1 - 1") are normal. The uterine mucosa is about 1 mm. in thickness; its surface epithelium is intact, but is low cylindrical or cuboidal in character. The glands are few in number and are here and there slightly dilated. The gland epithelium is low cylindrical in type and is intact. The stroma of the mucosa is somewhat lax and is made up of cells having elongated or oval nuclei which are separated from each other by red corpuscles and large vacuolated spaces. In other words, the tissue of the stroma is edematous, more especially in the superficial portions. The diffuse thickening in the posterior wall is due to a myomatous transformation of the uterine muscle, with here and there the development of young circumscribed myo- mata. Where the diffuse myoma is present in the anterior wall the uterine mucosa is found extending into the depth at many points, and in some places direct continuity with the surface can b e traced for a distance of 1.2 cm. (Fig. 9). Often the mucosa is recognized as islands of mucous membrane far down in the myomatous tissue and completely surrounded by it. The mucosa throughout the myoma differs in no way from that lining the uterine cavity. The glands are identical with those of the mucosa and are surrounded by the typical stroma (Fig. 10). The picture then represents a diffuse adenomyoma of the anterior uterine w r all extending almost to the peritoneal surface. That the gland elements are derived from the uterine mucosa is evident. Histological examination of the tubes shows that they are very slightly altered. Diagnosis. — Diffuse adenomyoma of the anterior uterine wall with the presence of a few small circumscribed myomata. Right side: Slight perisalpingitis; normal ovary. Leftside: Normal appendages. Gyn. No. 12,080. Path. No. 8715. Chr 11 i c e n d m e t r i t i s ; d i f f u s e a d e n m y - o m a of the u ferine w alls w i t h direct x t e n - si on of the mucosa into the depth, acute puru- 46 ADENOMYOMA OF THE UTERUS lent and chronic salpingitis; general pelvic adhesions. E. B., aged thirty, colored, married. Admitted April 28, 1905; discharged June 17, 1905. Complaint: pain in the lower part of abdomen. Her menses began at twelve, were not painful, lasting several days. Her periods of late have increased in duration; the last one continued for fourteen days. She has been married thirteen years and has had six children, no miscarriages. The youngest child is seven months old. Deliveries normal. On April 12, 1905, the menstrual flow began and appeared to be normal, but on the fourteenth day the patient suddenly felt very weak, and on April 17th, while doing her washing, she felt a sudden severe bearing- down pain in the lower abdomen, especially on the right side. The pain was not constant, but occurred every few minutes. Numerous clots were passed at this time, and the pain became so severe that the patient was forced to come to the hospital for relief. Note of May 22d : This patient has been in the hospital two weeks. On admission she apparently had peritonitis, and it was deemed wiser to delay operation for a time. At operation a large pus tube was found on the right side. This curved over the surface of an ovarian cyst and passed down into the cul-de-sac behind the uterus. On the left side a large pus tube could be seen winding out to the pelvic wall. This curved back into the depth. The rectum was adherent to the base of the broad ligament on the left side and also to the posterior surface of the uterus. The upper three-fourths of the uterus was free from adhesions, but below this point the organ was firmly fixed. The uterus was removed with a great deal of difficulty. After operation the patient showed signs of shock, but gradually improved, and was discharged on June 17, 1905. Her temperature on admission was 101° F., ran a regular course, reaching its highest point, 102.2° F.j on June 2d. From this time it gradually dropped. Path. No. 8715 . — The specimen consists of the uterus, which is 6 by 6 by 5 cm. and covered with many adhesions, espe- cially posteriorly. The uterine walls show considerable thickening. DIFFUSE ADENOMYOMA OF THE UTERUS 17 ( ) ii e x a m i m a t i o n of I h e s I i d e w i I h I li <• n a k e d eye it is possible to trace the uterine mucosa fori mm . into the depth by d i r e c 1 continuity. The mucosa has an intact surface epithelium. This, however, is swollen and the underlying tissue shows a great deal of small round- cell infiltration, especially in the superficial layers. There has been a chronic endometritis. The glands in the deeper layers are perfect ly normal. At the junction of the mucosa with the muscle, glands are seen penetrating into the depth. Examination of further sections shows practically the same appearance of the mucosa. There are dome-like projections which extend directly into the muscle for a long distance, then split up into branches. Sections from the tube show a chronic pyosalpingitis. Diagnosis . — Chronic endometritis, diffuse adenomyoma of the uterine walls with the glands coming from the mucosa; acute purulent and chronic salpingitis. Gyn. No. 2806. Path. No. 334. Diffuse adenomyoma of the uterine wall (Figs. 11 and 12). Interstitial and subperito n e a 1 m y o m a t a , general pelvic peritonitis. R i g h t side, tubo-ovarian abscess. Left side, healed salpingitis. Hysterecto m y . Recove r y . M. G., widow, white. Admitted May 30; discharged July 12, 1894. The patient entered the hospital in October, 1893, when a diagnosis of myomatous uterus was made, but operation was not advised at that time. Since then the patient has felt well until two and a half months ago, when she had a feeling of "her womb being out of position," followed in one month by an acute attack of pain in the lower abdomen. Since then this pain has been constant. She has also had chilly sensations accompanied by sweating. Operation. — June 14, 1S94. Hystero-myomectomy. Dou- ble salpingo-oophorectomv. The myomatous uterus was densely adherent to the pelvis. There was an abscess involving the left tube and ovary. This abscess contained lot) c.c. of thick, creamv, 48 ADENOMYOMA OF THE UTERUS sterile pus. The omentum and vermiform appendix were adherent to the rectum. The patient had much nausea and abdominal pain after operation, and there was great nervousness, and at times a certain degree of delirium. Gyn.-Path. No. 334 . — The specimen consists of a moderately enlarged uterus with adherent appendages. The uterus is 8 by 7 by 7 cm. ; it is bright red in color and every- where covered with dense vas- cular adhesions. On its anterior surface are two myomata, the one 2.5 cm., the other 1.5 cm. in diameter. On section the cervical mucous membrane presents the usual appearance. The anterior uterine wall aver- ages 2 cm. in thickness, the posterior slightly less. Situ- ated in the fundus are several small my omata (Fig. 11). One of these encroaches slightly upon the uterine cavity. At the junction of the cervix with the body is another myoma 1.5 cm. in diameter, and scattered throughout the walls are several minute my omata. The uterine cavity is 2.5 cm. in length and the mucosa is scarcely more than 1 mm. in thickness. Right side : The tube is 17 cm. in length, densely adherent to the ovary, and reaches 2.5 cm. in thickness. It is filled with pus. The ovary is considerably enlarged, somewhat cystic, and is the seat of an abscess which communicates with the tube. Left side : The tube and ovary form a densely adherent mass 5 by 3 cm. Fig. 11. — Diffuse adenomyoma of the uterus with several discrete myomata. (Natural size.) Gyn.-Path. No. 334. This is an antero-posterior section of the uterus and to one side of the median line, as we are only able to see portions of the uterine cavity a and a'. Situated in the anterior wall and fundus are six myomata, and in the posterior wall near the cervix there is a small interstitial nodule. Both uterine walls show a rather coarse arrange- ment of the muscle and the posterior wall is somewhat thickened. The uterine mucosa as seen at a is of the normal thickness and appears to be unaltered. For the histological picture see Fig. 12. DIFFUSE ADEN0MY0MA OF THE I TER1 - 11) • ->-. ... - b Histological Examination. The right tube is seen to be the seat of :i salpingitis. The left tube also shows an inflammatory process, I nil partial healing lias taken place. The chief interest lies in the condition of the uterine mucosa. The surface epithe- lium has disappeared, evi- dently owing to mechanical removal. The glands are somewhat degenerated, prob- ably owing to faulty harden- ing. Where preserved, they present the usual appearance. In places there is small round- cell infiltration. The stroma as a whole presents a wavy appearance. Its cells have spindle-shaped nuclei which closely resemble those of the normal muscle. They also run in definite bun- c- w^.-SecA-c^ . Fig. 12. — Diffuse adenomyoma of the poste- rior uterine wall. (10 diameters. G yn.-Path. No. 334. The sect ion dies. They, however, Stain isfromtheposteriorwallinFig.No.il. o repre- sents the uterine mucosa : owing to imperfecl harden- ing, the surface epithelium is wanting. The glands and stroma are. however, perfectly aormal. The uterine walls are composed of myomatous muscle. At a! the mucosa is seen penet rating the muscle, ami scattered throughout the deeper portions are cross-sections and longitudinal sections of glands. These are surrounded by stroma separating them from the muscle. At b the stroma around the gland seems to he sending off prolongations in all direc- tions. The dark areas <• and c' are also area- ol stroma, hut are devoid of glands. more deeply. At some points isolated glands or bunches of g 1 a n d s are seen extending d o w n i n t o t h e m u s - c 1 e (Fig. 12). These glands present the usual appearance and most of them are sur- rounded by stroma. A few, however, lie in direct contact with the muscle bundles. Down in the depth the muscle is gathered up into irregular bundles and presents the characteristic myomatous appear- 50 ADENOMYOMA OF THE UTERUS ance. Here also glands are present, in places surrounded by the characteristic uterine stroma. These glands are found at a distance of at least 1 cm. from the uterine cavity. We have, then, in this uterus faint evidences of an old endometritis and diffuse myomatous transformation of the uterine wall, with extension of the uterine glands into this myomatous tissue, especially in the posterior wall. As was noted, there are also well-defined subperitoneal and inter- stitial myomata. Diagnosis . — Subperitoneal and interstitial uterine myo- mata; diffuse adenomyoma of the uterine wall; general pelvic peritonitis; right side, tubo-ovarian abscess; left side, partially healed salpingitis. Gyn. No. 3204. Path. No. 526. Edema of the uterine mucosa; commencing adenomyoma in the body, the gland elements coming from the mucosa; general pelvic ad- hesions; small ovarian cyst. M. S., married, aged thirty-six, colored. Admitted November 22, 1894; discharged January 15, 1895. The menses began at four- teen; flow regular, lasting from three to five days. On November 11th her last period was accompanied by severe pain. The patient has been married eleven years and has had two children and prob- ably one miscarriage. Following this there seems to have been puerperal sepsis. Operation . — Hystero-salpingo- oophorectomy. The patient's temperature after operation was 101.5° F. It gradually fell, but on the sixteenth day there was another rise to 101.6° F. The pulse immediately after the operation, which was exceedingly difficult, was 145, but gradually fell to normal. Path. No. 526 . — The specimen consists of the uterus with tubo-ovarian masses on either side. The uterus measures 7 by 5 by 5 cm. Its anterior surface is smooth and glistening. Posteriorly it is fastened to the masses on either side by broad vascular adhesions. The under cut surface is 2 cm. in diameter. DIFFUSE AJDENOMYOMA OF THE C7TER1 - 51 The cervical mucosa is pale and glistening. The uterine walls average 2 nun. in thickness and arc pinkish-white in color and slightly striated. The uterine cavity is 5 cm. Long; at the fundus it is 2.5 cm. in breadth. The mucosa in the lower part is yellowish-white. smooth and glistening, but in the fundus presents numerous patches of ecchymosis. It varies from 3 to 5 mm. in thickness. Histological E x a m i n a t i o n . — The uterine mucosa in the vicinity of the external os shows small round-cell infiltration, but otherwise is normal. In the upper part of the uterus the mucosa is considerably thickened. The surface epithelium is intact. The glands are tortuous and abundant. The stroma in the superficial portion is very edematous, but in the deeper portion it is normal. With the low p o w e r the m u c o s a a t m a n y points is seen extending down into the depth and constrictions are forming, almost cutting off some areas from t he uterine mucosa. This can be traced in many places for at least 2 to 3 mm. Some of the glands are dilated, but the majority are perfectly normal. The uterine muscle, chiefly beneath the mucosa, is being divided up into whorls; in other words, the appearances suggest myomatous tissue. Where the glands extend into the depth, they are usually surrounded by stroma, but in some places lie in direct contact with the muscle. On the right side there are numerous adhesions, and there is a unilocular ovarian cyst, probably a dilated Graafian follicle. On the left side is a unilocular cyst, also probably a Graafian follicle. There are general pelvic adhesions. Diagnosis . — Edema of the mucosa ; early diffuse adeno- myoma of the body of the uterus; pelvic adhesions with small bilateral ovarian cysts. CHAPTER III CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELA- TIVELY NORMAL CONTOUR— (Continued) Gyn. No. 3192. Path. No. 525. Commencing diffuse adenomyoma. Adeno- myoma of the left uterine horn. M. D., white, aged forty-five, married. Admitted November 19, 1894; discharged December 15, 1894. Complaint: Pain in the lower abdomen. The patient has had frequent attacks of malaria, but otherwise has been perfectly healthy. Her menses began at nineteen and were regular, lasting two or three days. For the past year, however, the periods have occurred every three weeks, and there has been considerable pain for three days preceding the onset of the flow. The last period came on three weeks ago. The patient states that there has been frequent pain and a thin white but not copious discharge. She has been married twice, the first time twenty-four years ago; the second time two years ago. She has had five children. She had a miscarriage at the second month eleven years ago. For the past year the patient has complained of rather severe and persistent backache and pain extending down- ward and reflected to both lower limbs. Walking or any exertion has caused an aggravation of this pain. The patient appears to be debilitated and is pale. Her appetite is poor. Operation . — Hystero-salpingo-oophorectomy. The uterus was enlarged and on attempting to separate the adhesions the bleeding was somewhat profuse. Convalescence was uninter- rupted and the patient was discharged on December 15th. The highest post-operative temperature was 100.5° F. Path. No. 525 . — The specimen consists of the uterus, tubes and ovaries intact. The portion of the uterus present measures 6.5 by 7 by 6 cm. The anterior surface over its lower half is smooth 52 DIFFUSE ADENOMYOMA OF THE UTERI - 53 and glistening. The upper portion of the anterior surface and the posterior surface are covered with rich vascular adhesions. The uterine muscle averages 2.8 cm. in thickness and is grayish-pink in color and has numerous vessels scattered throughout its walls. The Largest of these is 2 mm. in diameter. The uterine cavity is 3.2 cm. long, but at the fundus 4 cm. broad. The mucosa is glistening, somewhat translucent, but on the left side presents a Large patch of ecchymosis. On the right side the tube at the uterine cornu measures 6 nun. in diameter. After passing outward 3 cm. it merges into a tubo- ovarian mass 5 by 4 by 1.5 cm. This is too mutilated for description. On the left side the tube is 8 cm. long, 5 mm. in diameter at the uterine extremity. The fimbriated end is occluded; it measures 1.5 cm. in diameter. This tube is free from adhesions. In the outer end of the parovarium is a thin-walled cyst, 2 cm. in diameter. This is covered with peritoneum which can be readily shelled off. It is seen to be intimately connected with the parovarium. The ovary is 3 by 3 cm. and much mutilated. Histological Examination . — The uterine mucosa varies from 3.4 to 5 mm. in thickness. The surface epithelium is intact but somewhat swollen. The glands are abundant and some- what tortuous. In a few places they are dilated. The lumina of the glands contain a small amount of granular material. The glands e x t e n d d o w n w a r d into the muscle at numerous points. Most of these are surrounded by stroma. A few, however, lie between muscle bundles. The stroma of the mucosa in the superficial portion is lax, but scattered everywhere throughout it are lymphoid cells with here and there a few poly- morphonuclear leucocytes. In many places are clear spaces rilled with a homogeneous substance which stains with eosin. The uterine muscle near the mucosa is being- divided up into myomatous bundles, and we are able to trace the mucosa for a considerable distance into the depth. Just beneath such areas we find isolated glands and glands surrounded by their normal stroma. There is no doubt that we are dealing with a commencing adenomyoma. 54 ADENOMYOMA OF THE UTERI'S Examination of the left uterine horn shows numerous gland-like spaces just beneath the cross-section of the tube. These in many places show evidence of communicating with one another. The majority of them are irregular and are lined with cuboidal epithelium. The epithelial cells lie in direct contact with the muscle. At other points, however, the epithelium is separated from the muscle by a faint amount of stroma. In this case we also have a gland-like space lying just beneath the peritoneal adhesions. This space is surrounded by muscle and has a lining of one layer of cylindrical epithelium. Diagnosis . — Diffuse adenomyoma of the uterus ; adeno- myoma of the left uterine horn. Gyn. No. 5768. Path. No. 2066. A d e 11 m y o m a occupying both the anterior and posterior uterine walls; in other words, forming a complete zone around the uterine cavity (Figs. 13, 14, 15, and 16). Hysterectomy. Recove r y . J. W., single, aged thirty-eight, white. Admitted January 3; discharged January 31, 1898. The menses commenced at fifteen, were regular, copious, and accompanied by many clots. The patient has had severe dysmenorrhcea as long as she can remember, this being more pronounced during the first three days of the flow. She has had a rather profuse leucorrhceal discharge, occasionally yellowish-red in color. The bowels are constipated. Micturition is frequent and burning and she has pain in the lower abdomen, especially on the left side, which is particularly severe at the men- strual period. The outlet is intact, the uterus about 7 cm. in diameter, regular, hard and smooth. Operation Jan. 5, 1898 . — Hystero-myomectomy. The right ovary was left in situ. The highest post-operative tem- perature was 100.6° F. The pulse did not rise above 92. She made an excellent recovery. DIFFUSE ADKNO.MYUMA OF THE I TER1 S .).) Gyn.-Pal h . No. 2066. The specimen consists of a pear-shaped uterus, considerably enlarged. This has been amputated ;t( t Ik* cervix; ii measures s cm. in length, 9 cm. in breadth, and 8 Uterine cav. Fig. 13. — Diffuse adenomyoma of the uterus involving the anterior and posterior walls and pundus. ', Datural size.) Gyn.-Path. No. 2 6(5. The uterus has been amputated through the cervix. Almost the entire body lias been transformed into a diffuse myomatous growth represented by several large coarse hands of fibres with many smaller bands passing off from them and winding in every conceivable direction. The thickening is most marked in the anterior wall, where the growth extends almost to the peritoneal surface. There is, however, a thin muscular covering, as indicated bye. The lower margin of the growth in the anterior wall is indicated by;. In the posterior wall the growth extends downward to 6. The entire growth, although well defined, is inti- mately blended with t he normal muscle. The uterine cavity is of the normal length and. although there are a few inequalities in the surface of the mucosa, it is comparatively regular and of normal t hickness. Fig. II. from a section through the cut ire body of the uterus, illusl rates the structure as seen with the low magnification. The finer details are shown in Figs. 1 •"> and lti. Clinically a bimanual examination of this uterus would show a moderately enlarged, globular, but smooth, firm fundus. No clue would be gained from introducing a sound into the uterine cavitv. cm. in its antero-posterior diameter. It is perfectly smooth, but has a rather uneven surface. On section the uterine cavity is found to be 6 cm. in length. It is recognized as a narrow slit (Fig. 13). Its mucosa is of the normal thickness and seems unaltered. The 56 ADENOMYOMA OF THE UTERUS V/ a "S o^isf ^ J V '% ^*i It increase in size of the uterus is t e^y ; |: due to a diffuse thickening of its walls. This is general, but more prominent in the ante- rior than in the posterior wall. The anterior wall varies from 4 to 5 cm. in thickness, the posterior from 3 to 3.5 cm. This diffuse thickening which is found in both uterine walls .,i consists for the most part of gc> myomatous tissue. Glistening j bands are found running in I and out in all directions and I forming definite whorls. Scat- X^, Fig. 14. — Diffuse adenomyoma of the S ANTERIOR AND POSTERIOR UTERINE '^|| ay alls. (3 diameters.) Gyn.-Path. No. 2066. This is an antero-posterior section through the entire thickness of the uterus in Fig. 13. . : ,! It is, however, taken nearer the side, hence f only a small portion of the uterine cavity •"S* ifl) is seen. At this level the anterior and posterior walls are practically of equal .« thickness. The myomatous transforma- tion of the muscle is hardly recognizable with this power. At b the uterine mucosa is of the normal thickness, but at c can be seen penetrating the surrounding muscle. .>-, At c' it can be followed for quite a distance. . i The mucosa penetrates en masse, carrying with it the normal stroma. Scattered V .-.* throughout both walls, but more par- ticularly the anterior, are bunches of mu- I §1 cosa. These are well shown at d and at d' . £*-.■'. We can trace the mucosa in its windings for a considerable distance. A goodly num- ber of isolated glands or glands in small bunches are distributed throughout the walls. At e are several dilated glands £ with little or no intervening stroma separ- ating them from the muscle. / is a dis- It is clearly evident that the glands in this diffuse myoma are due to **& $&M?: £2 v» V X crete myomatous nodule. down-growths from the mucosa. (For the finer structures of the adenomyoma see Figs. 15 and 16.) DIFFUSE ADENOMYOMA OF THE I TER1 - ■>, tered everywhere throughoul the growth are minute, cyst-like sp varying from a pin-poinl to 2 nun. in diameter. [ is t ologi cal E \ a m i n a t ion . rhe uterine mucosa * m "'•.V. K * ■2 <>&% .■•/ I* Fk;. 15. Method of penetration of the mucosa in a diffuse adenomtoma of the uterine wall. (8 diameters. Gyn.-Path. No. 2066. The section is from the body of the uterus in Fig. 13. a represents the thickness of I he uterine mucosa. The surface epithelium has been mechanically losl except over the small area indicated by b. The uterine glands are perfectly normal. A.1 three points, however, the mucosa can be seen extending into the underlying myomal This is especially well marked at c, where a Large mass of the normal mucosa is flow inn into the growth. It can be traced to the lower margin of the section at <•'. At d we have an island of mucosa which can be traced upward to the mucosa. The island of mucosa (e) resembles in every particular that lining the uterine cavity. Here and th< gland shows some dilatation. has an intact surface epithelium which presents the usual appearance (Figs. 14 and L6). The uterine glands arc somewhat convoluted, slightly branching;, and are lined with one layer of cylindrical 58 ADENOMYOMA OF THE UTERUS ,$&S0?;. ,■>-■■ ' .":■■ Wh Ska ■■■-■ ■■■■-; s '■■>■- .1 -.7 '....' .\v •.■...-•■■'. ;■;>.... . ,' j ; - ■->;-■%.':,:;«, :-.• '■■■■_:,- * ';•'•'" § =? -:: ,K& ; ' , *''*% [ : :.-'if"j^ ^; ^^i fjffifW:^ Fig. 16. DIFFUSE ADENOMYOJUA OF THE UTERUS 59 epithelium. The stroma of the mucosa is normal and hereand there an^ a few small round cells. At many points a most striking picture is noted. The mucosa extends down into the underlying muscle for a distance of 1 cm. or more, and at such points the glands are perfectly normal and are surrounded by the characteristic stroma of the mucosa (Figs. 14, 15, and 16). It looks as if the mucosa were just falling down quietly into the clefts between muscle bundles. The diffuse thickening in the uterine wall is due to a myomatous transformation of the muscle, with here and there the formation of a small, sharply circumscribed myoma. Scattered everywhere throughout this myomatous tissue are irregular areas of uterine mucosa, near the surface directly continuous with that lining the uterine cavity, but in the depth appearing as bands of mucous mem- brane surrounded by myomatous tissue. The glands in the depth frequently show some dilatation giving rise to the cyst -like spaces noted macroscopically. Nearly all of the glands are surrounded by the characteristic stroma of the mucosa. Covering the outer surface of the uterus is a zone of normal muscle, averaging 4 or 5 mm. in thickness. This is totally devoid of gland elements. The case is a most instructive one. We have a small uter- ine cavity s u r r o u n d e d o n all si d e s b y n o r m a 1 m u c o u s m embrane. This m u cons me m b r a n e h a s a n o u t e r c o v e r i n g v a r y i n g from 3 t o 5 cm. in thickness and consisting of diffuse Fig. 16. — Extension of uterine glands into the diffuse myomatoi s tissue of an ldeno- myoma. (")0 diameters.) Gyn.-Path. No. 2066. The section is from the body of the uterus in Kg. 13. a represents the limits of the mucosa; the surface epithelium is intact and normal. Them is of the usual thickness and its glands are unaltered. The stroma between the elands is slightly rarefied in the superficial portions owing to a slight edema. In the vicinity of 6 are a number of glands lying in the muscle. At c we have fortunately been able to trace a gland by continuity from the mucosa for a considerable distance into the diffuse myoma. It divides into two branches !<■'). which extend further into the growth, Accompanying the gland c are d and e. These have been much convoluted, as only occasionally we catch a glimpse of them, at \!.\ OF THE UTERUS 61 was adherenl to the uterus. The cysl was everywhere adherent to the lateral abdominal wall. The ureters ran from the pelvic brim almost straight across to the uterine cornua, being aboul 5 to 6 cm. Long, from the pelvic brim to the point of attachment of the uterus. Each ureter was dissected free for a distance of 8 to LO cm.; then the adherenl peritoneum was gradually worked away, exposing the uterine vessels which were tied. The right ureter was accident ally caughl in a large pair of artery forceps but freed two or three minutes later. The patient's convalescence w y as slow, owing to her great weakness. She was discharged well on the twenty-eighth day. Her highest temperature after operation was 102° F. Path. X o . 5668 . — The specimen consists of the uterus, left tube and ovary, and a very large ovarian cyst. The uterus is 11 cm. long, 9 cm. broad, and is covered with dense adhesion-, some of which contain adipose tissue. Its removal has evidently been associated with great difficulty. The enlargement of the uterus is clue chiefly to the presence of a myoma, 9 by 8 cm., in the anterior wall. There is also a nodule, 3 cm. in diameter, situated just an- terior to the left tube. The posterior wall of the uterus is considerably thickened o w i n g t o the presence of a diffuse myomatous condi- tion. The left tube and ovary are enveloped in adhesions; otherwise they appear normal. The right tube is 8 cm. long and attached to a cyst. The cyst is approximately 20 cm. in diameter; it is hard and smooth, but is covered with many adhesions, and has projecting from its surface numerous hard nodules. These vary from 3 to 4 cm. in diameter. On section they are whitish-yellow in color, homo- geneous in consistency, and divided up into alveoli by a septum of connective tissue. The cyst walls vary from 3 to 4 cm. in thickness. The inner surface is in places smooth, bul at numerous points the thickening is due to a shaggy growth which in places is covered by recent clots. At one point is a nodule. 4 cm. in length and 3 cm. in breadth, projecting into the cavity. This nodule is porous and closely resembles a carcinomatous growth. 62 ADENOMYOMA OF THE UTERUS Histological Examination . — Sections from the uterus show that the epithelium is intact. The mucosa is normal but shows a decided tendency in places to penetrate the underlying muscle en masse. Situated just posterior to the left uterine cornu is a circumscribed adenomyomatous nodule, fully 2 cm. in diameter. The gland elements in this case are clearly visible to the naked eye. The islands of mucosa vary from a pin-point to 2 or 3 mm. in length. They differ in no way from normal mucosa. Sometimes isolated glands are found. These are invariably separated from the muscle by the normal stroma of the endometrium. A few of the glands are dilated and are filled with brownish pigment. The nodule is very sharply circumscribed from the surrounding tissue. In the wall of the uterus where it joined the left broad ligament one of the glands is fully 3 mm. in diameter. It is filled with pigment and fresh blood-cells. The ovarian cyst has an inner lining of one layer of cylindrical epithelium. At many points there has been hemorrhage with sub- sequent partial organization of the clots. The inner epithelial lining in many places has proliferated, forming new glands, and these at some points are so crowded together that the masses of epithelial cells resemble sarcomatous tissue. The individual cells are fairly uniform. Some of them, however, are considerably en- larged and stain intensely. Although the growth may be now con- sidered as an adenocarcinoma, it has originally been a simple cyst. Diagnosis . — Multinodular myomatous uterus with marked adhesions. Diffuse adenomyoma of the fundus, discrete adeno- myoma. Adenomyomatous tissue in the left uterine wall at the junction of the broad ligament. Cyst of the right ovary probably undergoing carcinomatous transformation. H. A. K. Sanitarium No. 469. Path. No. 1758. Diffuse adenomyoma of both the anterior and posterior uterine walls with the glands coming from the mucosa. DIFFUSE AI)i;.\().MVO.MA OF THE [JTERUS 63 \V. J. R,., white, married, aged fifty-five. Admitted May 21, ls ( .)7; discharged .Inly 2, ls ( .)7. The patient lias bad Bis children. The menses began at nineteen and occurred every three week-. They were very free. Eight years ago she had a prolapsus, and during the last year it has been excee< limply diffirull to keep the uterus within the vagina. Operation. — Hystero-salpingo-oophorectomy. The uterus was removed entirely. The patient made a very satisfactory recovery . Path. X o . 1758 . — The specimen consists of the uterus and the right tube and ovary. The uterus measures 9.5 l>y 7..") by 5 cm. It is free from adhesions. At the left uterine cornu is a myomatous nodule 2.5 cm. in diameter. The cervical canal is 2 cm. in length. The uterine cavity is 5.5 cm. long. The mucosa lining the cavity is much thickened and there is a distinct projection from the posterior wall. The anterior uterine wall presents a diffuse myomatous appearance a n d here and there one can see fine porous areas v a r y i n g from 1 to 3 or more millimetres i n diameter. At some points, especially at the fundus, the mucosa can be seen with the naked eye extend- i n g for 7 m m . into the m y o m a . The same picture is found in the upper part of the cavity. The projection from the cavity into the posterior wall is due to a diffuse myomatous thick- ening. The posterior wall reaches 3.5 cm. in thickness. Here also are a few porous areas, evidently islands of uterine mucosa. On histological examination the vaginal por- tion of the cervix is found to be normal. Sections from the anterior and posterior walls show normal uterine mucosa. A t n n m e r o u s points this mucosa is found f 1 o w i n g i n t o t h e U n d e r 1 y i n g m y o m a . This is c 1 e a r 1 y d e m o n - s t r a b 1 e thro u g h o u t the e n t i r e n t e r i n e c a v i t y . The islands of mucous membrane everywhere are perfectly normal save for dilatation of the glands. The islands are most abundant near the mucosa and are totally absent in the vicinity of the peri- 64 ADENOMYOMA OF THE UTERUS toneum. We have here another example of a diffuse adenomyoma occupying both the anterior and posterior walls, with the gland elements everywhere derived from the uterine mucosa. Gyn. No. 2744. Path. No. 274. Diffuse myomatous thickening of the uterine walls, partly of the adenomyomatous type (Figs. 17 and 18) . Well-defined subperito- neal and interstitial myomata; subacute endometritis; slight pelvic peritonitis. Hysterectomy. Recovery. S. J., married, aged thirty-two, colored. Admitted April 28; discharged June 23, 1894. Menses regular up to two years ago, since when they have in- creased in frequency, with pain at the periods. She has had six children, four still-born, two dying at seven months. The last child was born six months ago. The bowels have been constipated; micturition has been frequent. For the past year she has had pain in the left side and back, growing gradually worse. Examination . — Five distinct myomata could be felt on the surface of the uterus, varying in size from 1 cm. to 6 cm. Lips and mucous membranes pale. Haemoglobin 39 per cent. First Operation . — April 2, 1894. Dilatation and curetting. Uterine cavity tortuous. A considerable amount of endometrial tissue was removed. The patient was discharged on April 13, 1894. Second Operation . — April 28, 1894. Hystero-myo- mectomy. Double salpingectomy. Incision 10 cm. The uterus was myomatous and contained irregular and nodular masses, which had developed mostly from the posterior wall and fundus. There was a double salpingitis with hydrosalpinx and double peri-oophoritis. There was some suppuration of the abdominal incision. The temperature varied between 99° and 102° F. for nine da}^s after the operation, reaching 102.2° F. on the ninth day. Pulse 80 to 114 (maximum on the third day). The temperature for a DIFFUSE Al)l.\o\nii\l.\ OF THE I I ER1 - 65 month occasionally rose to L00 c I'. The pulse was below 88 after the eleventh day. Result : Recovery. Gyn.-Path. No. 2 7 4.— The specimen consists of the uterus and appendages intact. The uterus has been converted into an irregular mass 7 cm. long, 8 cm. from side to side, and 11 cm. in its antero-posterior diameter. It is pinkish in color, smooth and FlG. 17. — INTERSTITIAL AM) SUBPERITONEAL UTERINE MYoMATA. INTERSTITIAL ADENOMYOMA. (Natural size.) Gyn.-Path. No. 2 74. This is an antero-posterior section of the uterus. The figures a, a, a, a, indicate myomata, one in the anterior wall and three in the posterior. The anterior wall, not implicated by the myomata, is considerably thickened. The organ has amputated through the cervix. The uterine cavity is of the normal length. The mucosa of the anterior wall is much thickened, but its surface is relatively smooth. Some of the glands arc dilated, forming small cysts. The mucosa of the posterior wall is little altered, but it also shows some glandular dilatation. The area represented by b has been magnified and is shown in Fig. 18. It contains a small diffuse adenomyoma. ghstening. Scattered here and there over the surface are bright red vascular adhesions. Springing from the posterior surface is a firm nodule. 5 cm. in diameter; from the left side is a similar one, 2.5 cm. in diameter. The under cut surface of the uterus is 7 by 5 cm. iFi.u - . 17). The uterine walls average 3.5 cm. in thickness, are pinkish in color, and contain several nodules, the largest of which is 2.5 cm. in diameter. The nodule situated in the posterior wall and also those scattered throughout the uterus are pearly white in 66 ADENOMYOaIA OF THE UTERUS appearance, are composed of concentrically arranged fibres, and are firm and non-yielding. The portion of the uterine cavity present measures 2.5 cm. in length. The mucosa is apparently 1 mm. in thickness, is pale and glistening, and in places presents ecchymoses. Ji. JBeefrei: %&/ b Fig. 18. — Small adexomyoma in the fundus of the uterus. (3 diameters.) Gyn.-Path. No. 274. The section represents the area b seen in Fig. 17. a is the upper part of the uterine cavity; b is the thickened mucosa of the anterior wall. The glands on the whole are normal, except that there is dilatation of some few of them. The line of demar- cation between mucosa and muscle is irregular and not well defined. The glands show a tendency to invade the muscle, c represents the mucosa in the posterior wall. This is thin, and there is some gland dilatation, but the mucosa is sharply outlined from the muscle. At d there is a regular colony of glands deep down in the muscle. They bear a marked resemblance to the normal uterine glands. From the text it will be seen that some of them are surrounded by the char- acteristic stroma of the mucosa. Others lie in direct contact with the muscle. The surrounding tissue and the uterine walls generally are made up of a diffuse myomatous tissue. At e and e' are discrete myomata. Near the fundus is a polyp 1-5 cm. in diameter, 5 mm. in thickness. (The uterus was curetted one month ago.) Histological Examination . — A description of the uterine mucosa is unsatisfactory, as the uterus has so recently been curetted. Sections from portions that have been unmolested show that the surface epithelium is intact. The glands are few in DIFFUSE A.DENOMYOMA OF THE I TER1 - , 1898. She complained of an enlargement in the lower abdomen. This was associated with pain. She had had one child, no miscarriages. Men- struation had been regu- lar, every four weeks, lasting from four to five days; flow scanty. She had had no pain until five years previously. Since then the menses had been irregular and the flow excessive, last- ing at times for two months and necessitat- ing her remaining in bed. At present the pain in the lower abdomen is sharp and intense. During the last month there has been con- stant bleeding, except Fig. 19.- (Nat- -DlFFUSE ADEXOMYO.MA OP THE UTERI'S. ural size.) Gyn.-Path. X o . 2 3 5 6. The section is an an- teroposterior one through the left side of the uterus. At this point nearly the entire uterine wall is composed of a diffuse myomatous growth. At points a. a. however, a small amount of normal uterine muscle remains. In other places the growth reaches the peritoneum. Scattered throughout the myoma are round, oval, irregular or slit- like cavities with smooth inner linings. Tiny are most abundant and reach their greatest diameters just beneath the peritoneum. Here they have a lining resembling mu- cosa which in places reaches 1 nun. or more in thickness. The two cyst spaces, seen at b, an- in reality merely two cross-sections of one convoluted cavity. See Fig. 21.) At <■ one of the cyst-like spaces ran be traced as a -lit for a considerable distance into the growth. On histological examination the large cyst-like spaces proved to be mini- ature uterine cavities. (See Figs. 2] and 22. for intervals of two or three days. There is no increase in frequency of micturition. The lower half of the abdomen is distended and there is marked tenderness on the left side, as well as in the inguinal and hypo- gastric regions. The outlet is well lifted up. the cervix is small. 70 ADENOMYOMA OF THE UTERUS The os admits the index-finger and the uterus is represented by a mass approximately 10 cm. in diameter. The lateral structures cannot be outlined. Operation . — Hystero-myomectomy. The patient made a perfect recovery. Path. No. 2356 . — The left side of the fundus shows some faintly raised bosses, which can be traced a short distance over the left posterior aspect. They are slightly yielding on pressure. The uterine cavity is 4.5 cm. in length and 3.5 cm. in breadth at the :v *$&,. : : , , mm Fig. 20. — Diffuse adenomyoma of the uterine wall. (4 diameters.) Gyn -Path. No. 2356. The section is from the body of the uterus. A glance at a shows that the mucosa is very thin and that some of the glands are dilated. At & is a small polypoid outgrowth consisting of normal mucosa. The uterine wall is transformed into the diffuse myomatous growth. At c the normal mucosa is seen extending for quite a distance into the diffuse myoma, and at points d, d, we have islands of the mucosa in the depth. At e there is considerable gland dilatation. Distributed here and there are isolated glands accompanied by their stroma, and at / is an island of stroma devoid of gland elements. The glandular elements of this diffuse adenomyoma have undoubtedly arisen from uterine glands. fundus. The mucosa has a roughened surface, is about 2 mm. in thickness, and has springing from it several small polypi, varying from 2 to 8 mm. in length. The posterior uterine wall varies from 2.5 to 3 cm. in thickness. It is easily divisible into two portions; an inner, about 2.5 cm. in thickness, very dense in character, consisting of strands running in all directions and closely resembling myo- matous tissue. This can be traced as far as the mucosa, but is easily differentiated from DIFFUSE A.DENOMYOMA OF THE I TER1 S , 1 it. T h e o u t c r p o r i i o n o f t h e p o s t e r i o r w a 1 1 c o n s i s i a o f ii o r m a 1 uteri n e m u s cle . The anterior uterine wall is aboul 4 cm. in thickness and differs materially from the posterior. It consists almost entirely of coarse bands of tissue running in all directions and forming definite whorls. In the fresh state, small cyst-like spaces were seen scattered throughout the myomatous tissue, but the differentiation was not marked. After hardening in .Midler's fluid, however, these cyst-like spaces, which vary from .5 to 5 mm. in diameter, are found to be situated in a fairly homogeneous tissue devoid of fibres and totally different from the surrounding myomatous tissue. Furthermore, in this homo- geneous tissue are many small openings, somewhat punctiform in character. These areas resemble uterine mucosa, and on examining the mucosa of the anterior wall we can at some points see the mucous membrane penetrating the muscle for at least 4 mm. These islands of homogeneous tissue, which resemble mucosa, vary greatly in shape. Some are comparatively round, others oblong, but the majority are triangular (Fig. 19). They are abundantly scattered throughout the myomatous tissue. The growth occupying the thickened anterior uterine wall, and consisting, as we have seen, of myomatous tissue and islands of mucosa, also involves the left side and to some extent the left posterior aspect of the uterus. It has an outer covering of uterine muscle, averaging 3 mm. in thickni - But at the points at which we noted the bosses on the left and pos- terior aspects of the uterus it has practically reached the peritoneal surface. On making an antero-posterior section through the uterus, near the insertion of the left tube, it is seen that the diffuse myoma contains several irregular cyst-like spaces a short distance beneath the peritoneal covering. The largest of these is 6 mm. in diameter. All have smooth inner linings which resemble mucous membrane. This inner covering is fully .5 mm. in thickness. Histological E x a m i n a t i o n . — Sections from the posterior wall of the uterus in the mid-line show that the surface i^\ the mucosa has in part disappeared. The underlying glands show no change, but the muscle directly beneath the mucosa reveals con- 72 ADENOMYOMA OF THE UTERUS siderable proliferation of the connective tissue around the smaller blood-vessels. The muscle bundles are denser than usual and show a greater tendency to wind in and out. No glands are demonstrable f ,a ^.. - ■—=--- .J-b-v -■-"-"■- tr -1 ; m e fta* "~$£.3ec7zer. Fig. 21. — Cyst-like spaces just beneath the peritoneum in a diffuse adenomyoma of the uterus. (12 diameters.) Gyn.-Path. No. 2356. The section represents the area b in Fig. 19. a is the thin outer covering of normal muscle; a' the peritoneum, b is one of the cyst-like spaces; it is lined with a definite mucosa. This mucosa has a surface epithelium and beneath it a mucous mem- brane containing many glands. The majority are small and round. Some of them are. however, dilated and convoluted. For the finer structures see Fig. 22, which is the area c much enlarged. The mucosa cannot be distinguished from the normal uterine mucosa and the entire cyst resembles a small uterine cavity. At d is an area of mucosa identical with that normally found lining the uterine cavity, e, e' , e" , e'" are evidently cross-sections of one cavity which is much convoluted. The mucosa in them resembles that lining the cavity b. The cyst space b and those represented by e, e', e" , e'" are also evidently part of the same cavity as seen by the connecting link of the mucosa /. in the muscle. The mucosa of the anterior wall has also lost its surface epithelium except at protected points. This loss is un- doubtedly due to the faulty preparation of the specimen. The glands DIFFUSE ADENOMYOMA OF THE UTERUS 76 in the mucosa, on the whole are normal. A few of them, however, arc dilated. At one point the mucosa is seen ex- t e n (1 i n g 4 in in . into t h e u n d e r 1 y i n g m us c 1 e (Fig. 20). Here the glands and stroma seem to penetrate ill the form of a wedge, and the muscle is to some extent arranged parallel with this entering wedge. The thickened anterior uterine wall is composed of myomatous tissue presenting the usual appearance and traceable up to the mucous membrane. Scattered freely throughout the myomatous tissue are islands of g 1 a nd s . These glands are usually circular or oblong in form and lined with one layer of fairly high cylindrical ciliated epithelium. They are invariably surrounded by stroma similar to that of the uterine mucosa. In fact, they appear to be nothing more than large and small islands of uterine mucosa scattered throughout the myomatous tissue. Some of the glands are dilated, and where such dilatation has occurred, the epithelium is usually paler and somewhat flattened. Such glands often contain desquamated epithelial cells and granular material — evidently coagulated serum. A few of the desquamated cells contain pigment droplets, the result of an old hemorrhage. Occasionally Ave find an isolated gland in the muscle or a small amount of stroma lying alone between muscle bundles. The muscle covering the outer surface of this diffuse myoma is normal. The large cyst-like spaces seen in the my- oma in the vicinity of the left horn are throughout lined with m ucous m e m b r a n e identical with that of the uterine mucosa (Figs. 21 and 22). The inner surface of each has a covering of one layer of epithelium, cylindrical in character, except where the space is very much dilated. Here the epithelium is pale-staining and cuboidal or almost flat. Occasionally, there is a little tuft of epithe- lium projecting into the cavity, but the individual cells of such tufts are in no way suspicious. Here and there the epithelium is raised by an old blood-clot which is partially organized. Beneath the epithelium are typical uterine glands, normal in appearance and 74 ADENOMYOMA OF THE UTERUS separated by the characteristic stroma of the mucosa. If we were to take a section through a portion of one of these cyst walls, it would be impossible to differentiate it from the mucosa lining a normal uterine cavity (Fig. 22). We have in this uterus a diffuse adenomy- oma consisting of coarse myomatous tissue, everywhere invaded by islands of uterine &=■<--< j b d a Fig. 22. — The mucosa lining one of the cyst-like spaces situated just beneath the PERITONEUM IN A DIFFUSE ADENOMYOMA OF THE UTERUS. (85 diameters.) Gyn.-Path. No. 2 3 56. The section is the area c in Fig. 21 much enlarged, a represents the mucosa; b, the myomatous muscle. The surface of the mucosa is comparatively regular and is covered by a single layer of cylindrical epithelium. At two points glands are seen opening on the surface. The glands of the mucosa are round or oval on cross-section, and are lined with cylindrical epithelium. Surrounding the glands and separating them from the muscle is a definite stroma. In this the endothelial cells of the blood capillaries are moderately swollen. c is a gland showing some branching; d and d are the bases of glands so cut as to resemble solid nests. This mucous membrane resembles uterine mucosa in every particular, and given such a sec- tion, not knowing its source of origin, we should unhesitatingly say that it was normal mucosa from the uterine cavity. glands, differing in no way, except for their dilatation, from normal uterine mucosa. The growth occupies the entire anterior uter- ine wall, the left side, and also the left portion of the posterior wall. This diffuse adenomyoma has, as was noted, an outer covering of uterine muscle, but on the left DIFFUSE ADEN0MY0MA OF THE [JTER1 - 1 5 s i (1 e b a s r cached the s u r f a c e and i b r e c o g - aized as small bosses. The growth is certainly benign. Gyn. No. 3136. Path. No. 497. Diffuse a d e n m y m a o f t h e a n t e r i o r uter- ine wall (Figs. 23, 24, 25, 26). Glandula r u t eri n e poly}); small interstitial an d subperitoneal myomata. Hysterecto m y . Recover y . L. W., aged forty-six, white, single. Admitted October 24, 1894. Complaint : Pain in lower part of the abdomen, painful and profuse menstruation. Menstruation commenced when she was eleven years of age and was always regular. For the past ten years she has had severe pains in the right ovarian region at the menstrual period. These pains radiated down both limbs, were accompanied by backache, and for the last two years have been so severe that she has been confined to bed for three or four days at each period. At present the flow lasts from ten days to two weeks and there is a considerable amount of clotted blood. Her last period ceased one week before admission. Her parents are both living and healthy. One brother died of tuberculosis. With the exception of an attack of diphtheria several years ago and influenza three years ago, she has always been well. Present Condition. — The patient is a rather anaemic woman and does not appear to be very strong. Her tongue is pale and flabby; the appetite is fair, the bowels are regular. She is unable to walk much and cannot lift heavy weights. Vaginal ex- amination: The outlet is very much relaxed, and presenting at the orifice is a hard, irregular mass which proves to be the cervix. The external os is patulous, admitting the index-linger, and projecting from the os is what appears to be a myomatous nodule about 2 cm. in diameter. The cone-shaped cervix is continuous with the en- larged uterus, which is apparently freely movable. Clinical Diagnosis . — Myoma . Operation Oct. 31, 1894 . — On opening the abdo- men it was found impossible to raise the uterus out of the pelvis, 76 ADENOMYOMA OF THE UTERUS and the operator was compelled to work in the narrow space between the uterus and the pelvic walls. The ovarian and uterine vessels on both sides were controlled and the uterus was amputated. The lips of the stump were then brought together, and, lastly, the peritoneum from the posterior wall was sutured to that of the anterior, thereby completely covering over the stump. The patient made an un- interrupted recovery, and was discharged December 1, 1894. Gyn.-Path. No. 497 . — The specimen consists of the enlarged uterus with its tubes and ovaries intact. The uterus is 13 cm. long, 12 cm. broad, and 10 cm. in its antero-posterior diameter. It is approximately globular and in its contour resembles a normal but enlarged uterus. Anteriorly it is smooth and glisten- ing; posteriorly over its lower two-thirds it is denuded of peritoneum. Situated in the posterior wall in the vicinity of the left uterine cornu are four sessile nodules, which are approximately circular. The largest of these is 2 cm. in diameter. On section they are whitish in color and are composed of fibres concentrically arranged. They present the usual myomatous picture. The under cut surface of the uterus measures 12 by 11 cm. In the centre of this is the cer- vical opening, which is 1 cm. in diameter. Projecting from the right side of this opening is a nodule 2.5 cm. in diameter; this is apparently covered with mucous membrane which is somewhat hemorrhagic. The anterior uterine wall is 7 cm. in thick- ness (Fig. 23) ; it can be divided into two dis- tinct portions; the outer, 1 cm. thick, re- sembles normal uterine muscle; the remain- der of the wall presents a coarsely striated appearance, the striae running in all direc- tions. Scattered throughout this thickened and striated portion of the uterine wall are round, oval, or elongate, brownish-yellow, homogeneous areas, some of which merge directly into the uterine mucosa. In one or two places small cysts, varying from 1 to DIFFUSE A l>i;\n.\IY<).\I.\ OF THE UTERUS t < I in in . , c a n I) e s c e n s c a t I o r e d I li r o U g li oul I li i B t h i c k e n e (I p o r t i o n o I" t h e u t eri d e w all . T h e s t r i a t e d a p p e a r a n c e c an be traced d i r e c I 1 y Fig. 23. — Dikfush aoenomyoma of the anterior vtkkixk wall. i|: natural >i Gyn. No. 497. The uterus has been cut open and is seen from tin- fr< mt . The drawing is from the specimen hardened in Mtiller's fluid. A small portion of the cervix is present. Pro- jecting through the cervical opening is a globular nodule u/) whose pedicle springs from the uterine Cavity just within the internal OS. Oil histological examination this was found to be a myoma everywhere penetrated by glands. The anterior uterine wall is much thicker than usual. It is divisible into two portions, an inner coarsely striated and an outer In it narrower zone which is the normal uterine muscle. This miter zone presents a parallel arrangement of its muscle bundles. ( )n examining the fundus carefully the coarse st nation is seen to be con lined to the anterior wall. The uterine mucosa, apart from slight undulation of the surface, is smooth. The small folds described as occurring near the internal os are obscured by the polyp. I >ne of the most striking features is that there is practically no encroachment of the growth on the uterine cavity, the anterior wall showing little, if any. convexity. This is in marked contrast to what takes place in cases of submucous myomata. For the histological picture see Figs. 24, 25, and _'o. u p t o t h e u t e r i n e m u c o s a , a n d in s o m e p 1 a c e s i n t o it. After hardening the specimen in Midler's fluid the contrast between the normal uterine muscle and the thickened 78 ADENOMYOMA OF THE UTERUS = y^4 ■'- i &i '7 P* ' v> jiffy: ^|§C^^F«^: P- ^1 striated portion is very sharp, the uterine muscle being much darker in color than the striated portion. The posterior wall of the uterus varies from 2.5 to 3.5 cm. in thickness. It is rather dense, but does not present any coarse striations. Situated in the posterior wall are two interstitial nodules 1 and 1.5 cm. in diameter; they are pearly white in color and are composed of concentrically ar- ranged fibres. Fig. 24. — Diffuse adenomyoma of the anterior uterine wall. (3 diameters.) Fig. 24 is a cross-section from the thickened an- terior uterine wall in Fig. 23. a indicates the uterine mucosa, b the adenomyomatous zone and c the nor- mal outer covering of uterine muscle. The surface of the mucosa presents a wavy outline. The surface epithelium is intact and the glands are for the most part normal in size. A few of them are dilated, one reaching a considerable size. On passing to the mus- cle large numbers of longitudinal glands are seen penetrating downward into the growth between the muscle bundles. These are surrounded by a tissue darker than the muscle — the typical stroma of the mucosa. The greater part of the specimen is com- posed of bundles of muscle fibres. Some of the bun- dles present a circular arrangement, others are ob- long and some wind in and out in all directions. These large bundles are again subdivided into smaller ones. Scattered everywhere through the thickened zone are dark areas. Some of these are triangular; some are semicircular, while others are irregular in shape. On examining these areas closely, the majority are found to contain longitudinal or cross-sections of glands. Some of these glands are dilated and irregular in contour. A longitudinal sec- tion of a gland with a dilatation on one side is seen near the junction of the myomatous zone with the uterine muscle. The large clear spaces scattered throughout the myomatous zone are dilated glands. Here and there a dark patch is seen in which no glands are present. Islands of stroma devoid of glands also occur. The glandular elements diminish in number in the outer portions of the growth and at the point where the uterine muscle commences they are absent. The outer zone consisting of uterine muscle presents the appearance of normal muscle. DIFFUSE A.DENOMYOB1A OF THE [JTERU8 79 The uterine cavity is 7.5 cm. in Length, and al the upper pari s cm. in breadth. T he mucous m e m b r a n e of 1 h e a n - terior uterine wall varies from 7 to 8 mm. in thickness, is yellowish-white in color, smooth and glistening. In many places, however, it presents ecchymoses in the superficial portions. In the vicinity of the internal os and extending upward for about 2.5 cm. are three or four longitudinal folds of the mucosa. The depressions between these are about 4 or 5 mm. in depth. The mucosa covering the posterior wall varies from 3 to 4 mm. in thick- ness. Right side: The tube is 11 cm. long, and averages 7 mm. in diameter. Its fimbriated extremity is patent; the parovarium is intact. The ovary measures 8 by 2.5 by 1.5 cm., is pale white in color, smooth and glistening. It contains two corpora lutea, the larger of which is 2.5 cm. in diameter. Left side: The tube is 9 cm. long and 6 mm. in diameter. Its extremity is patent; the parovarium is intact. The ovary measures 4 by 4 by 1 cm., is yellowish-white in color and somewhat lobulated. It contains a cyst 2.5 cm. in diameter. The walls of this are 2 mm. in thickness and the inner surface is dirty brown in color. Histological Examination .—The nodule project- ing into the uterine canal is composed of non-striped muscle fibres. Its outer surface is in places covered with cylindrical epithelium, but in most places apparently with several layers of spindle-shaped connective-tissue-like cells. Scattered everywhere throughout this muscle are gland-like spaces varying from a pin-point to 3 mm. in diameter. These are lined with one layer of epithelium, which in the smaller glands is of a high cylindrical variety. In the dilated glands, however, it is cuboidal, or has become almost flat. The protoplasm of the cells takes the hematoxylin stain. The nuclei are oval and vesicular, and in many places it is possible to make out the cilia. The glands are empty or contain a granular material that takes the hematoxylin stain. These glands resemble to some extent those of the cervix. The surface of the mucosa covering the anterior uterine wall 80 ADENOMYOMA OF THE UTERUS presents in places a wavy outline (Fig. 24). Its epithelium is of the high cylindrical variety and is everywhere intact. In a few places it is swollen and somewhat flattened. The glands are moderate in number, are small and round on cross-section, and have an intact epithelium. A few of them are slightly dilated and contain desqua- mated epithelium. The glands may be traced for from 7 to 10 mm. before any muscular sub- stance is encountered; they then end abrupt- ly or continue into the muscle, where they Fig. 25. — Cross-section of a gland taken from Fig. 24 at d. (150 diameters.) The gland is lined with one layer of cylindrical epithelium and is surrounded by cells having oval vesicular nuclei. Its appearance is identical with that of the normal uterine gland. Sur- rounding the stroma of the gland are non-striped muscle fibres, the majority of which are cut longitudinally. can in places be traced for at least 1 cm.; this down-growth is visible in many places. The stroma of the mucosa is composed of cells whose nuclei vary from the oval vesicular type, as seen near the surface, to deeply staining ones, as noticed in the depth of the mucosa. In some places the stroma cells have elongate oval nuclei; so that it is im- possible to distinguish them from muscle fibres. The superficial portions of the stroma show marked signs of hemorrhage, which is localized to certain areas. The stroma as a whole does not appear to be very vascular. DIFFUSE A MYXOMYOMA OF THE UTERUS 81 The thickened and striated portion of the anterior uterine wall is composed of non-stripod muscle fibres, which are for the most pari cul Longitudinally. The fibres run in all directions, are closely packed together, but only in n few places are concentrically arranged. Scattered throughout this tissue are numerous cell- having small, round, deeply staining nuclei which resemble those of Lymphoid b b' tf e e 4 Fig. 26. — A branching gland from a glandular area in an adenomyoma. (85 diameters.) Gyn.-Path. No. 497. The section is taken from the diffuse growth in the anterior uterine wall in Fig. '_':•>. a appears to be the main trunk of the gland. Upward we have three branches b, /<'. /<", downward it can be traced to d and to the right as far as c. The gland with its various branches appears to be lined with numerous layers of cells. This is due to the thick- ness of the section. It is in reality lined with a single layer. There is nothing in the leas! sug- gestive of malignancy. At points e are sections of other glands. The gland f IS cul on the bevel at /'. The stroma surrounding the glands is exceptionally dense owing to the unusual number of st roina cells. cells. Under the microscope it is impossible to tell where the coarsely thickened zone ends and the normal uterine muscle commences, the transition of the one into the other being so gradual. Traversing this thickened portion of the uterine wall are small clusters of glands, precisely similar to those of the uterine mucosa (Fig. 24). These glands are round or oval and are lined with one layer of cylindrical 6 82 ADENOMYOMA OF THE UTERUS ciliated epithelium. A few longitudinal sections of the glands are here and there visible. Some of the glands are dilated, one of them reaching 5 mm. in diameter. The epithelium of the dilated glands is in places somewhat flattened or has entirely disappeared. In one place two glands are seen opening into a dilated gland. Nearly all of the glands are surrounded by stroma similar to that of the uterine mucosa (Fig. 25). A small isolated gland is occasionally found lying directly between the muscle fibres, and a few of the cysts have no stroma surrounding them. The invasion by the glands can be traced to the point at which the coarsely striated tissue joins the uterine muscle. They are most abundant near the uterine mucosa and gradually diminish as one passes outward. They may be scattered anywhere throughout the myomatous growth, but appear for the most part to occupy the spaces between the muscle bundles. In only a few places can any concentric arrangement of muscle fibres be made out around the glands. The glands themselves show no evidence of degeneration. From the above it will be seen that there is a diffuse muscle thickening of the anterior uterine wall, and that there is a down- growth of normal uterine glands into the newly formed muscle. Along the lower margin of the growth is a typical myomatous nodule 5 mm. in diameter. The mucosa covering the posterior wall is normal. The right tube and ovary are normal. The left tube is normal. The small cyst of the left ovary has no epithelial lining, hence its exact origin cannot be ascertained. Gyn. No. 12,807. Path. No. 9699. Diffuse adenomyoma of the anterior wall w J th commencing adenomyoma of the pos- terior wall. Gland elements derived from the uterine mucosa; a few discrete myomata; general pelvic adhesions; s m a 1 1 G r a a f i a n f o 1 - licle cyst on the right side. DIFFUSE A.DENOMYOMA OF THE UTERUS s -'l A., colored, A pii 1 11, L906. Operation: Hysterectomy; right salpingo-oophoro-cystectomy ; lot* i salpingo-oophorectomy. The specimen consists of the uterus which has beeu amputated through the cervix. It measures 7 by 7 by 6 cm. and is everywhere covered with adhesions, .hist posterior to the utero-ovarian liga- ment is a myoma 1"> cm. in diameter. The .-interior uterine wall is dense and varies from 1.5 to 2.5 cm. in thickness. The posterior wall is also dense and slightly thicker. In the fundus is a myoma somewhat diffuse in character, 1.5 cm. in diameter. The uterine mucosa is very thin. The right tube is bound down by adhesions, but its fimbriated end is patent. The right ovary is converted into a cyst approxi- mately 6 cm. in diameter. This is likewise covered with adhesion-. Sections from the anterior uterine wall show that the surface is ragged, suggesting that the curette has previously been used. The mucosa is dense and the glands are flattened and several are running at right angles to the surface. The stroma of the mucosa is appa- rently normal. Just beneath the mucosa the tissue is definitely myo- matous, being divided up into large and small bundles, and between these are isolated glands. In some places the mucosa c a n be traced down into this m yomatous tis- sue, and cross-sections of isolated glands accompanied by stroma can be seen at least 1 cm. from the mucosa. In the posterior wall the mucosa presents essentially the same picture as in the anterior. There is, however, little tendency for the mucosa to extend into the depth, except here and there, where isolated glands project down into the myomatous muscle. We have here a definite adenomyomatous thickening of the posterior wall with commencing adenomyoma; dense adhesions covering the uterus; a few discrete myomata and general pelvic adhesions with a small Graafian follicle cyst on the right side. Gyn. No. 12,841. Path. No. 9744. Subperitoneal, interstitial, and submu- cous uterine m v o m a t a . Co m m e n c i n g a d e n - 84 ADENOMYOMA OF THE UTERUS myoma; general pelvic adhesions; old sal- pingitis. A. R., single, aged forty-three, white. Admitted April 13, 1906; discharged May 17, 1906. The patient entered the hospital com- plaining of a tumor of the uterus and irregular menstruation. Her menses commenced at fifteen, were regular, lasting from two to three days. For the past year they have been somewhat irregular and were prolonged a day or two longer than usual, associated with some pelvic discomfort, and pain in the leg. For the last two or three years she has had some slight leucorrhcea. Urination was somewhat frequent and there was dysuria for a time five or six months ago. At that time it was necessary to catheterize the patient. Three and a half years ago the patient had a slight uterine prolapsus. About seven months ago she had what was said to have been " inflammation of the bowels" lasting some weeks. Operation . — On entering the abdomen it was found that the bladder extended half-way to the umbilicus and the pelvic tumor was so adherent that its release was exceedingly difficult. During the manipulation a tear was made in the outer coat of the rectum. The tear was 2\ inches long and about \\ inches broad. The surfaces were brought together with fine black silk. The highest post-operative temperature was 101.5° F., on the third day. The patient made a satisfactory recovery and was discharged on May 17, 1906. Path. No. 9744 . — The specimen consists of a myoma- tous uterus, 8 by 8 by 5 cm. Projecting from the anterior surface is a pedunculated nodule 3 cm. in diameter and another 1 cm. in diameter. Scattered throughout the uterine walls are several myomatous nodules, the largest being about 3 cm. in diameter. Attached to the posterior surface of the uterus over almost its entire extent is an irregularly lobulated tumor, 17 by 12 by 12 cm. It is covered with dense adhesions and on the surface is apparently be- coming necrotic. The uterine walls average about 2 cm. in thick- ness. The mucosa has not been well preserved. Sections from the mucosa show that the surface epithelium is DIFFUSE ADENOMYOMA OF THE I TER1 - s " intact. There is a moderate amount of gland hypertrophy and also some polypoid formation. The mucosa shows a distinct tendency to project into the depth. We have at one point an area thai stains sharply with eosin and which mighl very readily be mi-taken for an area of necrosis or for a recent tubercle. Examination with the Midi power shows no resemblance to tuberculosis. A section from one of the myomata shows a great deal of hyaline degeneration and commencing liquefaction. The tube shows evi- dence of chronic inflammation. Diagnosis . — Subperitoneal, interstitial, and submucous uterine myomata; a practically normal uterine mucosa with a dis- tinct tendency to penetrate into the depth; general pelvic adhesion- : old salpingitis. Gyn. No. 9788. Path. No. 6008. Diffuse adenomyoma of the anterior w a 1 1 and fundus and diffuse thickening of the pos- terior wall with but little tendency for the g lands to invade the muscle. E. S., aged thirty-two, white, married. Complaint: "Bearing- down" in the lower abdomen and uterine hemorrhage. The menses began at fifteen, were regular, lasting from five to six days, but not profuse. The patient had some pain with her periods until after the birth of her child seven years ago. Since December. 1900, she has had several severe hemorrhages at the time of her periods. She has been married eight years, has had one child, but no mis- carriages. Profuse leucorrhcea has been present for the last year. In December, 1900, the patient had a severe hemorrhage which started at the time of the regular period and lasted for six weeks. She was in bed for four weeks after this. She had slight hemorrhage ;it the time of the period in February. 1902. when for a week she had a very profuse flooding, but not so severe as the firsl time. Since February the patient has had almost constant but very slight bleed- ing. This is apparently brought on by exertion. For two or three weeks the patient has had a good deal of bearing-down pain, which 86 ADENOMYOMA OF THE UTERUS is partially relieved by lying down. She is in a good condition, but shows slight pallor of the mucous membranes. Operation . — Hy stero-myomectomy ; left salpingo-oophor- ectomy; right salpingectomy. The patient made an uninterrupted recovery. Path. No. 6008 . — The uterus has been amputated through the cervix. It is 9 cm. in length and nearly 9 cm. in breadth. The uterine mucosa has been almost entirely curetted away, but near the right cornu some of the thickened mucosa still remains. The uterine walls, both anteriorly and posteriorly, show diffuse myo- matous thickening. They vary from 3.5 to 4.5 cm. in thickness. The appendages are normal. On histological examination the uterine glands show some hyper- trophy. The diffuse growth in the anterior wall has everywhere been invaded by islands of uterine mucosa. The glands composing these are for the most part normal, but in some places there is moderate dilatation. The uterine mucosa can be seen extending down in large quantities into this diffuse growth, and there is no doubt that the gland elements are derivatives from those of the mucosa. Sections from the fundus and from the upper part of the pos- terior wall also show infiltration with islands of mucosa. In the lower part of the posterior wall is a diffuse thickening, but there is little tendency for the glands to penetrate into the depth. Gyn. No. 10,519. Path. No. 6754. Diffuse adenomyoma of the uterus, the glands originating from the mucosa. S. R., single, aged forty-nine, white. Admitted May 29, 1903; discharged June 17, 1903. Complaint: Dysmenorrhcea. Her menses are regular, always painful. The patient had no bleeding from October to December, 1902. Then the periods were regular for five months. For the last three months there has been a foul yellowish discharge. At times, since the bleeding commenced, the DIFFUSE ADENOMYOMA OF THE UTERUS 87 patienl has had difficulty in holding her urine. For the last three years the pains at the periods have been much worse, nol only in the back but in both legs and groins. Haemoglobin 50 percent. Opera tion. Hystero-salpingo-oophorectomy. The patienl made a satisfactory recovery and was discharged on the twentieth day. Path. No. 6754 . — The specimen consists of a very evenly enlarged uterus with the tubes and ovaries attached. The uterus is rather dense and hard. It measures 7.5 cm. in lenuth, 1 cm. in breadth. The uterine mucosa in places presents a polypoid ap- pearance. This is especially seen in the vicinity of the internal os. The uterine walls have a coarsely striated appearance and there are little openings, suggesting the gland-like spaces of an adenomyoma. The thickening is uniform in both the anterior and posterior walls. The tubes and ovaries appear normal. Histological Examination . — Sections from the body of the uterus show r that the mucosa is perfectly normal, that it is much thickened, and in numerous places there is a tendency for the mucosa to penetrate into the depth. In the inner zone of the uterus, where the diffuse thickening is noted, the tissue is myomatous, and scattered throughout this are i s 1 a n d s of uterine m u c o s a similar to those found in an adenomyoma. One cm. from the outer surface of the uterus is a miniature cavity 4 mm. in diameter. At other points there are dilated glands filled with old hemorrhage. There is no doubt that the glands in this case have originated from the mucosa. Diagnosis. — Diffuse adenomyoma of the anterior and posterior uterine walls; normal appendages. CHAPTER IV CASES OF ADENOMYOMA IN WHICH THE UTERUS RETAINS A RELA- TIVELY NORMAL CONTOUR— (Continued) Gyn. No. 7569. Path. No. 3903. Diffuse a d e n o my o m a of the anterior and posterior uterine walls, most pronounced in the fundus and posterior wall (Figs. 27, 28, and 29) . L. C, married, white, aged forty-six. Admitted February 12, discharged April 26, 1900. The patient complained of discharge of urine through the vagina and of incontinence of feces. Her mother, who died of leprosy at the age of forty-seven, had two chil- dren while suffering from this disease. Both are living and well. When the patient was twelve years of age she had rheumatism, and since that time has complained of shortness of breath. At twenty years of age she had a second-attack of rheumatism. Her menses commenced at sixteen, were regular every four weeks, lasting four days. The flow, however, was accompanied by pain and she had to remain in bed for two days. The flow has always been profuse. For the last two years the menstrual periods have been painful and irregular ; sometimes an interval of two months will elapse. There has been no change in the character of the flow. Her last period came on on December 24, 1899. The previous period had occurred two months before. The patient was married at nineteen and had two children, both stillborn, no miscarriages. She had convulsions at the onset of the first labor twenty-five years ago and was badly torn. At the second labor, twenty-three years ago, there was a complete tear in which the bladder was implicated. Ever since the birth of her first child the patient has been suffering from incontinence of feces. The condition was not improved after the birth of the second child. At that time a vesicovaginal fistula developed. Nineteen years ago the patient DIFFUSE ADENOMYOMA OF THE UTERI - 89 was operated upon and an at tempi was made to close I be fisl ula with silver wire. A second attempt was made two years later, but both were unsuccessful. Following the birth of the second child the patient had phlebitis of the left leg. The leg has since been more or less swollen and al times painful. Apart from a presystolic murmur at the apex of the heart the thorax is clear. Both labia minora and majora are inflamed, ap- parently owing to the escape of urine. Protruding from the vagina is what appears to be a rectocele. The perineum shows a complete tear extending 4 or 5 cm. into the rectovaginal septum. The mucosa over the rectum protrudes slightly and is very red in appearance. In the upper part of the anterior wall, about 1 cm. from the cervix, is a scar which extends across the vagina, and at the left angle of the scar is a vesicovaginal fistula. The cervix is deeply lacerated. The external os is patulous. February 14th. Aniline solution and methylene-blue were used to determine the condition of the ureters and the relation of the fistula to the left ureter and the bladder. Diagnosis : A left ureteral fistula into the vagina and a vesico- vaginal fistula ; also a rupture of the rectovaginal septum. February 19th. The ureter was cut around on all sides and turned into the bladder. The rectovaginal septum was restored. March 11th. The stitches were removed from the vesicovaginal fistula. They were covered with incrustations. An area of granu- lation 4 cm. long was found with urine escaping from it. The site of operation for complete tear was entirely separated except for the two triangular areas in the vagina. An opening was now made into the peritoneal cavity. The uterus was found to be myomatous and the tubes and ovaries were adherent. The uterus, the left tube and left ovary were removed in the usual way. The ureter was then turned into the bladder and the vesicovaginal fistula repaired. Convalescence was slow and the patient complained of much 90 ADENOMYOMA OF THE UTERUS vomiting. There was con- • • v discomfort, especially of nausea and siderable vaginal pain. March 30th. She had a chill, the temperature rising to 102.8° F. On April 6th she developed phlebitis in the right leg. April 24th. The fistulous tract in the abdominal incision appears to have entirely closed. The perineum is in the same condition as at the time of ad- mission. The uretero vaginal fistula appears to have been converted into a vesicovaginal fistula. The patient was dis- charged on April 26th. Gyn.-Path. No. 3 9 3 . — The specimen con- sists of the uterus with its left appendages. The uterus, which has been amputated at the cer- vix, is 8 cm. in length, 6.5 cm. in breadth, and 5.5 cm. in its antero-posterior diameter. The anterior surface is smooth and glistening. The posterior aspect is covered with a few adhesions. At the fundus is a slightly rounded boss, 3 cm. in diameter. The uterine cavity is 2.5 cm. in length and at the fundus 3.5 cm. in breadth. The anterior uterine wall averages 2.5 cm. in thickness and in its inner portion is slightly coarse in texture. The posterior wall varies from 2.5 to 3.5 cm. in thickness and from the peritoneal surface to the mucosa is coarsely striated, resembling- diffuse mvomatous tissue (Fig. 27). Scattered through- a. a Fig. 27. — Diffuse adenomyoma of the body of the uterus. (Natural size.) Gyn.-Path. No. 3903. The uterus has been amputated through the cervix. Occupy- ing nearly the entire body of the organ is a diffuse myomatous growth. In the upper part all trace of the normal muscle has disappeared except at b. Downward the growth can be traced to a and a'. The myomatous portion is composed of coarse bands of tissue passing in all directions and often forming definite whorls with small round or irregular cavities in their centres. Some of these cavities are cross-sections of blood-vessels; others are small cysts. The portion of the uterine cavity seen presents the normal appearance and the mu- cosa shows no change. For the histological pic- ture see Figs. 28 and 29. DIFFUSE A MYXOMYOMA OF THE I TER1 - .»! o u I I li i s c o a r a e I i s a u e a r e a m a II cyst-lik e spaces, a o m e reaching I mm. in diameter. \'<> definite myomatous foci can be found. The left tube and ovary are covered with adhesions. II is t olo g i c a 1 E x a m i n a t ion . — The uterine mucosa liasan intact surface epithelium which in some places is considerably B*| u & S5 /' . -'. : S"'i.\"'*-'' f ?■''/'■ 4&E3P -,f -ft ^ ,."..,. e a I^ic. 28. — Extension of the Ihucosa into the muscle in a cask of diffuse adenomyoma of the I'TKKis. (50 diameters.) Gy n. -Path. No. 3 !)(»:}. The section is from the body of the uterus in Fig. _'7. a represents the thickness of the mucosa which is smooth save for t lie slight projection b. The uterine glands are normal in appearance and t he st roma is dense, resembling t hat normally found after the menopause. The mucous membrane is extending en massi into the myomatous tissue and can lie followed as far as c. / the natural size, measuring 9 cm. in length, ( .i cm. in breadth, and 6 cm. in I hickness. B o t h I h e a n i e r i o r a ml p o s t e r i o r w alls sh o w (I i i' I u s e in y o in a I o u s I b i c k e □ i n g , and here and there throughoul the myomatous areas are little cyst-like spaces. Microscopically it looks very much as if we are dealing with an adenomyoma. The anterior wall varies from 2 to 3 cm. in thickness. The posterior wall also reaches 3 cm. in thickness. The uterine mucosa is apparently considerably thinned out. being not over 1 mm. in thickness. The tubes and ovaries are apparently normal. Histological Examination . — The uterine mucosa is of the normal thickness and is rather dense. The glands present the usual appearance and the underlying muscle shows diffuse myo- matous thickening. The glands flow down into the depth from both the anterior and posterior w alls (Fig. 30). They can be traced for a considerable distance. The mucosa extends down like little bays into the depth. In some places we have miniature uterine cavities. In the islands of mucosa the glands show a good deal of dilatation. We have here, both in the anterior and posterior walls, diffuse adenomyoma with the gland elements coming from the uterine mucosa and diminishing as one passes outward toward the peritoneal surface. Gyn. No. 4364. Path. No. 1170. Diffuse adenomyoma of the anterior uter- ine wall; interstitial uterine m y omata; dila- tation of uterine glands; uterine polypi; very 1 a r g e a d e n c y s t m a of the left v a r y ; g e n e r - a 1 pelvic adhesions. H y s t e r e c t m y a n d c y s t - e c t m y . R e c o v e r y . M. H., aged fifty-nine, white, married. Admitted May 8, 1896; discharged June 12. 1896. Complaint : Abdominal tumor. The patient has had three children; no miscarriages. The menses began at fourteen and were regular until ten years ago. She has always 7 98 ADENOMYOMA OF THE UTERUS had severe dysmenorrhea, beginning two days before the period and lasting until the flow was fully established. The menopause occurred ten years ago. Two years ago she had a profuse hemor- rhage from the uterus lasting three days. She has had no leucor- rhcea. The bowels are constipated; micturition is frequent. Oper- ation, May 12, 1896. Cystectomy and hysterectomy. The ovarian cyst was intimately adherent to the surrounding structures and was removed with difficulty. The uterus was then amputated through its cervical portion. The patient made an uneventful recovery. Gyn.-Path. No. 1170 . — The uterus measures 6 by 7 by 4 cm. Its surface is covered with dense vascular adhesions. The anterior wall varies from 3 to 4 cm. in thickness and is very coarse in texture. The fundus is also somewhat thicker than usual. The posterior uterine wall averages 1.8 cm. in thickness and in the vicinity of the cervix contains two interstitial uterine myomata .6 and .5 cm. in diameter. The uterine cavity is 6 cm. in length and at the fundus 4 cm. in breadth. The mucosa is smooth and glistening, but contains numerous slightly dilated glands. Springing from the anterior wall are two small polypi: the one, 5 by 3 mm., also containing dilated glands; the other, a tongue-like process, 8 mm. in length and scarcely 1 mm. in thickness. This slender polyp is markedly hemorrhagic, especially at its tip, and contains dilated glands. Left side : The Fallopian tube is 6 cm. in length, 5 mm. in diam- eter, and covered with adhesions. The cyst removed is multilocular and measures 42 by 34 by 22 cm. It is pinkish or bluish-gray in color and covered by numerous adhesions. Histological Examination . — The epithelium cov- ering the surface of the mucosa has been poorly preserved, but is intact and normal. The mucosa presents a wavy outline and in places is gathered up into small polypoid projections or into definite polypi. The uterine glands are fairly abundant; some are small and tubular and frequently present forked extremities, but many of them are dilated, reaching 2 mm. or more in size. The stroma DIFFUSE AJDENOMYOMA OF THE I Ti;i;i - 99 is in some places denser than usual. The muscle of the anterior uterine wall is dense, resembling myomatous tissue, and scattered throughoul it are glands occurring singly or in groups. Although the outer uterine walls arc considerably mutilated, these glands can be traced laterally to the broad ligamenl attachment. They arc lined with one layer of epithelium, are identical with uterine glands, and are surrounded by a stroma, similar to thai of the uterine mucosa. Some of the glands are moderately dilated and at o n e p o i n 1 in the depth of the m u s c 1 e t h e r e i e a m i n i a t u r e uterine e a v i t y , there b e i n g s u r - face epithelium 1 i n i n g the cavity a n d n u m e r - ous glands opening into it, while 1 y i n ,<: be- tween the glands is a t y p i c a 1 stro m a . A t some points the uterine m u c o s a c a n b e t r a c c d into the myomatous tissue for a distance of 3 mm. or more. The glands in the depth evidently arise from the uterine mucosa. The uterine muscle shows little defeneration, but quite a number of its blood-vessels are unden>;oin<»; obliterative changes, and some of them contain calcareous plates beneath the intima. The multilocular ovarian cyst has connective-tissue walls and the inner surfaces of the cyst are lined with one layer of high cylindrical epithelium; in other words, it presents the typical appearance. Diagnosis. — Diffuse adenomyoma involving the anterior uterine wall. Interstitial uterine myomata. Dilatation of the uterine glands. Uterine polypi. Very la rue adenocystoma of the ovary. General pelvic adhesions. Church Home and Infirmary iDr. Hunner . Path. No. 6319. Diffuse a d e n o m y o m a o f t h e u t e r i n e w a 1 1 w i t h the g lands c o m i n ii - f r o m t h e m u c s a . November 22, 1902. The uterus is considerably enlarged. The walls reach 1.5 cm. in thickness. In some places the mucosa forms distinct polypoid outgrowths. Sections from the endometrium show that it has been curetted 100 ADENOMYOMA OF THE UTERUS and that the mucosa presents a very ragged appearance. Extend- ing down into the underlying tissue are uterine glands. These do not penetrate singly, but large areas of mucosa flow directly into the depth. We are in places able to trace the mucosa by continuity 6 mm. into the depth. The glands are perfectly normal except for here and there a dilata- tion. They are likewise accompanied by normal stroma of the mucosa. Where the glands are dilated, the epithelium sometimes is pale-staining. The muscular tissue in places presents the typical myomatous picture. Diagnosis . — Diffuse adenomyoma of the uterus with the mucosa flowing directly into the myomatous tissue. Gyn. No. 11,120. Path. No. 7351. Multinodular myomatous uterus, the no- dules being subperitoneal and interstitial. Diffuse adenomyoma in the uterine wall; dis- crete adenomyoma in the left uterine horn with formation of a miniature uterine cavity (Figs. 31 and 32). E. S., single, aged fifty-one, white. Admitted March 17, 1904; discharged April 10, 1904. Complaint : Uterine hemorrhages. The patient had inflammatory rheumatism and typhoid fever at twenty- six. Her menstrual history has been normal until the present illness. For two years the periods have been more profuse than usual, grad- ually increasing until now she has very severe hemorrhages. During the last year the periods have been two or three weeks apart and lasting from one to three weeks. She has lost considerable weight and strength. The patient is well nourished but looks anaemic. Operation March 21, 1904. — Hystero-myomectomy. Convalescence uneventful. The highest post-operative temperature was 100.8° F., which was on the fourth day. Path. No. 7351 . — The specimen consists of a myomatous uterus with the appendages intact. The uterus measures approx- imately 9 by 10 by 10 cm. (Fig. 31). Projecting from the left uterine DIFFUSE ADENOMYOMA OF THE I TER1 - 101 horn is a subperitoneal nodule approximately <*> cm. in diameter. There are also several smaller subperitoneal nodule-. Occupying the anterior wall arc two myomata, one 5 cm. the other 2 cm. in diameter. On section it is found thai the uterine cavity has beeD somewhat mutilated. The nodule in the anterior wall presents the usual appearance. The growth in the left uterine horn is sharply circumscribed and Pio. 31. — Discrete uterine myomata. Diffuse adenomyoma with the glands originating FROM THE MUCOSA. ADENOMYOMA OF THE LEFT UTERINE HORN. ,' natural -i/.e. (! y n . - 1' at h . No. 7 .'i ."> 1 . Scattered throughout the uterus are one medium-sized and several small myomata. Near the uterine horn is a distinct prominence which on section - even on macroscopic examination to he a diffuse adenomyoma. Histological examination of the uterus shows diffuse adenomyoma with the glands originating from the mucosa, for a Longitu- dinal section of t lie uterus !>et ween points a and b see Fig. 32. has on its margin two or three smaller ones. T h i s in y o m a is diffuse in character a n d has scattered t h r o u g h o u t it whitish- y e 1 1 o w p o r o u s a r e a s . e v i d e n 1 1 y i s 1 a n d s o f u t e r i n e m u c o s a . and at one point a cystic dilatation 1 cm. in diameter (Fig. 32), lined with a definite membrane and filled with a brown putty-like material. In the hardened specimen the uterine mucosa can be seen 102 ADENOMYOMA OF THE UTERUS d e macroscopically penetrating into the myoma, the mucosa ex- tending into the myoma fully 6 mm. Surround- ing the outer surface of the myoma is a zone of normal muscle varying from 3 to 6 mm. in thickness. On histological examination the endometrium is found to be much thickened. The surface epithelium is in- tact. The majority of the glands are normal. A few of them, however, are dilated. The mu- cosa shows a tendency in some places to pene- trate the uterine wall and at one point can be traced into the depth for a distance of 4 mm. The underlying muscle shows several small myomata scattered throughout the wall. The large porous growth occupying the left uterine horn is seen to contain many islands of mucosa. One island is 1.8 cm. in length and varies from 1 to 4 mm. Fig. 32. — Longitudinal section of discrete myomata; discrete adenomyoma near the left uterine horn. (| natural size.) Gyn.-Path. No. 7351. Fig. 32 is a longi- tudinal of Fig. 31 from point a to b. In the anterior wall are sections of two discrete niyomata. The posterior wall shows slight thickening. The discrete adenomyoma, although clearly defined, nevertheless is intimately asso- ciated with the surrounding muscle a, and could not be shelled out as could the other two myomata. It contains cystic spaces as indicated by b. The larger space has a definite smooth lining and was filled with yellowish putty- like material, — old and inspissated menstrual blood. in breadth. The uterine mucosa composing these islands differs little from the ordinary mucosa. Some of its glands are dilated and contain old blood, otherwise it is identical. Diagnosis . — Multinodular uterus, the nodules being sub- peritoneal and interstitial. Diffuse adenomyoma of the uterine walls; discrete adenomyoma in the left uterine horn, containing a miniature uterine cavity. DIFFUSE AI)i;\o.MV<).M A OF THE UTERI - L03 H. A. K. Sanitarium No. 2178. Path. No. 9803. Small i n t e r s t i 1 i a 1 u t e r i o e m y m a 1 a : v e r y e a r 1 y a d e n m y m a \v i t li the m u c b a e \ 1 e n d - i i) g into the depth; s 1 i g h t pel vi C a d li e 8 i D 8 . C. S., aged forty-six, white. Admitted May 2, L906 The patient has been married twenty seven years and has had one child and one miscarriage. Her menses have always been excessive and lately the flow has almost amounted to a flooding. No leucorrhoea. The patient has been greatly debilitated from excessive loss of blood. Operation. May 3d. Hystero-myomectomy, double sal- pingo-oophorectomy and appendectomy. This patient had been operated upon by Dr. Kelly several years ago and a number of myomata had been removed. At that time in addition to the my- omata there were many adhesions on the left side and the intestines were slightly adherent on the right side. The highest post-operative temperature was 101.2° F. The patient made a satisfactory re- covery. Path. No. 9803 . — The uterus, both anteriorly and pos- teriorly, is enveloped in adhesions. It is very little increased in size and contains three myomata, the largest 1 em. in diameter. The right tube is bound down to the uterus. Its fimbriated end how- ever, is free. The ovary is but little altered. The left tube and ovary have a few adhesions, but the fimbriated end of the tube is normal. Sections from the endometrium show that the tissue has been very poorly hardened and that the surface epithelium is in few places intact. The glands, where preserved, are normal. They sho w a c o 11 s i d e r ab 1 e ten d e n c y to extend into the depth. Sections from the body o{ the uterus show an island of mucosa, 2 mm. in length, a short distance below the normal mucosa. The direct continuity with the surface can be traced. The muscle beneath the mucosa shows commencing diffuse myo- matous transformation. Diagnosis . — Small interstitial uterine myomata : very earlv 104 ADENOMYOMA OF THE UTERUS diffuse adenomyoma with the mucosa extending into the depth; slight pelvic adhesions. Gyn. No. 12,678. Path. No. 9466. Subperitoneal, interstitial, and submucous uterine myomata; commencing adenomyoma with the glands originating from the mucosa. A. T., married, aged fifty-three, white. Admitted February 5, 1906; discharged February 26, 1906. Complaint: Pain at men- strual period, menorrhagia, difficulty in voiding. The patient was in the hospital ten years ago for nervous prostration. Her menses were regular, at first every four weeks, the flow last- ing four days and being normal in amount. There has always been marked dysmenorrhcea and the patient has remained in bed three or four days. There has been a gradual increase in the amount of flow for the past ten years. About six weeks ago she noticed a marked increase in amount, and from that time to the present the flow has been greatly augmented Now the periods last from four- teen to eighteen days. The pain is cramp-like and so severe as to require morphin at times. Large clots are passed. The patient has never had any children. For some time the patient was treated for anaemia, the real trouble not being suspected. She has been con- stipated for some time and has occasionally had hemorrhoids. There is a constant desire to urinate, and a feeling of pressure in the bladder. On opening the abdomen a small amount of straw-colored fluid escaped. On reaching with the hand down into the pelvis a myo- matous mass was with some difficulty delivered. No adhesions were present. The uterus was removed from left to right without any difficulty. The convalescence was uneventful. Path. No. 9466 . — The uterus is irregular in shape, measuring approximately 12 by 7 by 9 cm. It is free from ad- hesions and contains at least four good-sized myomata, the largest reaching 6 cm. in diameter. The uterine cavity is 4.5 cm. in length and is much distorted by a submucous myoma 3 cm. in diameter which completely fills the cavity. DIFFUSE A.DENOMYOMA OF THE UTERUS L05 On histological examination we have an intacl Burface epithe- lium, normal glands, with here and there hemorrhage into the stroma. \V e a 1 s o h a V e a C in in e n C i n g <1 i f f n 8 e thick e n - i n g o f t h e a n t e r i o r u t e ri n e w a 1 1 w i t h a f 1 o w - i n g (I o w n o f t h e g 1 a n <1 s into t h e d e p th . In other words, the picture is one of a typical commencing adenomyoma. Diagnosis. Subperitoneal, interstitial, and submucous uterine myomata; commencing adenomyoma of the anterior uterine wall. H. A. K. Sanitarium No. 1552. Path. No. 6536. Interstitial uterine my o m a t a ; m a r k e d penetration of the uterine m u c s a into the depth w i t h slight diffuse myomatous ten- den c y . V. Mc(\, white, aged fifty-three. Admitted March 10. 1<>03: discharged April 16, 1903. The patient has had five children. The menopause occurred six months ago. Operation . — Vaginal hysterectomy ; removal of the left tube; repair of perineum and excision of a vaginal cyst. The patient made a satisfactory recovery. Path. X o . 6536 . — The specimen consists of a mutilated, bisected uterus. In the uterine walls are small niyomata. The uterus itself is about normal in size. Sections from the uterine wall near the fundus show that the mucosa is normal. A t nu- merous points, however, the m u c o s a c an b e seen extending into the underlying t i s s u e f o r a c o n s i d e r a b 1 e d i s 1 a n c e . and farther out in the muscle are islands of mucosa or individual -lands surrounded by a small amount of stroma. There is a distinct myomatous tendency, as evidenced by the discrete 1 myomata. The uterine walls them- selves, however, show little tendency toward diffuse thickening. Sections from the discrete niyomata show the typical appearance and hyaline degeneration. Diagnosis. — Interstitial uterine myomata. marked pene- 106 ADENOMYOMA OF THE UTERUS tration of the uterine mucosa into the depth, with slight diffuse myomatous tendency. Gyn. No. 11,363. Path. No. 7593. Subperitoneal, interstitial, and submu- cous uterine myomata. Diffuse adenomyoma in the fundus with the glands coming from the mucosa (Fig. 33) , slight salpingitis; nor- mal ovaries. A. L., colored, aged forty-five, married. Admitted June 21, 1904; discharged July 9, 1904. Complaint: Uterine hemorrhages. Four brothers of the patient died of consumption. Her previous history is negative. Her menses were normal until four years ago, when the menopause occurred. She had one child, thirty years ago; two miscarriages about twenty years ago. Present illness : Nine months ago — that is, three years and three months after the menopause — she commenced to have some slight uterine hemorrhage. This has lasted on and off until the present time, but was never profuse. No other symptoms. She is well nourished. Her lungs are normal. Operation . — Hystero-myomectomy. Convalescence nor- mal. The highest temperature was 101° F., on the third day. Her pulse varied from 110 to 130 for the first three days. She was dis- charged on the sixteenth day. Path. No. 7593 . — The specimen consists of the uterus with the tubes and ovaries attached. The uterus is smooth and its anterior surface is covered with several nodular elevations. It measures 12.5 by 8.5 by 10 cm. and is rather soft. On section it is found to contain submucous, interstitial, and subperitoneal myomata. The largest measures 7 by 6 cm. The uterine cavity is 7 cm. in length. The mucosa in the lower part of the body appears to be atrophic. Near the fundus and projecting into the cavity is a polyp 2.5 cm. in length. The uterine walls in the vicinity of the fundus are coarsely striated and there is a general diffuse myomatous tendency (Fig. 33). From the character of DIFFUSE A.DENOMYOMA OF THE I l ER1 - 107 the growth we should no1 be surprised to find thai il was an adeno- myoma. On further examination il is seen thai the entire fundus is occupied by a diffuse and almosl circular myoma which is ap- f / l r u Fn;. :;:;. Schi'mhiton-eat,, interstitial and submucous i mkine mtomata; diffuse u>eno- MVoma OF THE ENTIRE FUNDUS. (\ n:i1ur:il size.) Gyn.-Pal b . No. 7. "> '.):;. The uterine cavity has been cut in two. In the righl half several polypi arc seen. Scattered throughout the uterine walU are subperitoneal and in- terstitial niyotnata, and at the cervix a fairly large submucous nodule. The uterine muscle in the body shows a very coarse diffuse myomatous appearance which instantly suggests adenomyoma. The pathological reporl shows that the uterine glands penetrate this diffuse myomatous tissue. proximately 7 cm. in diameter. S c a 1 1 e r e d I h r o u g h o u t t h i s a r e a f e w s p o n g y a r e a s i n d i c a t i v e of m u - c o s a , a n d a t o n e point is a d e f i n i \ e a r e a of mucosa 1 cm. in diameter, surrounded by typical 108 ADEXOMYOMA OF THE UTERUS myomatous tissue. At another point just beneath the mucosa is a circumscribed myoma in the diffuse growth. This contains three or four small cystic spaces. On histological examination some dilatation of the glands of the endometrium is noticeable, especially where the polyp is present. Here many of the glands are fully four or five times their normal size. At numerous points the mucosa is found to extend into the underlying tissue. Sections a little farther up in the cavity show large areas of mucous mem- brane penetrating into the depth, and in the underlying tissue are many islands of mucosa differing in no way from the normal except for gland dilatation. Some of the dilated glands contain a few desquamated epithelial cells. The ovaries are normal. There is a slight degree of salpingitis. Diagnosis .—Subperitoneal, interstitial, and submucous uter- ine myomata; diffuse adenomyoma with the glands coming directly from the uterine mucosa. Gyn. No. 701 1. Path. No. 3289. Multiple uterine myomata; diffuse adeno- myoma, the glands originating from the mu- cosa. Peri-oophoritis. E. B. S., aged thirty-three, white, single. Admitted June 20, 1899; discharged August 1, 1899. Complaint: Menorrhagia; ab- dominal tumor; dysmenorrhea. The menses began at thirteen and were always regular, lasting seven days. There was no severe pain, but a cutting sensation in the left side. For over a year the flow has been very profuse, amounting to hemorrhages. The bowels are, as a rule, constipated. Micturition is frequent. Operation, June 24. Hystero-salpingo-oophorectomy. The right ovary was left in situ. In addition to the uterus, a calcareous nodule was removed from the mesentery of the ileum about 10 cm. from the ileocecal valve. The highest post-operative temperature was 100.9° F., on the ninth day. The patient made a satisfactory recoverv. DIFFUSE A.DENOMYOMA OF THE UTERI - L09 P a t h . X o . 3 2 8 9 .- The specimen consists of the uterus, left tube and ovary, and several myomata, the largesl measuring 7.5 by 5 by 4.5 cm. The uterus Lndependenl of some of these large nodules measures ( .) by 7.5 by 8 cm. Its peritoneal surface i- some- whal injected. The uterine cavity is (i cm. long, f> cm. broad. At the fundus the walls are approximately 6 em. in thickness. Small myomata are seen scattered throughout them. The mucosa is 3 mm. in thickness. Its surface is very irregular owing to the presence of submucous myomata. It is, for the most part, smooth and glisten- ing. The righl appendages are covered with adhesions. On the left side the tube measures 6 cm. in length, 7 mm. in thickness. It is free from adhesions. The ovary measures 5 by 4 by -.') cm.; is soft and fluctuating, being apparently cystic. It is covered with a few vascular adhesions. On histological examination sections from the decalcified cal- careous nodule (3 by 2.5 by 2 cm.) removed from the mesentery, show that it possesses a capsule of fibrous tissue which contains a few connective-tissue cells. The centre of the calcareous area is practically devoid of cell elements. The nodule appears to be a calcified lymph-gland. Sections from the uterine wall sh o w dif- fuse thickening with d i r e c 1 extension of the glands into the d e p t h . Diagnosis. — Multiple uterine myomata, subperitoneal, in- terstitial, and submucous; diffuse adenomyoma. Pelvic adhesions; hydrosalpinx. Gyn. No. 7859. Path. No. 4122. M u 1 1 i n o d u 1 a r m y m a t us u 1 e r u s ; d i f f u s e adeno m y m a oft h e f und u s (Fig. 34), w ith the g 1 a n d s o r i g i n a t i n g f r m t h e m u c o s a : g e n e r a 1 pelvic adhesions; r i g b t h a* m a t o salpinx. A. B., married, white, aged fifty-two. Admitted May 29, 1900; discharged June 30. 1900. Complaint: uterine hemorrhage. The 110 ADEXOMYOMA OF THE UTERUS patient has been married thirty-six years, and had one child, thirty- five years ago, no miscarriages. Her menses were normal until the menopause. The patient has not been in good health for four years. She has had shortness of breath and palpitation for the last three years and has been having excessive hemorrhages, the bleeding- lasting from one week to one month. She has lost as much as a basin of blood in a few minutes, and has had to go to bed at these times. The bleeding always comes on after exertion. There has been no pain. She was formerly a robust woman, but has been reduced to a condition of great anaemia. The lungs are normal. There is a soft systolic murmur over the entire cardiac region. Haemoglo- bin 30 per cent. The urine contains a large amount of pus and some casts. For the last three years the patient has had a greenish, offensive discharge. Operation : Hystero-myomectomy. At the time of her discharge, on June 29th, her haemoglobin was 59 per cent. Just about an inch external to the anus was a fistulous opening. This probably accounted for her temperature, which on the third day rose to 103.5° F. Path. Xo. 4122 . — The specimen consists of an enlarged uterus, the right dilated tube and ovary, and the left tube and ovary. The uterus is converted into a nodular tumor measuring approxi- mately 12 by 10 by 10 cm. Its anterior surface is smooth, but pos- teriorly it is covered with a few adhesions. The under cut surface is 3 cm. in diameter. The uterine cavity is 6 cm. in length and 4 cm. in breadth at the fundus. The mucosa is smooth, pale and glisten- ing, but is gathered up into folds, ridges, or polypoid-like masses, in places 8 or 9 mm. thick. Situated in the posterior wall, near the junction of the cervix and the tube, is an interstitial myoma 5 cm. in diameter. Other smaller nodules are found in the fundus, just beneath the peritoneum. Both the anterior and pos- terior walls as well as the fundus are thick- ened to an average of 5 cm. (Fig. 34). This hyper- trophy is most marked near the mucosa. Covering the outer surface of the uterus is a mantle of normal muscle, 1 cm. thick. The thick- DIFFUSE ADENOMYOMA OF THE I l ER1 - 111 ened portion on section shows an unusually coarse arrangement, the fibres forming an irregular meshwork. with here and there a whorl- Adeni imyi una Img. 34. — Discrete myoma of the cervix; diffuse idenomyoma. oi rHEBODYOi imi rERUS. (Natural size. I Gyn.-Path. No. 1122. a represents a small portion of the uterine cavity. Situated ;it the cervix is a discrete myoma. The uterine walls are greatly t hickened as a resull of a diffuse myomatous change. Scattered throughoul this coarse tissue were large and small yellowish, porous areas at once recognized as islands of uterine mucosa. On histological examination the uterine mucosa was seen literally pouring into the diffuse myomatous muscle. Covering the outer surface is a mantle of normal muscle of varying thickness. like arrangement in the interstices. In this m e s h w o r k are c r e a m y 1 o o k i n g a r e a s . e v i d en t 1 y i s 1 a n tl s of mucosa. The line of junction between the mucosa and 112 ADENOMYOMA OF THE UTERUS the muscle is poorly defined and the muscle bundles apparently extend into the mucosa. The right tube is^converted into a pipe-like cyst. The stem itself is about 12 cm. long and varies in diameter from 5 mm. at the cornu to 14 cm. at the occluded fimbriated extremity. The tube is covered with a few adhesions. Its walls are extremely delicate and it contains dark, bluish-black fluid. The ovary is small and is covered with adhesions. Situated in the utero-ovarian ligament is a myoma, 2.5 cm. in diameter. On the left side the tube is 8 cm. long and is covered with adhesions. The ovary is small and is also involved in adhesions. Histological Examination . — The uterine mucosa has an intact surface epithelium, as was noted macroscopically. It is much thicker than usual. The gland elements are perfectly normal. Extending everywhere into the depth are large rivers of mucosa; in fact, the mu- cous membrane in the diffuse myoma of the fundus is more abundant than that lining the uterine cavity. The glands in the depth show a certain amount of dilatation, and many of them contain necrotic material. The isolated myomatous nodule shows considerable hyaline trans- formation. In places this is quite sharply defined and many of the remaining bundles stand out in marked contrast, reminding one at first sight of a malignant change. The right tube is the seat of a hydrosalpinx into which there has been hemorrhage. The ex- tensive invasion of the normal uterine mucosa into the myoma evidently accounts for the alarming hemorrhages that at times took place. We have here a myomatous uterus with discrete myomata and a widely diffuse myoma occupying the fundus. There is no question as to the origin of the glands. Diagnosis . — Multinodular myomatous uterus ; diffuse adeno- myoma of the fundus with the mucosa literally running into the depth. General pelvic adhesions; right hematosalpinx. DIFFUSE ADENOMYOMA OF THE I "I "l-.l.'i - 1 L3 Church Home and Infirmary No. 1019. Path. No. 9407. L a r g c i 11 t e r s 1 i I i a I a n d s u l> m u c o us ni e r i n e in y o m ;i t a s li o w i n g li y a line d e g e o e rat i o d , es- p e c i a 1 1 y p r o n o u n c e <1 in t h e w a lis of i h e I) 1 o o d - vessels. Diffuse a d e n o in y o m ;i in i h e w alls of theuterus, the glands c o m i n g f r o m t h e m u c o b a . W. B., married, aged thirty-nine, white. Admitted January L5, l ( .)()(i; discharged February 12, 1900. Complaint: Persistent hemorrhage from the uterus. The menses commenced at eleven and were normal except that they were rather profuse. The date of i lie last period is uncertain. For the past four months the patient has bled continuously, and the bleeding has been especially profuse during the last month. She has had no pain. She had two mis- carriages thirteen years ago, but has never borne children. On pelvic examination a mass is found extending half-way to the um- bilicus, occupying the entire superior strait of the pelvis. It is rounded in outline and not especially tender. Operation : Abdominal hysterectomy. The highest tem- perature was 100.8° F., twenty-four hours after the operation. Path. X o . 9407 . — The specimen consists of the upper part of the uterus. It is globular and contains a myoma measuring 12 by 10 by 10 cm. The uterine cavity measures 7 cm. in length and 7 cm. in breadth. The mucosa, which is somewhat granular and hemorrhagic, is put on tension by a large submucous myoma. This on section shows some cystic areas and a moderate degree of de- generation. Sections from the endometrium show that the mucosa, apart from some hemorrhage, is perfectly normal. In some places the m u c o u s m e m bra n e c an be s e c n e x t e n d i n g into I h e d e p t li f o r a c o n s i d e r a b 1 e d is t a n c e . and in the vicinity we have isolated glands or bunches of glands surround- ed by stroma, and lying in the depth. The muscle shows a definite myomatous tendency. Sections from the myoma show a good deal of hyaline degeneration, particularly pronounced around the blood- vessels. 8 114 ADEXOMYOMA OF THE UTERUS We have here a large interstitial and partly submucous myoma showing hyaline degeneration, and also a fairly well-defined diffuse adenomyoma of the body of the uterus with the glands originating in the mucosa. Gyn. No. 11,252. Path. No. 7507. Subperitoneal and interstitial uterine my o mat a; diffuse adenomyoma of the uter- ine walls; subperitoneal adenomyoma. F. S., colored, aged forty-four. Admitted May 5, 1904; dis- charged June 2, 1904. Complaint : Pain in the left side. The patient had always had considerable dysmenorrhcea. She had been married twenty-one years, but had never been pregnant. She complained of a burning discomfort during the first two days of menstruation, and for some years had had continued pain in the left ovarian region. She was well nourished. Several small myomata were detected and the uterus was retroflexed and adherent. It was decided to remove the uterus, as the patient was near the menopause and as she had come such a long distance for treatment (Jamaica) . Operation : Hystero-nryomeetomy. The highest tempera- ture was 100.5° F., on the second day. Convalescence normal. Path. X . 7507 . — The uterus has been amputated through the cervix and is 4 cm. in length. On the posterior surface is a pedunculated myoma, 1 cm. in diameter. Just above this is a slight elevation. On section the uterine walls are found to vary from 1.5 to 1.8 cm. in thickness. Scattered throughout the uterine tissue are a few minute myomata. In the anterior wall about its middle is an irregular mass, 1 cm. in diameter. This is not sharply circumscribed, but gradually blends with the surrounding uterine muscle. On histological examination the uterine mucosa shows much thickening. The surface epithelium is intact. The stroma cells immediately beneath are swollen, somewhat resembling decidual cells, and the tissue shows a great deal of small round-cell and poly- morphonuclear infiltration. The glands in the depth show marked DIFFUSE A MYXOMYOMA OF THE UTERUS 115 hypertrophy and t h e r e is a peculiar tendency for t li c m i ii (I i v i (I u ;i 1 I y o r i n l> U n C li e 8 I o e x 1 e ii d <| ii i 1 e ;i (list a n c e into I li e u n d e r 1 y i D g in USCle , u s u a 1 I y a c c <> in p a n i e d b y I li e i r s I r o w a . The myoma in (lie anterior wall is diffuse in character and con- tains islands of uterine mucosn ;iik1 also isolated glands, the majority of which are associated with the characteristic stroma of the mucosa. Some of the "lands, however, lie in direct contact with the muscle. We have here a uterus smaller than normal, one subperitoneal and several interstitial myomata, an endometrium which is thicker than usual and which shows definite invasion into the muscle. We also have a partially subperitoneal adenomyoma which is somewhat diffuse in character and blends with the surrounding muscle. We have not the slightest doubt that such a uterus in time would be the seat of a wide-spread diffuse adenomyoma. H. A. K. Sanitarium No. 1453. Path. No. 6216. Diffuse adenomyoma of the anterior a n d posterior uterine walls (Fig. 35). The gland elements are derived from the uterine mu- cosa. H. C, married, white, aged forty-seven. Admitted October 20, 1902; discharged December 11, 1902. The patient has had four children. Her menses, which were regular, have lately become ir- regular and more frequent. Operation : Pan-hysterectomy; repair of the perineum: removal of a urethral caruncle. The patient made a satisfactory recovery. P a th . X o . 2 1 6 . — The uterus is 13 cm. in length, 1<> cm. in breadth, and 9 cm. in its antero-posterior diameters. Its surface is smooth and glistening, except near the fundus. There are a few adhesions and the tubes and ovaries are bound down. The uterus is about the size of that of a three and a half months' pregnancy. The cervical canal, which is curved, is about 3 cm. in length. T h e increase in size of the uterus is due to a marked 116 ADENOMYOMA OF THE UTERUS diffuse thickening of the anterior wall, which reaches 7 cm. in thickness (Fig. 35) . Scattered throughout the thickened and diffuse m y o - Fig. 35. — Diffuse adexomyo.ma of the body of the uterus. (f natural size.) Gyn.-Path. No. 6216. A longitudinal section through the entire uterus. Sur- rounding the uterine cavity, which looks normal, is a broad zone of diffuse myomatous tissue, much thicker in the anterior than in the posterior wall. Covering this is a mantle of normal muscle, a, but at the fundus the coarse myomatous tissue almost reaches the peritoneum. Sec- tions show that the uterine mucosa extends into the depth and that many islands of mucous membrane are scattered throughout the myomatous tissue. matous tissue are a few cystic spaces lined with a delicate velvety membrane. The posterior uterine wall varies from 2.2 to 2.5 cm. in thickness. Its texture is DIFFUSE A.DENOMYOM A OF Till; [JTERUS 11/ also coarse. but the si rial ion is not as marked as in the anterior wall. Covering the diffuse growth in both the anterior and posterior wall is a mantle of normal uterine muscle. The uterine cavity is small, about 4.5 cm. in length. On histological examination the uterine mucosa is found to be slightly thickened, but otherwise normal. The diffuse thickening in the anterior wall is due to a diffuse myomatous transformation of the muscle. Scattered abundant! y 1 h r o u g h t h e m y o m a t o u s m u s c 1 e are la r g e a n d small i s - 1 a n d s o f uterine m u c o s a . Some of these are fully 8 mm. in length. Here and there the glands are dilated; otherwise this mucosa differs in no way from that lining the uterine cavity, and at many points the uterine mucosa can be traced directly into the myoma. In the posterior wall there is also a diffuse adenomyoma. Here likewise the continuity with the surface mucosa can be traced. In this case there is a diffuse mantle of myomatous tissue sur- rounding the entire uterine cavity, markedly developed in the posterior wall; and penetrating this mantle are large areas of uterine mucosa. Diagnosis. — Diffuse adenomyoma of the anterior and posterior uterine walls. The gland elements are derived from the uterine mucosa. Gyn. No. 12,358. Path. No. 8983. Subperitoneal, interstitial and submu- cous u ferine m y o m a t a ; s 1 i g h t en d ometritis; diffuse a d e n o m y m a w i t h the u t e r i n e g 1 a n d s e x t e n d i n g into the depth; a d e n o m y o m a tons areas in the left uterine h o r n . S. S., aged thirty-one, black, married. Admitted September 11, L905; discharged October 2, 1905. Complaint: A painful lump in the left side of the abdomen and uterine hemorrhages. The menses commenced at thirteen, were always regular but painful, and are now profuse. The flow lasts three days. There is some pain for twelve hours previous to the flow. She has been married twice. 118 ADENOMYOMA OF THE UTERUS She had one pregnancy six or seven years ago, normal until the sixth month, when a premature labor came on as the result of a fall. The child was born dead. Nine months ago patient noticed a lump in the left side, which has been almost constantly painful. She knows nothing about the growth of the tumor. She says that the tumor pushes upward and causes discomfort, which she can relieve by pressing down upon it with her hand. There have been no changes in the menstrual flow until two months ago, when there was increased pain and the flow was excessive, but without clots. One month ago the period did not appear at the expected time, but there was an excessive flow of a clear watery fluid. There has been much tenderness since she first noticed the tumor. No nausea or vomiting. Operation : Hystero-myomectomy ; double salpingectomy, left oophorectomy. The highest post-operative temperature was 101.4° F. Convalescence was uninterrupted. Path. No. 8983 . — The specimen consists of an irregularly globular uterus, 12 cm. from side to side, 12 cm. in length, and 14 cm. in its antero-posterior diameter. Posteriorly it is covered by tags of adhesions, none of which are very dense. In the anterior wall is a myoma 7 cm. in diameter. In the posterior wall is a myoma measuring 8 by 9 cm. Attached to the right side just behind the tube is a nodule 7 cm. in diameter. This is attached by a pedicle, 2 cm. in breadth, 5 mm. in thickness. This myoma on section presents a dark appearance in places and has undergone slight ne- crosis. The left tube is normal. The ovary is covered with a few ad- hesions. The right tube is normal . Sections from the endometrium show that it has been poorly hardened. The glands show a moderate degree of hypertrophy. Here and there they extend for a short distance into the muscle. There is some small round-cell infiltration. Sections from the fundus, which are better preserved, show considerable small round- cell infiltration in the superficial layers, and in the depth far down are here and there glands some of which show the characteristic DIFFUSE ADENOMYOMA OF THE I TER1 - 1 L9 pseudo-glomeruli described byvon Recklinghausen, the spaces being lined with cuboida] epithelium and a projection of stroma into the cavity being noted. This projection also is covered with epithelium, and in the spaces between this and the so-called capsule is desqua- mated epithelium. Near the outer surface the gland-like spaces are nnich more abundant. They are everywhere surrounded by muscle, and some of the larger spaces reach 2 mm. in diameter. They are lined with one layer of cuboidal epithelium which rests directly on the muscle. On further section of the uterine mucosa we find a t e n d e n c y f o r t h e g lands to extend i n t o the d e p t h i n 1 he form of a wedge. Sections taken from near the left cornu show that the tube presents some slight degree of small round- cell infiltration just beneath the epithelium. Surrounding this in many places are glands lined with one layer of epithelium rest in- directly on the muscle, or separated from it by a small amount of stroma. Some of the gland-like spaces are dilated, their epithelium is flattened, and they are filled partly with blood, partly with serum. Diagnosis . — Subperitoneal, interstitial, and submucous myomata ; slight endometritis; diffuse adenomyoma of the uterine wall with invasion of the mucosa into the depth; adenomyomatous areas in the left uterine horn ; slight adhesions of the ovaries. Emergency Hospital, Frederick, Md. Path. No. 8393. Diffuse adenomyoma of the anteri o r a n d posterior uterine walls; 1 a r g e c y s t i C s p a c e s in the uterine h r n d u e to d i 1 a t a t i o n o f por- tions of the a d e n o m y o m a t o u s e 1 e m e n t s Fig. 36) . The g 1 a n d elements in t h e d i f f u s e g r o w t h a i- e c 1 e a r 1 y s h o w n to 1) e d e rival i V e s of t h e u t e r i n e m u c o s a . Y. AY., aged fifty-three. Operated upon February 3, 1905. The patient lias been suffering for some time from a myomatous uterus and has had frequent uterine bleeding. On opening the abdomen we found a myomatous uterus about the size of that of a 120 ADEXOMYOMA OF THE E/TERUS four months' pregnancy. Numerous nodules were present. The cervix was adherent. Posteriorly and on the right side was a hy- drosalpinx. The tumor was removed with little difficulty and the patient made a satisfactory recovery. Path. X o . 8393 . — The specimen consists of a large glob- ular uterus and of the appendages on both sides. The uterus has been amputated through the cervix. It is 12 cm. in length, 15 cm. from side to side, and 10 cm. in its antero-posterior diameters. Covering its surface posteriorly are a few delicate adhesions. On Fig. 36. — Diffuse adenomyoma of the fundus with cystic spaces in the left uterine horn, (i natural size.) Gyn.-Path. Xo. 8393. The entire fundus is converted into a diffuse myomatous tissue and with the low power the uterine mucosa can be seen penetrating the myoma in all directions. The cystic space a, in the left uterine horn is due to gland dilatation, it being lined with cylindrical ciliated epithelium. The space b is filled with blood. On the right side is a tubo-ovarian cyst. The inner pole of the right ovary is normal. examination it is found that the thickening in the uterus is due to a diffuse myomatous ar- rangement around the uterine cavity (Fig. 36) . The thickening in both the anterior and the posterior wall reaches 5 cm. There is likewise a tendency toward a circumscribed diffuse area 2.5 cm. in diameter. The uterine mucosa is apparently consid- erably thickened. The general picture instantly reminds one of a diffuse adenomyoma occupying both the anterior and the posterior wall and encircling' the fundus. DIFFUSE ADENOMYOMA OF THE UTERUS L21 In the Left uterine eornu is an irregular cystic space, (> by 1 cm. This is partially divided by septa and has delicate trabecular passing from side to side. The cysl walls in the outer portion vary from 1 to 3 nun. in thickness. The riuht tube has been converted into a hydrosalpinx, which at its outer end is ( .) cm. in diameter. The ri-ht ovary is apparently Qormal. The left tube is enveloped in delicate adhesions. Its fimbriated end is patent. The ovary is very small and apparently contains a corpus luteum cyst 1 cm. in diameter. In the lower portion of the uterus is a myomatous whorl 2 cm. in diameter, and near the centre of this is a cystic area 8 mm. in diameter filled with yellowish contents. Sections from the body of the uterus show that the uterine mucosa has not been well preserved owing to faulty hardening. It can at several points be traced d i r e c 1 1 y into the depth for a considerable distance. Scattered abundantly throughout the diffuse myomatous growth, in the anterior as well as in the posterior wall, are islands of uterine mucosa, sometimes also an individual gland surrounded by stroma, and then again an area of mucosa containing imperfectly preserved glands. The same picture is noted no matter where the section comes from. Where the diffuse myomatous growth ends the glands also end. Sections from the cyst in the left eornu show that it is lined with one layer of ciliated epithelium. The myomatous nodule with the cystic centre, containing yellowish material, presents a very in- teresting picture. The nodule consists of typical myomatous tissue. The cystic space is filled with coagulated contents, fragments of nuclei, and a few polymorphonuclear leucocytes, and the walls of this cavity, partly organized, contain numerous small round cells. This has evidently been a portion of a miniature uterine cavity from which the epithelium has disappeared and a partially organized blood-clot has taken its place. Diagnosis. — Diffuse adenomyoma of the anterior and posterior uterine walls; large cystic spaces in the left uterine horn, evidently due to dilatation of portions of the adenomyomatous 122 ADENOMYOMA OF THE UTERUS elements. The gland elements in the diffuse growth are clearly shown to be derivatives of the uterine mucosa. H. A. K. Sanitarium No. 19 13. Path. No. 8641. Subperitoneal and interstitial uteri ne myomata; commencing diffuse adenomyoma of the uterine walls; normal appendages. McC, white, aged fifty-two, married. Admitted April 27, 1905; discharged June 9, 1905. In 1885 the patient had pulmonary tuberculosis, a left pyelonephritis, and an infected bladder. Present condition: The periods are regular but profuse. The patient has had a tumor which has been increasing in size for some time. Operation : Hystero-myomectomy and appendectomy. The patient was of a very nervous temperament, but made a satis- factory recovery. Path. No. 8641 . — The specimen consists of a myomatous uterus which would be practically normal in shape were it not for a subperitoneal nodule projecting far out from the left side. The uterus with the nodule is 9 cm. in length, 8 cm. in breadth, and 1 1 cm. in its antero-posterior diameter. It is smooth and glistening. Projecting from the posterior surface just behind the insertion of the left tube is a nryomatous nodule approximately 7 cm. in diameter. The uterus on section is found to be riddled with myomata. In the upper part the nodule is 3 cm. in diameter. The uterine cavity is 5 cm. in length and the mucosa 2 mm. in thickness. The appendages on both sides are normal. Sections from the mucosa show that the surface epithelium is intact. The glands are normal. There is a tendency for the glands to dip down into the depth, and here and there it is possible to trace them for a considerable distance. Undoubtedly we have here a commencing adenomyoma. Diagnosis . — Subperitoneal and interstitial uterine my- omata; commencing diffuse adenomyoma. DIFFUSE A.DENOMYOMA OF THE UTERI - L23 H. A. K. Sanitarium No. 1944. Path. No. 8807. M u 1 1 i p 1 e uteri d e m y m a t a . s u b p eril n e a 1 . interstitial, a 11 d s u b m u c ous; dif f u s e a d e □ - 111 y m a < u s 1 h i c k e n i n g in 1 h e a t eri r a d d posterior uteri n e W alls \v i t h d i r e C t ex 1 e D - e i d f t h e u t e r i n e m u c s a into t h e d e p t h , t g ether with t h e f r m a t ion f a in iniatu r e u t e r i n e c a v i t y . A. C, married, aged forty-eight. Admitted May 17, 1905. Discharged June 21, 1905. The patient has been married twenty- two years, has had three children and one miscarriage three years ago. The menses are normal. There has been some watery leu- corrhceal discharge. The patient is very frail and has lost somewhal in weight. Her haemoglobin is 40 per cent. She has had chronic constipation. Pier family and previous history are not important. For about a year she has noticed that her abdomen has been growing rapidly and she has had constant backache. She suffers from fre- quent vesical irritation and obstinate constipation. Operation, May 18. Hystero-salpingo-oophorectomy. After the operation this patient had a slight infection about the cervix which caused some elevation in temperature — 100.4° F. on one occasion. The temperature gradually subsided. Path. N o . 8807 . — The specimen consists of a nodular myomatous uterus with appendages. The uterus is approximately 12 cm. in length, 12 cm. in breadth, and S cm. in its antero-posterior diameters. It is for the most part smooth and glistening. Pro- jecting from the surface are pedunculated and sessile myomata, and scattered throughout the walls are a few other nodules. Projecting from the right side and extending out into the broad ligament is an irregular, nodular, myomatous growth, which measures 15 by 18 by 14 cm. This is partly covered by peritoneum, but beneath the smooth surface is a good deal of adipose tissue, evidently from the broad ligament, and coursing over the anterior surface is the right round ligament, which can be traced for a distance of 12 cm. Very little of the uterine cavity is to be seen except in the upper portion. 124 ADENOMYOMA OF THE UTERUS The uterine mucosa varies from 2 to 3 mm. in thickness. Three mm. beneath the mucosa is a miniature uterine cavity, 4 mm. in diameter, filled with coagulated chocolate-colored fluid, and lined with a mucosa 1 mm. in thickness. Just beneath the peritoneal surface of the uterus are a few cyst-like spaces, the largest 2 mm. in diameter. The tubes and ovaries look normal. Sections from the fundus show a most instructive picture. The surface epithelium is intact. The glands are to a great extent normal, but some are much dilated, others skein-like. The mu- cosa is flowing down everywhere into the underlying tissue. In some places it can be traced by direct continuity for 6 or 7 mm. The mucosa that flows into the depth is perfectly normal except for here and there some gland dilatation. On the opposite side of the cavity we are able to trace the mucous membrane for 1 cm. into the underlying myomatous muscle. Here and there a small band of mucosa will pass down and then branch out in all directions. The brownish area apparently surrounded by a definite mucosa and noted macroscopic- ally is a miniature uterine cavity. This cavity is filled with blood and is lined with one layer of high cylindrical epithelium. Opening into it are numerous glands surrounded by the characteristic stroma of the mucosa. Diagnosis . — Multiple uterine myomata, subperitoneal, interstitial, and submucous; diffuse adenomyoma of both the anterior and posterior walls, the gland elements being distinctly derivatives of the uterine mucosa. The presence of adenomyoma was immediately suspected as soon as the chocolate-colored area surrounded by a definite lining of mucosa was detected. As a rule, no other condition in the uterus would give rise to such a picture. CHAPTER V SUBPERITONEAL AND INTRALIGAMENTARY ADENOMYOMATA Subperitoneal and intrali^amentary adenomyomata arc con- sidered together, inasmuch as the process is similar in both instances, namely, the extension to the outer surface of the uterus. If situated above the middle of the uterus, the adenomyomata tend to become subperitoneal; below this point and lateral to the uterus they are likely to spread out between the folds of the broad ligament. SUBPERITONEAL ADENOMYOMATA Subperitoneal adenomyomata may be very small and com- pletely isolated, as seen in Fi<>;. 61, p. 219, 1 in which an adenomyoma less than 1 cm. in diameter was found in a patient operated upon for adenocarcinoma of the body of the uterus. The two processes were entirely independent of each other. This small nodule, to the unaided eye, differed in no way from an ordinary myomatous nodule. Subperitoneal adenomyomata may, on the other hand, be of goodly size. Fi"-. 37 represents a subperitoneal nodule measuring 13 by 10 by 8 cm. and attached by a broad base. As seen from the drawing, it was partly cystic, partly solid. The distal or free portion had been converted into a thin-walled and irregular cysl partially filled with blood. The solid portion consisted of myomatous tissue traversed by several small cysts, some not more than 1 mm. in diameter, others are more than 1 cm. On histological examinatioD the large cyst was found to be in the vicinity of the solid area, lined with one layer of cylindrical epithelium; bu1 where the walls were 1 very tense and thin, the epithelium had become very low or had entirely disappeared. In Fig. 38, a low magnification, it is seen that the cystic spaces scattered throughout the solid portion are l Cullen, Thomas S.: Cancer of the Uterus, L900, p. 460. 1 25 126 ADEXOMYOMA OF THE UTERUS dilated glands lined with one layer of cylindrical epithelium. Some of these are separated from the muscle by the typical stroma. In neither of the foregoing cases was there any evidence of adeno- myomata in the body of the uterus. In Case 3293 we have another example of a cystic subperitoneal adenomyoma. As noted in the history, the uterus was greatly in- creased in size, chiefly owing to the presence of a large submucous myoma and a huge subperitoneal and pedunculated myoma spring- ing from the left side. Projecting from the right side of the fundus was a nodule measuring 6 by 5.5 by 5 cm. This was soft and boggy, and over an area fully 5 cm. in diameter was made up of thin-walled cysts (Fig. 39;. On histological examination the cyst walls were found to consist of myomatous tissue and the cavities were lined with one layer of cylindrical, ciliated epithelium (Fig. 40). The cells closely resembled those of the normal uterine mucosa. In some places the walls of the cavity were gathered up into little papillary -like folds. In other places, irregular gland-like cavities were found scattered throughout the walls. These closely resembled the gland hypertrophy so often seen in the uterine mucosa. In. a few places the walls of the cysts showed evidence of old hemorrhages, their cells having taken up large quantities of fine yellow granular pigment. Here also we have a subperitoneal adenomyoma with elements closely resembling uterine mucosa. San. Xo. 1872 is the most striking example of a subperitoneal myoma that we have ever seen. Fig. 41, p. 142, gives the relative contour of the uterus. It was the seat of a diffuse adenomyoma. At a is a subperitoneal and pedunculated myoma which is partly cystic. On section of this subperitoneal nodule we found large islands of mucosa, and the cystic areas formed miniature uterine cavities filled with chocolate-colored contents. The islands of mucosa and also the cystic spaces are depicted in Fig. 42, p. 144. Of interest is the case of Xeumann. 1 In a woman forty-four 1 Neumann, Siegfried: Ueber einen neuen Fall von Adenomyom des Uterus und der Tuben mit gleiehzeitiger Anwesenheit von Urnierenkeimen im Eierstock. Arch. f. Gynaek., 1899, Bd. lviii, S. 593. SUBPERITONEAL AM) [NTRALIGAMENTARl U5ENOMYOMATA 127 years of age he found an intersl i< i;il myoma, the size of a fist, and on the anterior surface of the uterus in the vicinity of the cervix a subserous myoma, I lie size of a walnut. Lying in dose proximity to this was a cyst as large as a hen's egg. This had a broad base. The walls of the cyst were composed of uterine muscle, near the base having a thickness of 3 mm., but becoming thinner until at the con- vex and free surface they were not thicker than parchment. The inner surface of the cyst was smooth and the cavity contained a coagulated, friable, grayish mass. In the vicinity of these cysts were two others, the size of hazelnuts and with very thin walls. Situated in the tissue, at the base of these two, was still another cyst about as large as a bean. This was subdivided into several smaller cavities. The large cyst had a wall composed of muscular tissue and was lined with a single layer of cylindrical ciliated epithe- lium. This rested on a connective-tissue stroma, which separated it from the muscle. Scattered throughout the myomatous muscle were glands bearing a marked resemblance to uterine glands and surrounded by stroma similar to that of the uterine mucosa. Neu- mann says that this was undoubtedly a large adenomyoma of the uterus, cystic in character. There was also an adenomyomatous polyp in the uterine cavity and another adenomyoma in one of the uterine horns. He was unable to trace any connection between the uterine mucosa and the adenomvomata. Among the most remarkable subperitoneal adenomvomata of the uterus ever reported w T as the "voluminous" tumor of Pick. 1 which occurred in a woman forty-one years old, sprang from the posterior surface of the uterus, and was adherent to the anterior abdominal wall and to the intestinal loops. Landau experienced much difficulty in its removal. The tumor, as shown in the illustra- tion which Professor Pick kindly sent me, presented a very coarse shaggy appearance. It consisted of many large, blunt, papillary masses, and in the vicinity of the median line tin 1 mass contained a glistening, slimy, cystic tumor, about the size of a man's head. It 1 Tick, Ludwig: Ein neuer Typus des voluminoseD paroophoralen Adenomy- oms. Arch. t'. Gynaek.. Bd. liv. S. 117. 128 ADENOMYOMA OF THE UTERUS was everywhere adherent. The cyst cavity contained clear muco- colloid material. On the surface of the growth were many isolated nodules consisting of myomatous tissue and containing large and small spaces. Pick found that the solid portions of the tumor con- sisted of a fibromyomatous substance surrounding well-formed glandular tissue. This glandular tissue consisted of cylindrical glands lined with a single layer of cylindrical epithelium. Sometimes the glands occurred in groups and were surrounded by a definite stroma; others showed cystic dilatation. From the description it is seen that this tumor was a subperitoneal and adherent adeno- mvoma. Cases of Subperitoneal Adenomyoma Gyn. No. 8647. Path. No. 4838. Diffuse adenomyomatous thickening of the uterine walls; interstitial and subperi- toneal myomata; slight edema of the uter- ine mucosa with extension of the gl ands into the depth. Subperitoneal, cystic adeno- myoma. (Figs. 37 and 38.) F. M. R., single, aged forty, white. Admitted April 8, discharged May 2, 1901. The patient was operated upon for hemorrhoids two years ago. Her menses began at twelve and were regular, lasting- three days. For several years at the menstrual period the patient has complained of headache and nausea. There has been no marked disturbance of menstruation at any time, but occasionally the period has been delayed a few days. The last period occurred one week ago. The patient does not know when she first noticed a lump in the right side of the abdomen. In the beginning it was about the size of an egg, but for the last year has been increasing. There has been no pain or discomfort associated with it. The general condition has been good. In the right lower abdomen is a definite prominence. This is firm on palpation, distinctly movable, and reaches to a point 2 cm. SUBPERITONEAL AND [NTRALIGAMENTAR1 ADENOMYOMATA L29 below the umbilicus. It is smooth and oblong in shape The in- guinal glands are palpable, bul nol tender. Operation April loth. A large multinodular myomatous litems was exposed. The uterus was bisected and removed. The tubes we're likewise removed, but the ovaries were left in -situ. The patient was discharged in excellent condition on the twenty-third day. Gyn.-Path. N o . 4 8 3 8 . — The specimen consists of a bisected, multinodular uterus and of both tubes. One nodule, which projected from the right cornu and was attached by a pedicle, 4 cm. in diameter, measures 13 by 10 by S cm. Its inner half is firm and dense; its outer portion is soft and cystic, but everywhere covered with smooth peritoneum (Fig - . 37). On section the solid por- tion of this nodule is seen to be made up of typical myomatous tissue, but at two points are seen irregular cystic areas 1 and 2 cm. in diameter respectively. The smaller of these has a smooth inner surface and apparently a definite lining. The large cystic portion of the subperitoneal myoma contains a single cavity, approximately 7 cm. in diameter. The walls of this vary from 1 mm. to 1 cm. in thickness; the cavity contains a thick, viscid, chocolate-colored substance. The uterus is very irregular in form and has project ing from its surface numerous small myomatous nodules. It measures 8 by 8 by 5 cm. The tubes are apparently normal, but attached to the fimbriated extremity of one of them is a subperitoneal cysl meas- uring 1.5 by 1 cm. Histological E x a m i n a t i o n . — Sections from the uterine cavity show that, where the mucosa has been protected, there is an intact surface epithelium, slightly flattened but perfectly normal. The uterine glands are normal in number. Near the cavity they are narrow, but in the vicinity of the muscle are much convo- luted. The gland epithelium is normal. The stroma of the mucosa just beneath the surface 1 epithelium shows considerable edema. At one point in the uterine eavii y t h e m u c o sa is seen penetrating the m u s c 1 e to a d e p t h of 1 . 5 m m . Here the glands are dilated and surrounded by diffuse 9 130 ADENOMYOMA OF THE UTERUS myomatous tissue. The uterine walls show partial myomatous transformation of their muscle bundles, and scattered throughout the walls are numerous small myomata. Some of these are not more than 1 mm. in diameter. Fig. 37. — A cystic subperitoneal adenomtoma of the uterus. (Natural size.) Gyn.-Path. No. 48 3 8. The drawing represents one-half of the tumor, which was attached to the enlarged fundus by the very short broad-based pedicle situated in the vicinity of d. The tumor is roughly divided into a semi-solid and a cystic portion. The cyst is irregular in out- line and, as seen in Fig. 38, at a it connects with little bays extending off into the solid portion. In some places the cyst wall is very thin, as at a. The ragged appearance in the interior of the cyst and the smooth homogeneous substance just within the cyst wall are due to coagulated cyst con- tents. The inner surface of the cyst is in reality smooth and velvety. The solid portion of the tumor is composed of a diffuse myoma. Scattered throughout it are large and small cyst-like spaces, b is such a cavity. It is, however, irregular in form and branches out considerably. It has a smooth inner lining. In the space c the coagulated contents still remain. There are also numerous smaller spaces scattered throughout the myomatous tissue. These spaces, on careful study, do not convey the idea of cysts, but it seems as though the muscle were being tunnelled in various directions by spaces of variable size. For the very low magnification see Fig. 38. Sections from the large subperitoneal myoma show a very in- teresting picture. This nodule consists essentially of myomatous tissue, but here and there bundles of normal muscle still remain (Fig. 38). The small cyst-like spaces noted in the solid portion of the tumor have an inner lining of a single layer of cylindrical and SUBPERITONEAL WD [NTRALIGAMENTARI ADENOMYOMATA 131 apparently ciliated epithelium. This is in mosl places separated from the surrounding myomatous tissue by a stroma somewhal resembling thai of the uterine mucosa; and scattered throughout the stroma are occasional small glands identical with those of the uterine mucosa. At some points in these cysts the epithelial lining Fig. 38. — A cystic subperitoneal adenomyoma of the uterus, i 1 \ Datura] size. Gyn.-Path. No. 4 8 3 8 . The sect ion is through the same tumor as Fig. 37, bul a< another level. A is the same large cyst cavity. It has a small bay (a) extending off to the left. It is lined with a single layer of epithelium, which from the text is seen to lie cylindrical. Jusl beneath the epithelial lining a1 6 is a small gland : c represents the coagulated cysl content-. /•' and C are irregular cyst-like spaces lined with one layer of epithelium. In the aeighborhood of d are numerous small glands, also lined with cylindrical epithelium. Some of t he glands, notably al - . are surrounded by a definite circular zone of myomatous muscle. The deeply staining area-, as seen at <■', are the myomatous muscle bundles. The intervening pale framework i- a somewhal rarefied connective tissue. We should not be much surprised if at one time all the large cysl cavities communicated with one another. has disappeared and the underlying tissue shows distinct evidences of old hemorrhage. These cyst-like spaces contain a variable quan- tity of Mood. Scattered throughout the solid portion of this sub- peritoneal nodule are numerous smaller cysts varying from 1 to 3 mm. in diameter. These are lined with one layer of cylindrical epithe- 132 ADEXOMYOMA OF THE UTERUS Hum and are separated from the muscle by a definite stroma, They contain a good deal of blood. One of these cysts may be roughly likened to a cross-section of a miniature uterine cavity, as it is partially surrounded by glands similar to those of the uterine mucosa. Scattered here and there throughout the myoma are similar glands, the majority lying in direct contact Math the uterine muscle and not being surrounded by stroma. It is particularly interesting to note that the myomatous tissue is most dense immediately around the cyst-like spaces. The large cystic portion of the subperitoneal myoma consists essentially of one cavity. Near the solid portion, where there has not been much opportunity for stretching, this cyst is lined with one layer of fairly well preserved cylindrical and apparently ciliated epithelium. Sometimes this epithelium rests directlv on the muscle, but in many places is separated from it by stroma similar to that of the mucosa; in this stroma the blood- vessels are often greatly dilated. As we gradually approach the more prominent portion of the cyst, where the walls are very thin, the epithelial lining becomes thinner and thinner and entirely dis- appears. Clinging to the inner surface here is fibrin, holding in its meshes a variable quantity of blood. As is clearly evident from the description, this is a subperitoneal adenomyoma which has become cystic. Although we have cut many sections, it has been impossible to trace a direct connection between the uterine mucosa and the glands of the subperitoneal adenomyoma, Nevertheless, we have seen that the uterus shows a diffuse myomatous transformation and that the uterine glands, at one point at least, are commencing to extend into the depth. Diagnosis . — Diffuse myomatous thickening of the uterine walls; interstitial and subperitoneal myomata; slight edema of the uterine mucosa with commencing extension of the glands into the depth; subperitoneal cystic adenomyoma, Gyn. No. 3293. Path. No. 583. Subperitoneal, interstitial, and sub- mucous myomata. Multiple cysts in a sub- SUBPERITONEAL AM) [NTRALIGAMENTARY \ DENOM V »M \'l A L33 peritoneal myoma (Figs. 39 and in. Atrophy and edema of the uterine mucosa. Double pe r i- s al pi n g it is and p e r i o 6 p h. or i t is . 11 y s t er e c - 1 o m y . R e c o v e r y . P. S., single, aged forty, colored. Admitted January 23, L895; discharged February 24, 1895. One child, twenty years ago; no miscarriages. The menses appeared at fifteen; they were regular but painful. Since the onset of the present trouble they have been much more profuse, lasting three days and accompanied by intense pain. The patient has had a thin bloody, offensive, leucorrhoeal discharge, containing shreds for two weeks after each menstrual period, then giving place to a white, offensive discharge lasting until the next period. Ten years ago she noticed a small lump in the abdomen, more prominent during menstruation. The tumor has grown steadily and now practically fills up the abdomen; there has been some dull pain over the region of the mass (following an accidental blow thereon), the pain being more severe at menstrual periods. Examinatio n . — The abdomen is much distended by a hard. sensitive, irregular mass. The cervix is pushed against the sym- physis; the whole vaginal vault is filled with a hard immovable mass. per a t ion. January 30, 1895. Panhystero-myomectomy. General peritoneal adhesions, three large subserous myomata; sub- mucous myoma; involvement of posterior lip of cervix necessitating panhysterectomy. Recovery. Gyn.-Path. No. 5 8 3 .—The specimen consists of a large irregularly shaped uterus, with tumors springing from both sides. The portion of the uterus present is approximately 14 cm. long, 14 cm. broad, and 15 cm. in its antero-posterior diameter. The anterior surface is roughened and anteriorly and posteriorly it is covered with many dense adhesions. Springing from the an- terior and posterior surfaces are somewhat flattened nodules, vary- ing from 1 to 4 cm. in diameter. The under cut surface of the uterus is 9 cm. in diameter and the cervical canal, which is completely 134 ADENOMYOMA OF THE UTERUS blocked by a reddish injected mass, is 5.5 cm. from side to side. The uterine walls average 3 cm. in thickness. Their muscle fibres are Fig. 39. — A subperitoneal cystic adenomyoma occurring in the case of a large myo- matous uterus. (| natural size.) Gyn.-Path. No. 583. The uterus is much enlarged, owing to the presence of myo- matous tumors. Projecting through the cervix is a small portion of a submucous myoma and situated anteriorly and to the left are the large myomata a and b, only dimly outlined. The right tube, although lengthened, is little altered. It is attached to the ovary by a few bands. Scattered over the posterior surface of the uterus are several sessile nodules and one of moderate size with several cysts springing from its surface, c is a single cyst and at d a group of seven are seen. All are thin- walled and semi-translucent. As learned from the text, they are not subperitoneal cysts, their walls being composed of myomatous tissue, and furthermore they are lined with a single layer of cylindrical epithelium. For the histological picture see Fig. 40, which is taken from the area d. SUBPERITONEAL A.ND [NTRALIGAMENTAR1 ADENOMYOMATA L35 much coarser than usual, and scattered here and there throughout the walls are whitish nodules varying from .5 to 2.5 cm. in diameter. 'The port ion of the uterine cavity present is L2 cm. in length, and springing into it are several nodules, the largest reaching 2.5 cm.in diameter. The uterine mucosa is pinkish-white in color and aver 1 .5 mm. in thickness. ( )ver the large nodule it is somewhat atrophic. Projecting into the cavity from the left side is an irregular, globular, pear-shaped mass measuring 16 by 10 by 10 cm. It is the lower portion of this that projects through the cervix. This nodule pres- ents depressions corresponding to the small submucous nodules. It is covered with mucosa which is apparently very edematous. The mucosa averages 1 mm. in thickness, but where edematous is fully 4 or 5 mm. thick. Springing from the right side of the uterus is a nodule, 6 by 5.5 by 5 cm. This is covered with adhesions, and has springing from it numerous subperitoneal cysts forming a mass fully 5 cm. in size. The tumor is soft and boggy. Projecting from the left side of the body of the uterus are two kidney-shaped masses. The larger measures 22 by 13 by 11 cm., is pinkish in color, slightly lobulated, and is covered with numerous adhesions binding it to the uterus and the adjoining tumor. The adhesions are very vascular. The smaller tumor measures 12 by 7 by S cm. and closely resembles its neighbor. The uterine tumors on section are pinkish-white in color and for the most part consist of fibres, having a concentric arrangement. The large tumor to the right of the uterus contains areas, fully 2.5 cm. in diameter, consisting of a fine network of fibres traversing a cavity filled with clear transparent fluid. Numerous smaller but similar areas are scattered throughout the tumor. They are undoubtedly areas of degeneration. The small kidney-shaped nodule springing from the fundus presents numerous small, yellow- ish-white, granular areas foci of calcification. The small and soft nodule to the right of the uterus shows some degeneration. This nodule on section is found to be partially cystic over an area 5.5 cm. (Fig. 39). These cysts in the hardened specimen vary from the size of a pea to ;>.5 cm. in diameter; they have exceedingly thin walls, smooth inner surfaces, and at once suggest a multilocular ovarian 136 ADENOMYOMA OF THE UTERUS cyst. There are numerous similar areas scattered throughout the tumor. There is absolutely no connection between the ovary and this tumor, as the latter is situated 8 cm. from the ovary. The tubes and ovaries are enveloped in dense adhesions. Histological Examination . — The uterine mucosa is much atrophied, but near the fundus, where it is somewhat pro- tected, it reaches 3 mm. in thickness. The surface presents an intact epithelium. The glands are in places abundant, in other parts Fig. 40. — Cystic subperitoneal adenomtoma of the uterus. (6 diameters.) Gyn.-Path. No. .58 3. The section is from point d, Fig. 39. a is the solid myoma- tous portion of the tumor; b is the thin myomatous layer forming the outer walls of the cysts c and d. The outer peritoneal covering is represented by b' . The cyst spaces, c and d, have convoluted inner surfaces and at many points (e) there are gland-like depressions. The cysts and also the depressions are lined with a single layer of cylindrical ciliated epithelium. Situated in the myo- matous tissue at / and / are two gland-like spaces which bear a most striking resemblance to hyper- trophic uterine glands, g is the edge of a neighboring cyst. scanty. Some are small and round on cross-section, others are slightly dilated, but all have an intact epithelium. The stroma of the mucosa is of a moderate density and is composed of cells having oval or elongate-oval nuclei. Over the small submucous nodule at the fundus the mucosa has almost entirely disappeared. The surface is here covered with epithelium which in some places is cylindrical, in other places almost flat, while at some points it is two or three layers in thickness, is swollen, and resembles squamous epithelium. Beneath the surface epithelium are a few stroma cells and beneath SUBPERITONEAL AM) [NTRALIGAMENTAR1 A DENOM V >M AT A i£t these. -ire Qumerous small round cells. The glands al this point have entirely disappeared. The mucosa over the Large submucous nodule in the most prominent portions is represented by one layer of epithe- lium, which is poorly defined, being almost flat. Beneath this is a small amount of stroma, hut all of the glands have disappeared. Where the mucosa looked edematous the epithelium covering the surface is intact, but rests directly on the muscle, there being no intervening stroma. The muscle has undergone partial or complete hyaline degeneration and has in many places practically disappeared, leaving a colorless tissue, scattered throughout which are a few small round cells, red blood-corpuscles, and polymorphonuclear leucocytes. The portions that have not yet broken down show numerous cells which have taken up golden-yellow pigment. Taken as a whole, the mucosa, where present, is normal, but where subjected to pressure has undergone partial or almost complete atrophy. In some places it shows considerable edema. The nodules scattered throughout the uterus or situated on its outer surface are composed of non-striped muscle fibres which have been cut in various directions. They all show a moderate amount of localized or diffuse hyaline degeneration. The cystic portion of the nodule situated to the right of the uterus presents a very unusual picture. The cyst walls are composed of tissue that cannot be distinguished from the muscle fibres of the part and the cyst cavities are lined with a single layer of cylindrical epithelium (Fig. 40). The nuclei of the epithelial cells are oval or almost round and are situated near the centres of the cells. These cells are ciliated and closely resemble the epithelium covering the surface of the uterine mucosa. In some places the walls of the cavity are gathered up into little papillary-like folds; in other places ir- regular, convoluted, gland-like cavities are found scattered through- out the walls. These are very strongly suggest ive o'l gland hyper- trophy as seen in the uterine mucosa. In a few places the walls of these cysts show evidence of hemorrhage, their cells having taken up large quantities of hue yellow granular pigment. These glands and cvsts occurring in the myoma are evidently due to embryonic 138 ADENOMYOMA OF THE UTERUS displacements. I am inclined to think that they have been derived from Mliller's duct: (1) because the epithelium bears such a striking- likeness to that of the uterine mucosa; and (2) because of the pig- ment in the cyst wall. If these cysts are derivatives of Mliller's duct, we should naturally expect them to take part in the menstrual flow. The blood resulting cannot escape and must needs be taken up by the cyst walls. This will account for the pigment. The ap- pendages are covered with numerous adhesions, but are otherwise normal. Diagnosis . — Subperitoneal, interstitial, and submucous myomata. Multiple cysts in a subperitoneal myoma, these cysts probably being due to remains of Mliller's duct. Atrophy and edema of the uterine mucosa. Double perisalpingitis and peri- oophoritis. Gyn. No. 9024. Path. No. 5187. Subperitoneal and partly interstitial a d e - nomyoma removed by excision through the abdomen. L. C, married, aged thirty-eight. Admitted August 30, .1901; discharged September 2, 1901. The patient entered complaining of constant uterine hemorrhage. Her periods have never been regular. Since she had typhoid when twenty years of age, the duration of the flow has been increased and the intervals have been gradually growing shorter. In July of this year (1901) she was ad- mitted to the hospital, and previous to this had had constant bleed- ing for nine weeks, with considerable dysmenorrhea. Shortly after admission to the hospital she was curetted. Three weeks after leaving the hospital she had another period, and bleeding has con- tinued ever since, becoming more and more profuse and occasionally being clotted. The patient has pain in her back and lower abdomen. Operation . — Abdominal myomectomy, hysterotomy, curet- tage and suspension of the uterus. Two small nodules were found in the posterior surface of the uterus. These were removed. The uterus was then split, the cavity exposed, and the mucous mem- SUBPERITONEAL WD [NTRALIGAMENTAIH ADENOMYOMATA L39 brane found to be apparently normal. The cervix was dilated from above. The uterus was then suspended in the usual way. The patienl made a satisfactory recovery. Path. No. 5187. The specimen consists of a small amount of curettings and of a piece of tissue 1.8 cm. in diameter. The surface of this tissue presents a smooth peritoneal covering. Beneath this is a dense nodular myoma, 5 mm. in diameter. In the centre of this nodule is a cavity, 2 by 1 mm., lined with a very thin smooth membrane. Sections show the tumor to be a typical myomatous growth, and scattered throughout it are several cysts lined with a definite mucosa. The epithelium lining the cavity is of the cy- lindrical variety. The underlying stroma is similar to that of the uterine mucosa. The growth is a typical adenomyoma. Of course, it is impossible for us to trace any relationship with the uter- ine mucosa, as the uterus was not removed. Gyn. No. 9637. Path. No. 5840. A d e n o m y o m a a p p a r e n t 1 y subperitoneal : remove d t h r o u g h the a b d o m e n . I. D., colored, married, aged nineteen. Complaint: Cramps in the lower left side of the abdomen. Her menses were normal up to a year ago. Since then there has been cramp-like pain in the lower abdomen. She has had one child and one miscarriage. Her periods now last longer than formerly. Operation : Abdominal myomectomy. The patient made a satisfactory recovery and was discharged on the twentieth day. Path. No. 5840 . — The specimen consists of a mutilated myoma which is oval in shape and approximately 2.5 cm. in diameter. On h i s t o 1 g i c a 1 e x a m i n a t i n this presents the typical myomatous appearance, and scattered throughout it are areas which resemble uterine mucosa. It is a clear case of adenomyoma. apparently subperitoneal. D i a g n o sis . — Adenomyoma, apparently subperitoneal. 140 ADENOMYOMA OF THE UTERUS Gyn. No. 12,585. Path. No. 9336. Gland hypertrophy. Small uterine myo- mata. Adenomyoma, apparently subperito- neal, 4 mm. in diameter. K. H., married, aged thirty-five, white. Admitted December 28, 1905; discharged January 17, 1906. Complaint: Pain in the lower abdomen; a leucorrhceal discharge and a bearing-down sensation in the pelvis. The menses began at twelve and were regular every twenty-eight days. The flow was rather scanty and occasionally clotted. The last period occurred three weeks ago. The patient has been married four years but has had no children. She is some- what emaciated; the mucous membranes are rather pale. Operation : Dilatation and curettage. Abdominal my- omectomy, resection of right ovary. Several small myomata were removed from the uterus. The patient made a very satisfactory recovery. The highest post-operative temperature was 100° F. Path. No. 9336 . — The specimen consists of a moderate amount of curettings and of two nodules from the right ovary and two myomata from the uterus. On histological examination we find gland hyper- trophy, a corpus luteum, and two small myomata. One myoma presents the usual appearance and shows hyaline transformation. A note was made that macroscopically one of these small nodules from the uterus looked like a little black vesicle and somewhat resembled a thrombosed vein. It is a myoma containing small cystic spaces. The cystic spaces are lined with one layer of epithe- lium and are filled with blood. In the immediate vicinity are several small gland-like spaces and some stroma. The growth is a typical adenomyoma. It is not over 4 mm. in diameter. Diagnosis . — Gland hypertrophy ; discrete uterine myo- mata and discrete adenomyoma. H. A. K. Sanitarium No. 1872. Path. No. 8433. Uterine myomata, subperitoneal and in- terstitial nodules, adenomyoma of the uter- SUBPERITONEAL A.ND ENTRALIGAMENTARY ADENOMYOMATA 111 in e walls; discrete adenomyoma of the utero- ovarian Ligament, showing Large islands of in u c o s a , t y p i c a 1 m i n i a t u r e u I e r i n e c ;i v i I i e e < Figs. 11 and 42). I)., white, married, aged fifty-one. Admit led March 22, L905. Died April 1"), 1905. Patient has always been a frail woman. Since the menopause there has been a slight vaginal discharge. She has been aw T are of the presence of an abdominal tumor for the pasl six months. There has been a great deal of pain and a feeling of weigb.1 in the abdomen. She apparently had an attack of pelvic peritonitis in January. Her haemoglobin is 50 per cent. Operatio n . — Hystero-myomeetomy, repair of the perineum. The patient after operation was exceedingly nervous and had a great deal of pain. On the fourth day she was as bright as usual, when she suddenly began to scream and became unconscious and died in a very short time. Embolism was thought to have been the cause of death. Her highest post-operative temperature was 100° F. Path. No. 8433 . — The specimen consists of a multi- nodular myomatous uterus which has been amputated through the cervix. It is 14 cm. in length, 13 cm. from side to side, and perfectly smooth. The nodules seen on the outer surface vary from 2 to 9 cm. in diameter. The right tube and ovary are normal. The left tube presents the usual appearance. The left ovary contains what ap- pears to be a corpus-luteum cyst, 3 cm. in diameter, at its outer pole. Perfectly independent from the uterus and attached to the utero- Ovarian ligament on the left side is a myoma, 6 cm. in length, 4 cm. in breadth, and 3 cm. in thickness (Fig. 41). Projecting slightly from the surface are a subperitoneal cyst, 1 cm. in diameter, and numerous smaller ones. On making sections of the nodule projecting from the left utero- ovarian ligament we find in the lower part cystic spaces reaching 1.5 cm. in diameter. Sections through the middle portion show cystic spaces 1 mm., others 2 mm., and some 4 mm. in diameter. Section through the attachment of the myoma to the utero-ovarian ligament reveals a cystic space, 7 mm. in length and approximately 142 ADENOMYOMA OF THE UTERUS 3 mm. broad. It has a definite yellowish lining and encloses choco- late-colored contents. Several of the spaces are filled with a brown- Fig. 41. — Subperitoneal axd ixterstitial uterine mtomata; adexomyoma of the body OF THE uterus. Adbnomyoma sprixgixg from the left utero-oyariax ligamext. (f natural size.) Gyn.-Path. Xo. 843 3. The uterus is the seat of subperitoneal and interstitial myomata. Xear the cerYix on the anterior surface is a small cyst. The left tube is normal. The left ovary contains a small corpus-luteum cyst. b. Projecting from the left utero-OYarian ligament is a subperitoneal myoma, a. This has a few cysts projecting from its surface as indicated. On section this nodule was found to contain cysts. 1 cm. or more in diameter, lined with mucosa and filled with chocolate-colored blood, miniature uterine caA'ities. also whitish yellow areas, and normal uterine mucosa. (See Fig. 42. ) It may be of interest to know that the uterine mucosa extended into the myomatous uterine walls. ish putty-like material and have yellowish margins. The ovary contains a cystadenoma. On section the uterine cavitv is 7 cm. in length and the mucosa SI BPERITONEAL AND [NTRALIGAMENTART? AJ>ENOMYOMATA 143 in places reaches 9 nun. in thickness. Some of the glands are dilated. The muscular layers of the uterus present a rather coarse, striated appearance. On his to 1 o g ical ex a m inal i o n the cervical mucosa is perfectly normal in many places; al other points, however, there is a greal deal of gland dilatation, and there is a large thin-walled cysl lined with one layer of fiat epithelium and filled with coagulated ma- terial presenting a picture almost identical with one of the thyroid. This appearance is due to massive dilatation of some of the cervical glands. We also have small cysts presenting a sieve-like appearance. This picture is due to a polypoid formation at certain points. The uterine mucosa in places reaches 11 mm. in thickness. In mam- places it has been most imperfectly preserved. The surface, how- ever, is practically intact. The glands are ribbon-like owing to degeneration, and we are unable to tell why the mucosa was so thickened, on account of this degeneration. There is, however, not the slightest evidence of any malignancy. The underlying muscle is somewhat dense, and in it near the mucosa we find isolated glands which have extended down from the surface. In one of the sections an island of mucosa with the characteristic stroma surrounding it can be seen at least 3 mm. from the mucosa. The g r o w t h is a definite adeno m y o m a , with the g 1 a n d s c o m - i n g from the mucosa. Sections from the nodule spring- ing from the left utero-ovarian ligament show a most instructive picture (Fig. 42). A transverse section over the point of attach- ment of the utero-ovarian ligament, where we noticed several spaces. shows that these are lined with one layer of cylindrical epithelium. This at times projects out as little tufts and beneath it. and sepa- rating it from the muscle, is a certain amount of characteristic stroma. In other portions of this nodule we have little gland-like spaces extending out into this main cavity. Still other sections contain glands resembling uterine glands in every way. These are separated from the muscle by a characteristic stroma. Sections from the centre of the nodule show a most interesting picture. We have cyst-like spates similar to those above described, and 144 ADENOMYOMA OF THE UTERUS likewise miniature uterine cavities. Some of the glands are dilated. In the vicinity is a group of glands similar in appearance. We have here subperitoneal and interstitial uterine myomata ; marked thickening of the endometrium with definite ade- nomyomatous formation, and adenomyoma of the left utero-ovarian ligament. This myoma is diffuse in character, contains cyst-like Fig. 42. — Cross-section through a pedunculated subperitoneal adenomyoma. (4 diam- eters.) Gyn.-Path. No. 843 3. The picture represents a cross-section through the subperitoneal adenomyoma a in figure 41. Scattered throughout the tissue are isolated cystic and dilated glands (a) . Near the centre are two large areas of typical uterine mucosa ; one of these contains a miniature uterine cavity as indicated at b. The darker tissue as seen at c indicates the myomatous muscle. This stands out in sharp contrast to the paler staining stroma as indicated at d. spaces and miniature uterine cavities. In other areas it is a typical adenomyoma, differing in no way from an adenomyoma with the glands originating from the mucosa. The mucosa in this case shows a definite adenomyomatous tendency as it extends into the under- lying muscle. It seems reasonably probable that the adenomyoma of the utero-ovarian ligament at one time lay next to the uterine mucosa, and that it was gradually pushed outward until it became SUBPERITONEAL AM) [NTRALIGAMENTARY ADENOMYOMATA L45 subperitonea] and bo all intent and purpose lost its continuity with the uterus. Gyn. No. 12,036. Path. No. 8579. S u I) p eri 1 o e a l a n d interstitial ui e r i d e m y m a t a , n e o f \v h i <• h w a s a 11 a <1 e n m y m a . M. V., aged forty-six, white, married. Admitted April 8, L905; discharged May 22, 1905. Complaint: Right inguinal hernia; descensus and retroposition of the myomatous uterus, ulceration of the vagina. One aunt has cancer. The menses commenced at eighteen. The menopause occurred in November, 1904. The patient has been married fourteen years and has never been pregnant . The inguinal hernia was noticed two years ago. In the posterior vagina*! wall there is a granulating area about 8 mm. in diameter just two inches from the outlet. On opening the abdomen a small flat myoma was found in the posterior wall near the cervix. This was removed, and some small interstitial nodules were shelled out. The hernia was repaired and the patient made a good recovery. The highest post-operative temperature was 99° F. Path. No. 8579 . — The larger specimen consists of a myoma, 4 by 2 by 2 cm. This is partly subperitoneal. There are also small interstitial nodules. On section numerous cyst-like spares are to be made out in the myoma, which presents a coarse striation and suggests adenomyoma. Throughout this myoma definite spaces can be seen. These are lined with a single layer of columnar epithelium. At one or two points the glands can be traced for a distance of 5 mm. As the uterine cavity was not opened, of course it is impossible for us to trace the continuity with the mucosa. D i a g n o s i s . — Subperitoneal adenomyoma : small inter- stitial nodules. INTRALIGAMENTARY ADENOMYOMATA Case 8780 is a very good example of this variety, although the growth also projects into the uterine cavity. As seen in Fig. (•">. 10 146 ADENOMYOMA OF THE UTERUS it is a goodly sized tumor which extends far out into the right broad ligament, the folds of which it widely separates. Where it becomes submucous, its character is more evident. It is covered over with mucosa, but presents a rather lobulated appearance owing to the presence of cysts of varying size projecting inward from the growth. From the soft character of the growth sarcoma was suspected at the time of operation, particularly as the mucosa was intact and showed no evidence of a carcinomatous process. Fig. 44 is a cross-section of the opened uterus, taken near the fundus. The growth is seen to be a myoma covered externally with a layer of normal muscle and internally with mucosa. Traversing it everywhere are large and small irregular cyst cavities. On histological examination some of these cavities were found to communicate with one another. They were in part empty, in part filled with coagulated serum or blood. They had a smooth inner lining resembling mucosa. This in places was of appreciable thickness. The microscopic examination re- vealed the fact that some of them resembled miniature uterine cavi- ties, having an inner lining of cjdindrical epithelium beneath which were typical uterine glands embedded in their usual stroma. At c in Fig. 45 we even noted hypertrophy of some of the glands so char- acteristic of the uterine mucosa in some cases. Others of the cysts had no glands, merely a row of cylindrical cells separating them from the myomatous muscle. The uterine mucosa was normal and no connection was found between the adenomyoma and the mucosa lining the uterine cavity. Kroenig 1 reports a very interesting instance of a cystic adeno- myoma springing from the posterior wall of the uterus and extend- ing backward beneath the peritoneum of Douglas' pouch. It con- sisted of one large, thin-walled cyst containing a litre of brownish- red fluid, and of a more solid portion consisting of about thirty small spaces so arranged that the} 7 resembled a honeycomb. The walls of the large cyst, especially of that portion lying free in the abdominal 1 Kroenig, B.: Ein retroperitoneal gelegenes voluminoses Polycystom entstanden aus Resten des Wolff'sehen Korpers. Beitrage zur Geburtshulfe und Gynak., 1901, Bd. iv, p. 61. SUBPERITONEAL AM) I \TK.\ l.KJA.M K\T\i; Y ADENOMYOMATA 117 Cavity, were very thin, in places measuring scarcely more than I mm. The cyst walls were composed of fibrous tissue and of a varying amount of muscle. The inner surface was in places lined with cylin- drical ciliated epithelium. The more solid portion of the tumor was a typical cystic adenomyoma which, as Kroenig says, in form, in ar- rangement of glands and in the cystic spaces, corresponded in prac- tically all points with the adenomyomata of von Recklinghausen. There were definite "roups of "lands surrounded by the character^ lc stroma. Kroenig thinks that the tumor originated in the uterine wall, and was later pushed out into the connective tissue of Douglas 5 pouch. Hartz 1 observed a similar case in Sanger's clinic. While considering intraligamentary adenomyomata we must not omit the two interesting cases reported by Breus 2 in 1894. In his ( ase 1 a large, partly cystic and partly solid myoma was met with in the right broad ligament. On removal it was found to be made up of a framew r ork of myomatous tissue containing several large cysts. Their dimensions may be imagined from the fact that 7 litres of thick grayish-brown fluid were evacuated prior to the removal of the tumor. The cyst cavities had smooth inner surfaces and ap- peared to be lined with mucous membrane. In the more solid por- tions, definite myomatous nodules as large as a fist were found. Such nodules on section contained large, smooth-walled cavities, which were filled with either light or dark brown, friable or thick. fluid contents similar to those of the large cyst. The tumor proved to be a typical myoma. The large cyst was lined with a single layer of cylindrical ciliated epithelium. Breus thought that the tumor was of uterine origin and that it had spread out between the folds of the broad ligament. Breus' Case 2 is even more instructive than the first. The patient was fifty-one years of age. There was a tumor tin 1 size of a child's 1 Hartz, A.: Neuere Arbeiten iiber die mesonephrischen Geschwulste. Monats- schrift f. Geburtshiilfe und Gynakologie, Bd. xiii. 2 Breus, Carl: I'cber wahre opithelfuhrende Cystenbildung in Uterusmyomen. Leipzig, 1S94. 148 ADEXOMYOMA OF THE UTERUS head springing from the posterior surface of the uterus and covered by the peritoneum of Douglas' sac and the left broad ligament. The tumor on its upper and posterior surface was hard. On section it was seen to be composed of myomatous tissue, but the central portion contained several cavities. These varied from a pea to an apple in size and were in part separated from one another by thick partitions. Several of them, however, communicated one with the other. The cysts had smooth inner surfaces and were filled with a thick, choco- late-brown fluid. The largest cyst communicated directly with the uterine cavity by a funnel-shaped opening just above the internal os. The cysts were lined with cylindrical, ciliated epithelium, and where the large cyst communicated with the uterine cavity the sur- face epithelium of the uterine mucosa was directly continuous with that of the cyst. Breus considered the tumor as a subperitoneal and intraligamentary cystic myoma of the uterus. The intraligamentary cystic adenomyomata differ in no way from the subperitoneal growths except for the fact that they spread out between the folds of the broad ligament, and hence offer greater difficulty in removal. All of the tumors consist of myomatous tissue and contain characteristic glands and stroma, and furthermore all the cysts are lined with cylindrical and usually ciliated epithelium. Particularly instructive is Breus' second case, in which the epithe- lium of the uterine mucosa was directly continuous with that of the large cyst. Nearly all of the intraligamentary cysts are also par- tially filled with blood. It will be noted from the foregoing cases that wherever the subperitoneal or intraligamentary adenomyomata reach any size they become cystic. In some the cysts were single, but they were usually multiple. The cyst walls were made up of myomatous tissue and their inner surfaces were lined with cylindrical epithelium, on which the cilia were usually demonstrable. The cysts almost without exception contained a chocolate-colored or bloody fluid. In the solid portion of the tumor tubular glands were found, sur- rounded by a definite stroma; in short, a definite mucosa, identical with that normally found lining the uterine cavit3 r , was present. SUBPERITONEAL WD [NTRALIGAMENTART ADENOMYOMATA L49 Subperitoneal adenomyomata differ in do way from t he* diffuse uterine myomata save for the fact thai they become cystic; and this difference is easily explained inasmuch as the subperitoneal tumors are released from the contracting and controlling influence of the uterine muscle. Their glands are occluded, and from the con- stant accumulation of the epithelial secretion and the frequent hemorrhages, which undoubtedly occur at the menstrual period, rapidly become larger. It will be noted thai the Large cysts are invariably found where the least amount of muscle is present. AN INTRALIGAMENTARY ADENOMYOMA OF THE UTERUS Gyn. Nos. 6855 and 8780. Path. No. 4966. I n t rali g a m e n t a r y a d e 11 o m y o m a of the uterus exte n d i n g into the r i g h t b r o a d lig- ament and also becoming submucous (Figs. 4o. 44, and 4o). G 1 a n d h ypertrophy of the uteri n e mucosa, slight pelvic adhesions. Hysterec- tomy. Recovery. (See page 160, for first operation. 1 A. B. W., aged thirty-six, white, married. Admitted May 21; discharged June 11, 1901. Complaint: Continuous bleeding from the uterus and pain in the right lower abdomen. The patient has been married sixteen years and has had three children. The menses commenced at twelve, and w^ere regular, lasting about four days. There was no pain and the flow was moderate. On April 22, 1899, a vaginal myomectomy was done, a sub- mucous adenomyoma being removed. Before this operation there had been a slight bloody discharge at irregular intervals. Menstrua- tion was normal after the operation until five years ago. when the patient began to have continuous profuse bleeding from the uterus and pain in the right side. She was curetted two or three times and the last two periods were normal. For the past two or three years leucorrhcea has been profuse. At times there has been dysuria, when the uterus seemed to press on the bladder. On such occasions it was necessary for her to push the uterus up before she could urinate. The bowels arc constipated. 150 ADENOMYOMA OF THE UTERUS The outlet is very much relaxed. The cervix is lacerated and the orifice is 2 cm. in diameter, slightly bluish. The uterus forms a mass filling two-thirds of the pelvis, the organ being about the size of that of a three and a half or four months' pregnancy. The uterine cavity is 13 cm. long and is displaced somewhat to the left. Operation, May 22, 1901. Panhysterectomy. Suspension of the corners of the vagina to the round, infundibulo-pelvic and sacro-uterine ligaments on either side. On opening the abdominal cavity the appearance strongly suggested a sarcoma involving the right uterine walls and extending into the right broad ligament. The right tube and ovary were adherent to the pelvic floor. The left tube and ovary were normal except for slight ovarian adhe- sions. Gyn.-Path. No. 4966 . — The specimen consists of an enlarged uterus with the tubes and ovaries intact. The uterus is somewhat pear-shaped and irregular in outline. It is 14 cm. in length, 13 cm. in breadth, and 12 cm. in its antero-posterior diameters. Anteriorly it is smooth and glistening; posteriorly, much injected and covered with a few recent adhesions. The increase in the size of the uterus is in great part due to a tumor occupying the right side of the body and extending out into the folds of the right broad liga- ment and also to the posterior and right side. This tumor is ap- proximately 10 cm. in diameter, is exceedingly soft, and feels like a cyst with the walls probably 5 mm. thick. On opening the uterus the external os is found to be 2.5 cm. in diameter; the mucosa of the vaginal portion is intact, but just beneath the mucous mem- brane are a few Nabothian follicles. The cervical canal is much dilated and is 3.5 cm. in length. Its mucosa is intact, but apparently somewhat thickened (Fig. 43). The cavity of the uterus is 8 cm. in length and averages 5 mm. in breadth in its middle portion. The uterine walls vary from 2 to 3 cm. in thickness. Projecting into the uterine cavity and apparently continuous with the mass on the right side is a somewhat globular tumor, 7 cm. in length and 6 cm. in breadth. This has a very broad basal attachment, presents a fairly lobulated surface, and is everywhere covered with mucosa, SUBPERITONEAL AM) [NTRALIGAMENTARY ADENOMYOMATVA 1 gSSi9«| ." ■- z 1 3 / / x / >. / — -£■ ^3 *~ ^ ' ■s -|? u T3 £ X . •*'■ T z ~ _ 0) 1 E 2 / ■- 7 _ "3 - 2 fc 5 - - g :, u 1* : j. / t — - 0) z /. - 9J ~i "S . - ~l. c > i— ~ j i. z [g 3 .- fn ® — -^ JJ r / x, _= = 7 _E /. - ■ — u _ :i "" M — Si Z 'C _ Z U ij ~ r ■- ■-i - z ■p /. ~~i -5 - - ■" 33 — :/ — 2 'C T X tr. •" ~ B ^ - C / '£! T x c — — ~ ^ - a . _e - — ^ / z S M ""■ .£ ~ r ' z - ~ - * — — Z . 7 — - 1= .« 'Z ~ '- - JJ J - •- g — z - — — - > ' r p r. _1 5 Z ■Q 03 — /. — r: ii £ — 7 Z - z z _■- z - - < fe ~ ta X \l < 't- " - P Ti pi E- L z z r - - — — (A 'A r. w ~ ■ £ _z >i >. -= u — >. - E t - - b 152 ADENOMYOMA OF THE UTERUS which, however, is somewhat thinned out. On pressure the sub- mucous tumor gives the impression of being cystic. The uterine mucosa averages 2 mm. in thickness, is smooth and grayish- white in appearance. Right side: The tube is 12 cm. in length and near the uterus averages 5 mm. in diameter; it is free from adhesions. The fim- FlG. 44. A CYSTIC INTRALIGAMENTARY AND PARTLY SUBMUCOUS ADENOMYOMA OF THE UTERUS. (Natural size.) Gyn.-Path. No. 4966. The drawing illustrates a section through Fig. 43 between b and b'. a is a cross-section of the left tube, b is a small portion of the uterine cavity, c is the submucous portion of the cystic adenomyoma and d its intraligamentary pole, e is one of the irregular cyst-like spaces with a smooth velvety inner lining resembling mucosa. Just above it is a similar but smaller one. The other spaces, as indicated by /, also irregular in outline, are filled with glistening coagulated contents which have not been removed. The coagulation, of course, was due to the hardening fluid, g is the characteristic myomatous tissue. The outline of the myomatous growth is well defined, but notwithstanding this fact the tumor merges gradually into the normal muscle. briated extremity is occluded and covered with adhesions. The tube in the vicinity of its outer end is 8 mm. in diameter and very firm. Situated just beneath the tube and within 3 cm. of its fimbriated end is a firm bean-shaped area 1.2 cm. in length. On section it is found to be a cyst-like space lined with smooth mucosa and filled with a brownish-yellow material, partly soft, but at one point evidently organized and adherent to the cyst wall. The ovary measures 3 by -i BPERITONEAL WD [NTRALIGAMENTART ADENOMYOMATA LOd 2.5 by I cm. and is partially enveloped in adhesions and adherent to the t ube. Lefl side: The tube is 1 1 cm. in Length, and throughout its entire extent is very small, averaging not more than 3 or 1 nun. in diameter. The fimbriated extremity is patent, bul the tube near its outer end is attached to the ovary by fan-like adhesions. The ovary measures 1 by 3.5 by 2 cm. It contains a recent corpus luteum and apart from the tubal adhesions is free. On making a transverse section of the uterus after the specimen has I .ecu hardened in Midler's fluid it is found that the tumor occupy- ing the right side and extending out into the right broad ligamenl is directly continuous with the submucous nodule which occupies the uterine cavity. In other words, we have an interstitial myoma, which on its inner side has become submucous and on its outer side extends into the broad ligament. This nodule is fully 8 cm. in diameter and is sharply differentiated from the uterine muscle, which on its outer side forms a covering 5 mm. in thickness. The myoma is irregular in contour and in places presents the usual pic- ture. It contains at least eight medium sized cyst-like spaces, the largest reaching 2.5 cm. in length and 1 cm. in breadth (Fig. 44 . Each of these has a smooth lining membrane, waxy in appearance and varying from .5 to 1 mm. in thickness. The cavities of nearly all of these spaces are filled with a jelly-like material, evidently coag- ulated serum. One contains coagulated blood. The cyst-like spaces are more abundant in the central portions of the growth and toward the uterine cavity. They are similar to those noted beneath the surface of the submucous myoma. Histological E x a m i n a t i o n . — The mucosa lining the vaginal portion of the cervix and the cervical canal is normal. That covering the anterior portion of the uterine cavity is thickened; the surface epithelium is somewhat flattened and its glands show marked hypertrophy. The stroma between the glands shows con- siderable small round-cell infiltration and is very lax. In the deeper portions it is unaltered. The mucosa covering the submucous portion of the tumor is somewhat thinned out. The surface epi- 154 ADENOMYOMA OF THE UTERUS thelium is intact, but the glands show slight hypertrophy. One of the cysts, 1.5 cm. in length, .5 cm. in breadth, and situated directly beneath the mucosa, has a lining in no way distinguishable from uterine mucous membrane (Fig. 45). Its inner surface is covered with one layer of cylindrical and, in places, slightly flattened epithe- lium. Beneath this the characteristic stroma of the mucosa is 3'!?^. ' '- Fig. 45. — The submucous portion of a cystic adenomyoma op the uterus. (5 diameters.) Gyn.-Path. No. 4966. The section is from the submucous myoma seen in Figs. 43 and 44. a represents the uterine mucosa, which has an intact surface epithelium and per- fectly normal uterine glands. The stroma of the mucosa is rarefied but normal. A is one of the cyst-like spaces. At some points it is lined with a layer of cylindrical epithelium lying directly on the muscle. At other points this is separated from it by a small amount of stroma similar to that of the uterine mucosa. While in some places, as at b, there are definite uterine glands beneath the epithelial lining, at c we have a uterine mucosa equally as thick as that covering the surface of the submucous myoma and consisting of a typical gland hypertrophy. B, C, D and E are other cyst- like spaces lined with cylindrical epithelium. A and B are evidently one and the same cavity, communicating as they do with one another by the bar d consisting of the characteristic stroma of the mucosa and containing two small glands. found, and scattered throughout the stroma are normal or hyper- trophied glands precisely similar to those noted in the mucosa lining the uterine cavity. Some of the cyst spaces, which are rather small, are lined with a layer of epithelium closely resembling that lining the uterine cavity. In a few places the nuclei of the epithelial cells are slightly drawn out and irregular. The myo- matous tissue as a whole presents the usual appearance. It has SUBPERITONEAL AM) [NTRALIGAMENTAR? ADENOMYOMATA L55 scattered bhroughoul it, however, many small round cells, but prac- tically no polymorphonuclear leucocyte-. The tubes and ovaries offer nothing of interest . We have, then, in this case a rather large and sharply defined myoma situated in the right uterine wall. This contains large and small irregular spaces lined with mucous membrane identical with thai of the uterine mucosa. This myoma on its inner side has become submucous and its cyst-like spaces are seen projecting into the uterine cavity and lying just beneath the mucous membrane. Diagnosis : Adenomyoma of the uterus extending into the right broad ligament and also becoming submucous. (Hand hypertrophy of the uterine mucosa, slight pelvic adhesions. CHAPTER VI SUBMUCOUS ADENOMYOMATA These are certainly not very common. We have already dis- cussed Case 8780 (Fig. 43, p. 151) under the heading of intraliga- mentary adenomyoma, but fully one-third of the growth is sub- mucous, projecting into and filling the uterine cavity from cervix to fundus. The surface is smooth but lobulated, on account of the underlying cysts which project toward the uterine cavity. As was said elsewhere, the growth was a typical adenomyoma and the cyst spaces were lined with cylindrical ciliated epithelium. Case 5973 offers a very good illustration of a small submucous adenomyoma. The mucosa over the nodule has to a great extent disappeared, but here and there a gland is still visible. The growth is essentially a myoma. It contains three definite bunches of glands resembling uterine glands and surrounded by the typical stroma of the mucosa (Fig. 46). There are also a few isolated glands, some surrounded by stroma, others lying in direct contact with the muscle. Near the free surface is a cystic gland. In this case there were other myoma ta, necessitating the subsequent hysterectomy. In Case 6855 the submucous nodule contains a few small uterine glands. In Case 10,872 the myoma contains three cystic spaces, each 1 cm. in diameter and with a smooth lining, which on histo- logical examination is seen to consist of one layer of columnar epithe- lium. In Case 10,314 (Fig. 47, p. 162) we have a typical example of a submucous myoma containing collapsed and dilated spaces lined with a definite mucosa. Some of these cavities are filled with chocolate-colored contents. On histological examination they are found to be miniature uterine cavities. In this case the uterine mucosa can be followed directly into the myoma. In 1896, when reporting two cases of diffuse adenomyoma of 156 SUBM1 C01 B ADENOMYOM A'l \ \.>t the uterus, 1 attention was directed to cases of submucous adeno- myomata reported by Diesterweu and Schatz. 2 In Diesterweg's rase a nodule the size of a hen's egg presented al the external os. Its surface was somewhat eroded; it was attached above the in- ternal OS and projected downward by a pedicle an inch in thickness. The nodule was composed of myomatous tissue, and in the centre was a large cavity lined with mucosa and traversed by numerous small depressions, producing an appearance suggestive of a ventricle. There was a smaller cavity the size of a cherry. These cysts were lined with cylindrical ciliated epithelium and filled with brownish- black blood. Two years later, after the administration of ergotin, a submucous myoma, 9 by 7 by 6 cm., was expelled. This con- tained a cyst the size of a walnut. The cyst was lined with cylin- drical ciliated epithelium and filled with blood. In Schatz's case the uterus was 16 cm. long, 8.5 cm. in diameter, and its walls varied from 2 to 2.5 cm. in thickness. The uterine cavity contained five rows of broad-based polypi. Each row con- sisted of from two to six polypi. Between the rows were deep de- pressions. The polypi pointed toward the internal os and varied from a pea to a hen's egg in size. The uterine cavity was completely filled with them. On section the polypi were found to have a rich blood-supply and in several places bundles of muscle fibres could 1 e seen extending into them and reaching almost to the free surface. Where the muscular elements predominated, the polypi were firm. Scattered throughout the uterine wall were small myomata which were not easily shelled out. In the myomata near the peritoneal surface no cysts were to be seen, but in those near the uterine cavity and also in the muscle they were present. The outer portions of the uterine wall were entirely free from cysts. The polypi consisted 1 Cullen, Thomas S. : Ailcnonivonia Uteri Diffusum Benignum. Johns Hopkins Hospital Reports, 1896, vol. vi 2 Diesterweg: Ein Fall von Cystofibroma uteri verum. Zeitschr. f. Geb. u. Gyn., lss.">. Bd. ix,S. 191. Schatz: Ein fall von Fibro-adenome cysticura diffusum et polyposum corporis el colli uteri. Arch. f. Gyn., 1884, Bd. wii. S. 456. 158 ADENOMYOMA OF THE UTERUS of spindle-shaped cells, and scattered throughout them were gland- like cavities lined with high cylindrical epithelium. It would appear that in these cases there had been a diffuse adenomyoma and that the uterus was trying to free itself of the new growth in the same manner in which it extrudes ordinary myomata. A polypoid condition had naturally resulted. Remembering the diffuse adenomyomata of the uterus and subse- quent extension of the growth to the outer surfaces, with the forma- tion of subperitoneal or intraligamentary cystic adenomyomata, it is easily understood that portions of the growth, at least, are forced inward and become submucous. In the submucous adenomyomata we do not generally expect much cystic dilatation of the glands, since the growth is continually subjected to the uterine pressure from all sides. CASES OF SUBMUCOUS ADENOMYOMA OF THE UTERUS Gyn. No. 5973. Path. No. 2250. Submucous adenomyoma of the uterus (Fig. 46j . Removal per vaginam. Subsequent hys- terectomy on account of uterine myomata. Recovery. S. G., single, aged thirty-nine, black. Admitted March 22, 1898; discharged June 3, 1898. Complaint: continuous bloody vaginal discharge. The patient had one miscarriage twenty years ago. Her menses commenced at twelve and were regular, but for the past two years the flow has lasted about twice as long as heretofore. Since December there has been an almost continuous bloody dis- charge, at times profuse. About two years ago the patient commenced to have pain in the lower abdomen. This pain lasted about six months. For the last three years she has been short of breath, and since August, 1897, her feet have been swollen. For several months there has been a profuse yellowish leucorrhoeal discharge. First operation, March 24, 1898. Myomectomy per vaginam; evacuation of a pelvic abscess. A polyp was removed through the SI BM1 COUS A.DENOMYOMATA 159 vagina. The uterine cavity at this time varied from LO to 12 cm. in Length and in the posterior wall was a myoma. The pelvic abscess was opened and a small amount of necrotic material and pus came away. Second operation, April 27, 1899. Kystero-myomectomy, righl salpingo-oophorectomy. There were general intestinal adhesions and the bladder was markedly lifted up. A right tubo-ovarian ab- scess was removed together with a myomatous uterus. Conva- Fig. 46. — Submucous adenomyoma of the uterus. (7 diameters. Gyn.-Path. No. 2 2 50. Nearly all trace of the mucosa formerly covering the growth lias disappeared. Nevertheless, some of the stroma remains and is recognized at :-• :./ i" . r^: >: -- : '.- - : *?.*--: '■■■ ,).■ ■ . . -> .. b ^ Jf.J3ecJ— — Large venous sinuses in the uterine mucosa causing severe bemorrb 80 diameters. I Gyn.-Path. No. 2048. a is a portion of the surface epithelium, which is greatly flattened. In the lower pari . as well as in the upper third of the field, are several uterine glands of the usual size and shape, and lined with one layer of cylindrical epithelium. They arc perfectly normal, and arc surrounded by the normal stroma of the mucosa. Over one half of the section is made up of three large venous sinuses b . showing exceedingly delicate walls. That there is do malignant process is clear. It is little to be wondered at that free hemorrhages should have taken place, when such large blood sinuses existed. that the bleeding was due to enormous sinuses scattered throughout the uterine mucosa. The patienl was greatly benefited by the curet- tage. A year later she was again curetted, and in a short time she felt better than she had for years. 180 ADENOMYOMA OF THE UTERUS The difference between the mucosa in this case and that in a case of adenomyoma is very plain, as can be gathered from Fig. 52. MARKED PROLIFERATION OF THE STROMA OF THE MUCOSA ASSOCIATED WITH COPIOUS UTERINE HEMORRHAGES On page 478 of " Cancer of the Uterus ' ' I described several cases in which free uterine hemorrhage w T as apparently due to a marked proliferation of the stroma of the uterine mucosa, the glands re- maining perfectly normal. The stroma was very rich in cellular elements; the nuclei were slightly larger than normal. Numerous nuclear figures could be seen scattered throughout the stroma, and were it not for the fact that the spaces between the glands were every- where approximately equal, one might have suspected sarcoma. The histological picture shows clearly the difference in the mucosa of cases of this character and those of diffuse adenomyoma. Clinic- ally, the contrast is even more striking. All the patients were under twenty-five years of age and in each case the hemorrhages ceased in the course of a few years. A THICK UTERINE MUCOSA; VERY LARGE AND DILATED UTERINE GLANDS WITH AN OVERGROWTH OF THE STROMA OF THE MUCOSA Clinically we have a by no means small group of cases in which a patient, usually between forty and fifty, comes complaining of a very profuse menstruation and at times of an intermenstrual flow or a leucorrhoeal discharge, and in which carcinoma of the body of the uterus is suspected. On histological examination we find a most characteristic picture (Fig. 53). The mucosa is much thickened. The glands are large and many of them are dilated. This dilatation is, however, not due to occlusion and cj^st formation, as the gland epithelium is proliferated and higher than usual instead of flattened. Many of the enlarged glands- are irregular in outline. . The stroma of the mucosa is very rich in cell elements and nu- clear figures can at times be detected. I have examined the mucosa in many such cases and am at a IMFFKHKVn Al. DIAGNOSIS b IM Fig. 53. -Thickening of the uterine mucosa. Marked dilatation of some of ihk glands without ant; atrophy of their epithelium; veri densestroma. (38 diameters. Gyn.-Path. No. 7026. The section is a portion of a scraping. The surface epithe- lium is intact as seenasaand o. At b are two normal uterine -lands. Fully half of the clan. Is are more or less dilated. At c is an irregular and dilated gland filled with coagulated serum. d and e are also dilated bul nol spherical -lands. The gland / is markedly dilated and spherical. In none of the dilated -lands is there any atrophy of the epithelium. The stroma between the -lands is very dense, in some of these cases large veins are found scattered throughout the stroma. Given such a mucosa as this, one can say with almost absolute certainty that the patient lias had very profuse menstrual bleeding. 182 ADENOMYOMA OF THE UTERUS loss to give the condition a definite name. With such a mucosa one can say with absolute certainty that the patient has been subject to very free uterine bleeding. It is not malignant. The clinical picture in this condition resembles to some extent that of diffuse adenomyoma of the uterus, but, as noted, the histo- logical patterns are totally different. UTERINE MYOMATA Myomata are primarily interstitial and may become subperitoneal or submucous. Often these give rise to no symptoms whatever save those of pressure. When the myomata become submucous, more or less menorrhagia is present. This is due to the fact that the uterine mucosa is put on tension by the myoma, which is gradually forcing its way into the cavity of the uterus. I have known a small submucous myoma give rise to almost fatal hemorrhage, while, on the other hand, a patient with an 89-pound myoma had never had any excessive menstruation. The hemorrhage depends entirely on the situation of the tumor. Bimanual examination will often reveal the presence of a large myomatous uterus. On curettage normal or atrophic uterine mucosa will be found, provided the tubes and ovaries are normal. The differential diagnosis between a uterus containing simple discrete myomata and one the seat of a diffuse adenomyoma is often difficult, if one of the simple myomata be submucous. The difficulty is increased by the fact that there is a marked tendency for discrete myomata to be associated with a diffuse adenomyoma. How- ever, where simple myomata exist there may not be the marked tenderness at the menstrual period, so frequently noticed in adeno- myoma, and further, examination of the curettings will usually demonstrate a much thicker mucosa in the adenomyomatous uterus. MITKKKNTIAI. DIAGNOSIS L83 SARCOMA OF THE UTERUS In the examination of over twelve hundred myomata we have found sarcoma developing in or associated with uterine myomata in seventeen cases. The points of difference between cases of uterine myomata and diffuse adenomyoma apply equally well to those of sarcoma of the uterus. In sarcoma, however, we have a history of a tumor which has probably lain dormant for years, and then suddenly has com- menced to grow rapidly. If portions of the growth project into the uterine cavity, the diagnosis of sarcoma can readily be made from pieces removed with the curette. Where sarcoma arises primarily from the uterus and not from a pre-existing myoma, the growth may also be correctly diagnosed from scrapings, if portions of it project into the uterine cavity. ABORTION Uterine bleeding often follows a miscarriage, especially when remnants of the placenta have been left behind. This bleeding is usually continuous, while in adenomyoma the bleeding usually con- sists in an exacerbation of the menstrual period. Further, in the one case there is likely to be a history of a recent conception; in the other the bleeding has been noticed for months or years and has gradually increased. Where an abortion has occurred placental villi or decidual re- mains are usually obtained on curettage. In diffuse adenomyoma a perfectly normal uterine mucosa is found. CHORIOEPITHELIOMA Chorioepithelioma is infinitely rarer than adenomyoma, and follows an intrauterine or extrauterine pregnancy usually a hy- datid mole. The clinical history is generally sufficient. Examination of the scrapings will aid materially in settling the question. Where chorio- epithelioma exists we usually have placental villi showing marked 184 ADENOMYOMA OF THE UTERUS proliferation of the syncytium and usually of Langhans' layer. There are also many vacuoles between and also in the masses of cells of the growth. While one cannot from the scrapings differentiate absolutely between a very active hydatid mole and chorioepithelioma, yet one can say with certainty that a pregnancy has existed and that the growth, if not actually malignant, is very suspicious. In the cases of diffuse adenomyoma the mucosa is perfectly normal. TUBAL PREGNANCY Pregnancy in the Fallopian tube is usually associated with a cessation of the period for one or two months, followed by a slight continuous uterine bleeding. In some cases the periods have been perfectly regular, but the last period has never completely stopped and the patient has continued to lose a little blood. Later she com- plains of pain in one side, and if she does not consult a physician she suddenly collapses from internal hemorrhage. Pelvic examina- tion before rupture of the tube will show slight enlargement of the uterus with a small mass on one or the other side. In adenomyoma the periods remain regular, but are profuse, and there is usually no intermenstrual bleeding. Moreover, there is little or no intermenstrual pain. Examination of the uterine mucosa in the one case usually yields a slight decidual formation ; in the adenomyoma, a normal mucosa. SALPINGITIS AND ENDOMETRITIS The patient with pelvic inflammation usually gives a history of an acute infection followed by a profuse uterine discharge and pain laterally. Bleeding is occasionally present and may suggest adeno- myoma. On examination of the scrapings we usually find a thinning out of the mucosa and definite infiltration with small round cells or poly- morphonuclear leucocytes. In those cases in which tuberculosis is present typical tubercular areas or areas of caseation are seen. DIFFERENTIAL DIAGNOSIS I s "' Both pictures are totally different from that presented by the normal uterine mucosa associated with diffuse adenomyoma of the uterus. CARCINOMA OF THE UTERUS Carcinoma of the uterus is clinically divisible into two varietii - 1. Carcinoma of the cervix. 2. Carcinoma of the body of the uterus. Usually the first symptom of a carcinoma, whether situated in the cervix or body, is uterine hemorrhage. This is frequently sudden and may be meagre or abundant. The hemorrhages are usually intermenstrual. In adenomyoma the bleeding is usually profuse at the periods and there is no hemorrhage between the periods. In car- cinoma a watery or purulent and usually offensive discharge is pres- ent between the periods. This is due to disintegration of the de- generating carcinomatous tissue. In adenomyoma there is usually no such discharge because there is no dissolution of tissue. Where carcinoma of the cervix exists the growth can usually be detected on digital examination. Sometimes it is recognized as a cauliflower-like outgrowth from the cervical lips, but in the later stages a crater-like cavity is present where the cervix should be, and the vaginal vault is board-like in consistency as a result of car- cinomatous infiltration. In cases of diffuse adenomyoma of the uterus the cervix is usually perfectly normal. 'Where carcinoma of the body of the uterus exists, uterine scrap- ings yield the characteristic pattern of adenocarcinoma and the cell changes leave no doubt as to the malignant nature of the growth. In cases of adenomyoma the mucosa lining the uterine cavity is, od the contrary, perfectly normal. CHAPTER XI TREATMENT OF ADENOMYOMATA OF THE UTERUS Not infrequently the case will be looked upon as one of simple myoma and its true character will be determined only after opera- tion. Should a diagnosis be made, abdominal hysterectomy is in- dicated provided the bleeding is so severe that the patient's health is being undermined. Myomectomy is inapplicable, as the growth is so interwoven with the normal muscle that it cannot be shelled out. In cases of intraligamentary and cystic adenomyomata evacuation of the cyst contents will often be found necessary, before it is possible to shell the tumor and the uterus out from the pelvic floor. As these growths will lift up the peritoneum of Douglas' sac, it will be advisable to dissect the peritoneum back so that it can be replaced after removal of the tumor, thus avoiding a raw area on the pelvic floor. If this precaution be not taken, intestinal loops are apt to drop down and become adherent. In these cases supravaginal hysterectomy is all that is required. This occasionally greatly diminishes the dangers of the operation. For example, in one of our recent cases in which we suspected carci- noma of the body a complete abdominal hysterectomy was com- menced. Release of the cervical portion proved to be very difficult on account of the very long cervix. With the gradual loosening up of the uterus we found strong suggestions of adenomyoma. The uterus was accordingly amputated through the cervix and at once opened. The diagnosis of adenomyoma was immediately confirmed. In this case complete removal of the uterus would have entailed much painstaking dissection and would have prolonged the operation in the case of a very anaemic woman. 1S6 CHAPTER XII PROGNOSIS IN CASES OF ADENOMYOMA OF THE UTERUS When considering these growths in 189(5, I agreed with von Recklinghausen that they are benign. 1 The glands are perfectly normal uterine glands and are surrounded by the normal stroma of the mucosa. They are confined entirely to the new growth and do not show the slightest tendency to invade the normal muscle. Wherever possible, it is always well to back up the impressions gained from histological study by the clinical sequence. And in two of our cases this has been unconsciously and yet admirably done. In Case 3600, on opening the abdomen, a diffuse myomatous thicken- ing was found in the posterior uterine wall. It was considered to be only a myomatous thickening, and a wedge-shaped piece of the growth was removed; in other words, a partial myomectomy was performed (Fig. 54). The histological picture as seen in Fig. 55 shows that the growth was a typical and diffuse adenomyoma of the uterus. The patient made a good recovery, and eleven years afterward, in response to an inquiry as to her condition, said that she had been greatly bene- fited by the operation and that she was in perfect health. The mass was certainly not entirely removed, and the subsequent history con- firms what was indicated by the histological findings, namely, the benign character of the growth. In Case 4415 we were also dealing with a diffuse myomatous uterine growth. A wedge, 5 by 2 cm., was removed through the abdomen. This patient also recovered. On examination the growth proved to be an adenomyoma. Here, also, notwithstanding the fact that portions of the growth were left behind, the patient was 1 Vod Recklinghausen, Friedrich: Die Adenomyome und Cystadenome tier Uterus und Tubenwandung; ihre Abkunft von Resten 'It- Wolff'schen Kor Berlin. 1896. is; 188 ADENOMYOMA OF THE UTERUS much improved. For two years she had no trouble, but since then the periods have been longer, and sometimes last for weeks. She has, however, been completely relieved of pain at the menstrual periods. We see, therefore, from the his- tological and clinical pictures that these growths are benign. Since these two cases were pub- lished 1 we have had several similar instances under observation. Fig. 54. — A portion of a diffuse adeno- 1IYOMA OF THE POSTERIOR "WALL OF THE uterus. (Slightly enlarged.) Gyn.-Path. No. 777. At opera- tion the posterior uterine wall was found much thickened. A wedge was removed and the cut surfaces were brought together as in an ordinary myomectomy, a is the peri- toneal surface; just beneath it is a narrow zone of normal muscle. The growth presents the typical appearance of a diffuse myoma. Along the outer margin it gradually merges into the normal muscle, b corresponds to the point nearest the uterine cavity. The uterine cavity was not opened. Scattered throughout the myoma are small round oval or oblong spaces. Some are dilated glands, others cross-sections of small blood-vessels. For the histological findings see Fig. 55. At the time the operation was performed we were unfamiliar with these adenomyomatous growths. CASES GRAPHICALLY ILLUSTRATING THE BENIGN CHARACTER OF ADENOMYOMATA OF THE UTERUS Gyn. No. 3600. Path. No. 777. Diffuse adenomyoma of the posterior uter- ine wall (Figs. 54 and 55). Removal of a wedge- shaped portion of the growth. Complete re- lief from former symp- toms. G. H. W., married, white, aged twenty-five. Admitted June 24; discharged July 20, 1895. The patient has been married ten years, but has never been pregnant. Her menses began at thirteen, were regular and always associated with severe pain, dull and grinding in character, with sharp paroxysms referred to the abdomen and in the back. This pain has been growing- much worse recently and has been associated with nausea. It is only present during the periods. The flow is very profuse and is growing more so. It is occasionally clotted. The patient has a slight leucorrhceal discharge. 1 Cullen, Thomas S.: Adenomyome des Uterus, Berlin, 1903. PROGNOSIS 89 Two months ago she noticed thai the abdomen was larger than normal. Operation, June 20, 1895. Myomectomy. A myo- matous thickening was noted in the posterior wall. This thickening extended from the cervix to the fundus, and the uterus was the Bize of that of a three months' pregnancy. A wedge-shaped piece was /* &?« * "& «**• X f — --c d Fig. 55. — Diffuse ajdenomyoma. (6 diameters.) G yn.-Path. No. 777. The section is taken from Fig. 54. The growth under the higher power was recognized as a diffuse myoma. At a and a' we find groups <>f glands resembling uterine glands both in form and in their even distribution. They are embedded in a definite stroma which separates them from the muscle. Some of the glands in the islands of mucosa show slight branching. At c the glands are arranged in "goose march" fashion. They are in all prob- ability sections of one and the same gland which has been much convoluted. At ./one of the glands is moderately dilated, e shows a more marked dilatation, and here SO much tension has taken place that little of the surrounding stroma remains. / corresponds very well to a miniature uterine cavity. On the one side it has become flattened out so that there is merely a layer of epithelial cells and a faint amount of stroma. On the opposite side is a well developed mucosa. Isolated glands are scattered throughout the growth. Without exception they arc surrounded by the characteristic stroma and nearly all closely resemble uterine glands. The cystic dilatation is to be expected where the glands are subjected to the myomatous pressure. excised from the posterior wall and the uterine walls were brought together. The length of the incision in the uterus was S cm. The patient made a satisfactory recovery. January, 1907. The patient is perfectly well eleven years after operation. G v n . Path. N o . 7 7 7 . — The specimen consists of sev- 190 ADENOMYOMA OF THE UTERUS eral large and small pieces of tumor. All of the tissue is pinkish- white in color, firm on pressure, and apparently composed of coarse fibres arranged in interlacing bundles (Fig. 54). Histological Examination . — The tissue consists of non-striped muscle fibres cut in various directions. Scattered here and there throughout it are glands occurring singly or in groups (Fig. 55). They are lined with high cylindrical ciliated epithelium and are surrounded by a stroma identical with that of the uterine mucosa. These glands are precisely similar to uterine glands. Some of them are dilated. Diagnosis . — Adenomyoma uteri diffusum benignum. Gyn. No. 4415. Path. No. 1207. Removal of a wedge-shaped piece of an adenomyoma of the posterior uterine wall. Complete cessation of the previous symp- toms for two years, followed again by pro- fuse menstruation. I. C. R., white, married, aged forty. Admitted May 28; dis- charged July 11, 1896. The patient has been married eighteen years and has never been pregnant. The menses commenced at twelve and were regular up to two or three years ago. Since that time they have occurred every twenty-second or twenty-third day The flow is profuse, dark and clotted, and associated with bearing- down pains in the abdomen and also with backache and pains in the legs. Micturition is frequent and the patient has a constant feeling of pressure on the bladder. The bowels are constipated. She suffers but little discomfort except at her menstrual periods. For the past year she has noticed a slight increase in the abdominal girth. Operation, June 1, 1896. Myomectomy. A wedge- shaped piece of the diffusely thickened wall was removed; also a pedunculated and partly cystic myoma, 5 by 2 cm. Convalescence was interrupted by an attack of phlebitis and one of pleurisy. The pleurisy developed at the base of the left lung and persisted for nine PROGNOSIS I'M days. The phlebitis developed in the femora] vein on the twenty- second day. The patient made a satisfactory recovery. She remained well for two years and then again began to have profuse menstruation. (; y n . Path. No. 1207 . — The specimen consists of a subperitoneal myoma and several fragments of an interstitial myoma. The subperitoneal myomatous nodule measures 5 by 5 by 4.5 cm. ; it is pinkish in color and on pressure is firm. Springing from its surface is a cyst 2.5 cm. in diameter. This is whitish in color, its walls are semi-transparent, and it contains clear yellow fluid. On section the nodule presents the typical myomatous appearance. The walls of the cyst average 3 mm. in thickness and are rather soft. The inner surface on one side is smooth; on the other, roughened. The cyst appears to be a portion of the myoma that has undergone degeneration. The tumor also contains another area of degeneral i< m measuring 2.5 by 1 cm. The fragments of the interstitial myoma are nine in number and the largest measures 4 by 3 by 1.5 cm. All of them are composed of bundles of coarse fibres forming an irregular network, in the meshes of which are minute cystic areas. One of these pieces is covered with peritoneum and the outer covering of normal muscle at that point is 4 mm. in thickness. The line of junction between the myomatous tissue and the normal muscle is sharply denned, but it is impossible to shell the tumor out at any point. Histological Examination. The subperitoneal nodule is composed of non-striped muscle fibres, which in places have undergone moderate hyaline degeneration, at other points complete hyaline transformation. The line of demarcation between the in- tact muscle fibres and the degenerated portions is abrupt. The interstitial myomatous tissue is also composed of inter- lacing bundles of smooth muscle, but shows very little tendency toward hyaline degeneration. Scattered between the muscle bundles almost to the peritoneal covering are groups of glands or single gland- like spaces. 192 ADENOMYOMA OF THE UTERUS These glands are small and round and sometimes send off one or more branches; some are dilated, reaching 1 to 2 mm. in diameter. They are lined with cylindrical epithelium, having oval vesicular nuclei situated in the centres of the cells. Surrounding the 'glands and separating them from the muscle is a moderate amount of stroma consisting of oval or elongate cells having oval vesicular nuclei. These cells are identical with the stroma cells of the uterine mucosa and the glands are in every respect similar to those of the uterus. The myomatous tissue has a moderately abundant blood- supply. Diagnosis . — Subperitoneal myoma. Interstitial adeno- mvoma of the uterus. CHAPTER XIII ORIGIN OF ADENOMYOMATA OF THE UTERUS In L896 von Recklinghausen reviewed the literature of adeno- myomata and added many new cases. After a careful consideration of all, he concluded that in the vast majority of instances the glandu- lar elements were derivatives of the Wolffian duct. This opinion was based upon the supposed close analogy between the elements of the Wolffian duct and the glandular structures present in adenomyomata of the uterus. In only one case was he certain that the glands were due to down-growths of the uterine mucosa. This case of von Reck- linghausen was included in the appendix to his most instructive treatise. Since his publication appeared, much attention has been devoted to this subject and quite a number of new cases have been reported. Many writers have espoused von Recklinghausen's theory, but not a few have claimed that nearly all, if not all, of these cases owe their origin to the uterine mucosa or to a portion of Midler's duct. It would be unnecessary for us to review at length this lively controversy, but to those wishing the full details we would recom- mend the careful presentation of the subject as given by von Reck- linghausen, 1 Meyer, 2 Pick, 3 and Kossmann. 4 In my previous publication 5 I reported nineteen cases of diffuse adenomyoma and pointed out that in the majority of these cases the process was still limited to the uterus, thus enabling us to determine definitely the origin of the glands in most of the rases. Since then 1 "\'«>ii Recklinghausen, Friedrich: Die Adenomyome und Cystadenome der Uterus- und Tubonwandung; ihre Abkunfl von Etesteo des Wolff'schen Korpers. Berlin, L896. '-' Meyer: Ueber Driisen, Cysten und Adenome im Myometrium bei Erwachsenen. Ztschr. I', (icl). u. Gyn., L900, Bd. xlvii, S. 618; xlviii, S. 130 u. 329. 3 Pick: Archiv. Fur Gyn., Bd. liv. * Kossmann, B.: Die Abstammung der Driiseneinschliisse in den Adenomyomen des Uterus und der Tuben. Arch. f. Gynaek., Bd. liv. s. 359. 5 Cullen, Thomas S. : Adeno-Myoma des Uterus, Berlin. 1903. 13 L93 194 ADENOMYOMA OF THE UTERUS we have subjected each myomatous uterus to the most careful scru- tiny, and wherever adenomyoma was suspected we have had very large sections made from many parts of the uterine cavity. If adeno- myoma was present and no connection between the glands in the depth and the uterine mucosa could be detected, we kept on cutting more tissue, until finally in the vast majority of the cases we found that the gland elements were derivatives of the uterine mucosa. I have been greatly helped in this work by Mr. Benjamin O. McCleary, our laboratory assistant. We have had fifty uncomplicated cases of diffuse adenomyoma of the uterus, some very extensive, others in their early stages. In every one of these cases we have been able by persistent search to trace the uterine mucosa into the myomatous tissue. In other words, islands of mucosa in the diffuse myomata originated from the mu- cosa lining the uterine cavity in every case. Any one can verify this statement for himself by studying the pathological description in each case. In six other cases there was squamous-cell carcinoma of the cervix and diffuse adenomyoma of the body. In five of the six cases the origin of the gland elements in the myoma could be traced to the mucosa. In one case (Gyn. 9971), where the process was a rather indefinite one, it was impossible to show the origin of the glands from the mucosa. We thus see that in fifty -five out of fifty-six cases of diffuse adeno- myoma of the body of the uterus the gland elements were shown to be derived in part at least from the uterine mucosa. In Gyn. 8438 and also in Sanitarium No. 1852 diffuse adenomyoma of the body and adenocarcinoma of the body were present. In both of these the uterine mucosa has been destroyed, and the carcinoma- tous growth so overshadowed the picture that the origin of the glands in the myomatous growth was naturally totally obscured. SUBPERITONEAL ADENOMYOMATA In eight cases we have found subperitoneal adenomyomata. In Case 8647 there was a large subperitoneal adenomyoma, and exami- ORIGIN OF ADENOMYOMATA OF THE UTERI - 195 nation of the uterine mucosa showed that the glands extended L.5 nun. into tlie muscle. Of course, no continuity will) the subperitoneal nodule could be traced. In Case 3293 subperitoneal cysts of an adenomyomatous type were found, but in this case the uterine muroa was normal. In Sanitarium Xo. 1872, in which the most typical adenomyoma lay perfectly free from the uterus, being attached to the utero-ovarian ligament (Fig. 41), the uterine mucosa extended into the muscle and the uterus was also the seat of discrete myomatous nodules. In Gyn. 5782 the adenomyomatous nodule was small and the uterine mucosa had been completely destroyed by the adeno- carcinoma. In the remaining case of subperitoneal adenomyoma the nodule alone was removed, and we had no chance to examine the uterine mucosa to determine if any continuity with the adenomyoma persisted. SUBMUCOUS ADENOMYOMATA We have had seven cases of submucous adenomyomata. Some consisted of diffuse myomatous growths containing only a few small glands. In others the glands had become cvstic; in one case the myoma was riddled with miniature uterine cavities. In this case the direct continuity with the uterine mucosa was readily established. Where the uterine glands are seen penetrating the myomatous muscle, as in Figs. 2, 3, 6, 15, and 30, there is no question as to their being derivatives of the uterine mucosa, and, as will be seen from a study of our cases, in the majority of which the uterus was removed. the mucous-membrane origin was established. This fact is very significant when compared with the figures of those claiming the Wolffian duct origin. With the increase in thickness and the ir- regular growth of the diffuse myoma it is very natural that the con- tinuity of the uterine glands into the depth should be lost after a time, as is evidenced by the formation of cysts. It is not necessary that the uterine glands be traced by continuity to establish the mucous- membrane origin. The islands of glands lying deep down in the myomatous muscle correspond identically with those seen in cases in 196 ADENOMYOMA OF THE UTERUS which the continuity is traceable, and moreover they are precisely the same as in normal uterine mucosa. Furthermore, they are sur- rounded by a stroma identical with that surrounding the uterine glands. In some cases miniature uterine cavities are scattered throughout the myoma. Fig. 22, taken from a cavity near the peri- toneal surface of an adenomyoma, could not be distinguished from normal uterine mucosa. From the uterine mucosa there is a periodic hemorrhage every month. According to Hartz, 1 Sanger, when speak- ing to his students of the uterine mucosa, said : " This is no simple mucous membrane, but is an organ which has an important function to fulfil." With Sanger's view I am in thorough accord. In no other part of the body do we find a mucosa with a similar function, and nowhere else do we meet with such histological peculiarities. Now, if portions of this uterine mucosa be far removed from the parent mucosa, we should still expect them to retain their function, and this they do. In nearly every instance in which cyst spaces are present, the cavities are, in part or almost completely, filled with blood; and even in the small and undilated glands blood is fre- quently present, or the epithelial cells contain blood pigment, the remnants of old hemorrhages. It is natural that the cysts in the uterine walls should remain small, as they are compressed by the muscle; on the other hand, when they have once become subperi- toneal they may dilate until they can contain several litres of blood, although even in these cases they still show the evidence of the menstrual phenomenon as seen in their chocolate-colored contents. In the solid portions of these growths islands of typical uterine mu- cosa are still demonstrable. It is so easy to understand how inter- stitial myomata become subperitoneal or submucous, and yet in considering the subsequent history of adenomyoma the majority of authors have forgotten to apply the same principle. When the growth becomes subperitoneal, we should expect its glandular ele- ments to gradually lose their continuity with those of the mucosa, and such is the case. Hence the confusion as to their origin. Case 1 Hartz, A. L.: Neuere Arbeiten ueber die mesonephrischen Geschwiilste. Mon- atsschrift f. Geburtshulfe unci ( lynaekologie, 1901, Bd. xiii, S. 95 u. 244 ORIGIN OF ADENOMYOMATA OF THE I TER1 - 19*3 2 of Broils' and Kroenig's case illustrate very well the intraligament- ary variety. In Kroenig's case we have all the elements of normal uterine mucosa, and also large cysts. In Breus' case we find the same, but fortunately the communication between the uterine mucosa and the cystic tumor still persists, showing beyond doubt that the gland elements in this case were from the uterine mucosa. A definite example of a portion of a diffuse adenomyoma becom- ing subperitoneal is furnished by Lockstaedt. 1 The adenomyoma occupied the posterior wall and right side, and in the gross specimen it was possible, in at least five places, to see the mucosa extending deeply into the myoma. In this case there was a subperitoneal adenomyoma, the size of a cherry, that by its pedicle was in direct communication with the diffuse growth, so that its glands were un- doubtedly derivatives of those of the uterine mucosa. Were we in need of still further proof that these islands of mucosa are identical with normal uterine mucosa the case reported by J. Whitridge Williams' would certainly tend to convince the most skeptical. In examining the uterus of a patient entering the hos- pital in a desperate condition and dying two hours after labor he found that it was the seat of a diffuse adenomyoma and that the stroma of these islands had been converted into typical decidua. A somewhat similar decidual formation is reported on page 247. In this case I found a subperitoneal myoma near the right uterine horn. On the left side was an unruptured tubal pregnancy. The stroma of the adenomyoma had been in part converted into decidual cells, although the adenomyoma was at least 9 cm. away from the tubal pregnane)'. ' Breus, Carl: Ueber wahre epithelfiihrende Cystenbildung in Uterus-Myomen. Leipzig und Wien, L894. - Kroenig,B.: Kin Retroperitoneal ireleirenos voluminoses Polycystom entstanden aus Etesten des Wolff'schen Kdrpers. Beitrage zur I leb. u. Gyn., L901, Bd. iv,S. 61. s Lockstaedt: Ueber Vbrkommen und Bedeutung von Driisenschlauchen Lndeo Myomen Uterus. Monatschr. f. Geb. u. Gyn., L898, Bd. vii, S. L88. 'Williams, J. Whitridge: Decidual Formation Throughoul the Uterine Muscu- laris: A Contribution to the Origin of Adenomyoma <>t' the Uterus. Transactions of the Southern Surgical Association, 1904, vol. xvii. 198 ADENOMYOMA OF THE UTERUS RESUME In the examination of fifty uncomplicated diffuse adenomyomata of the uterus the mucous-membrane origin of the glands could be traced in every case. In six additional cases where squamous-cell carcinoma of the cervix complicated adenomyoma of the body the continuity was established in five cases. In the two remaining cases of diffuse adenomyoma of the body the clue as to the origin of the glands was destroyed by the presence of adenocarcinoma of the body. Thus in only one case out of fifty-six in which we expected to find the glands originating from the mucosa, if our view as expressed in 1896 was correct, did we fail to find it substantiated. In the re- maining fifteen cases of subperitoneal or submucous adenomyomata we would naturally not expect to trace the relationship between the mucosa and the glands in the myoma ; nevertheless in one case, Gyn. No. 10,314, the mucosa had literally flowed into the myoma. It will thus be seen that when we include adenomyomata of every kind, out of subperitoneal, submucous, or diffuse, we have been able in fifty-six out of seventy -three cases to trace the origin of the gland elements to the uterine mucosa. All adenomyomata of the uterus in which the gland elements are similar to those of the uterine mucosa, and are surrounded by stroma characteristic of that surrounding the normal uterine glands, owe their glandular origin to the uterine mucosa or to Muller's duct, no matter whether they be interstitial, subperitoneal, or intraligament- ary, whether solid or cystic. 1 1 Frequently there are small cyst-like spaces apparently just beneath the per- itoneal surface of the uterus. These are lined with a single layer of cuboidal cells and rest directly on the muscle. They are due to depressions from the peritoneal surface, but at another level. In favorable sections their continuity with the per- itoneal cavity can be traced. Meyer has recently pointed them out. We thoroughly agree with his findings, and have also often met with them on the under or protected side of tubal adhesions or lining the small depressions occurring on the surface of the ovary. The peritoneal cells, where protected, tend to become cuboidal. CHAPTER XIV CAUSES OF ADENOMYOMA OF THE UTERUS We thought that possibly pregnancy with its incident extensive stretching of the uterus might leave crevices into which the mucosa could later flow. A reference to page 174, however, show- thai fifteen out of forty-nine patients had never been pregnant, so that even were this a possible cause we must find another solution for those cases in which the adenomyoma had developed in a uterus that had never been subjected to the stret chins; incident to pregnancy. From a study of the clinical history we gain no clue as to the causation. Histological examination in a number of cases gives a decided impression that the diffuse myomatous growth is the primary factor. In these cases there is a myomatous tendency, as evidenced by the almost constant presence of discrete myomatous nodules. The uterine mucosa flows into the chinks of the diffuse myomatous growth. As has been pointed out so frequently, the surface of the mucosa is perfectly regular and intact and the uterine glands are in no wise altered. The only pathological change, in such cases, lies in the extension of normal glands into the crevices throughout the myomatous growth. [99 CHAPTER XV HYPERTROPHY OF THE CERVIX AND DIFFUSE ADENOMYOMA OF THE BODY OF THE UTERUS In the examination of thousands of specimens this is the most unique we have ever encountered. There is a marked increase in the size of the cervix due to simple hypertrophy, while the fundus has kept pace by the development of an adenomyoma. We ac- cordingly have a uterus which, although greatly enlarged, still has retained its relatively normal proportions. Gyn. No. 6240. Path. No. 2532. Very extensive hypertrophy of the cervix; diffuse adenomyoma of the anterior and poste- rior uterine walls (Fig. 56) with glands origin- ating from the uterine mucosa. L. C, aged fifty-two, married, white. Admitted July 15, 1898 ; dis- charged September 20, 1898. Complaint: Prolapsus of the uterus and uterine hemorrhage; pain in the abdomen. Her menses began at sixteen and were profuse, occurring every three weeks and lasting from seven to eight days. They have been irregular for the last two years and have been more profuse, the bleeding assuming the pro- portions of a hemorrhage. There has been a leucorrhcea and pro- fuse vaginal discharge for many years. The patient has had nine children, the eldest thirty years, the youngest fourteen. On examina- tion a large tumor is found projecting through the outlet — apparently Fig. 56. — Very extensive hypertrophy of the cervix, discrete myoma and diffuse ADENOMYOMA OF THE BODY OF THE UTERUS. (Natural size.) Gyn. -Path. No. 2532. We have purposely had the specimen drawn the natural size so that an accurate idea of the great and almost uniform increase in size of this organ is obtained. The cervix shows a very extensive hypertrophy, but is everywhere intact. A few of the cervical glands are dilated. At the fundus the subperitoneal myoma is seen. The uterine walls show considerable diffuse myomatous thickening, and scattered throughout them are seen islands of typical uterine mucosa. The continuity between them and the parent mucosa has in places been traced. 200 ASSOCIATED in PERTROPH? OF < |.I;\ i\ 2( Fig. 56. 202 ADENOMYOMA OF THE UTERUS a complete prolapsus. The cervix is very prominent, 7 cm. in diam- eter and apparently ulcerated. Operation . — Vaginal hysterectomy; repair of perineum. Path. No. 2532 . — The specimen consists of the uterus, tubes and ovaries intact. The uterus is exceedingly long, being 16 cm. in length, 7 cm. in breadth, and 4 cm. in its antero- posterior diameters (Fig. 56). It is free from adhesions. The pos- terior surface presents a more or less even appearance, while the anterior surface is round and shows a nodular mass just beneath the attachment of the left tube. The great length of the uterus is due to hypertrophy of the cervix, as the cervical portion is fully 8 cm. long. The outer portion of the cervix is rough and nodular and everywhere covered with mucosa. The mucosa lining the cervix is gathered up into folds. The mucous membrane of the body of the uterus in some places reaches 3 mm. in thickness. Both uterine walls present a coarse myomatous striation. Histological Examination . — The hypertrophy of the cervix is confined chiefly to the over-growth of the stroma. The surface epithelium is everywhere intact. The papillae are in places long and branching and the overlying epithelium shows more hornification than usual. Sections from the anterior wall show that the mucous membrane is normal, but slightly thicker than usual. The wall is com- posed of diffuse myomatous tissue and scat- tered throughout it are typical islands of uterine mucosa. In a few places direct con- tinuity from the mucosa into the depth can be traced. The posterior wall also shows normal uterine mucosa with some thickening. Here there is likewise a diffuse adenomyoma. The islands of mucosa throughout the myoma closely resemble normal mucosa. In many places extension of the mucosa into the depth can be traced. Diagnosis . — Very extensive hypertrophy of the cervix ; diffuse adenomyoma of both the anterior and posterior uterine walls. CHAPTER XVI ADENOMYOMA IN ONE HORN OF A BICORNATE UTERUS It is interesting to find one horn of a bicornate uterus the seat of an adenomyoma. Whether the opposite horn was likewise involved we cannot say, as the uterus was not removed. From a clinical standpoint it is also instructive, as in this case there was absolutely no connection between the vagina and the uterine cavity, there being practically no cervix. The condition in this case absolutely excludes any possibility that pregnancy has necessarily any causal relation to the development of the adenomyoma. Gyn. No. 10,516. Path No. 6764. Early adenomyoma in the left rudiment a r y horn of a bicornate uterus ( Fig. 57), the g 1 a n d s coming from the uterine mucosa. V. P., black, aged twenty-four, married. Admitted May 27. 1903; discharged June 25, 1903. Complaint: Absence of menstrua- tion. The menses did not commence until she was twenty-one. Then there was just a slight stain once, and none since. There has been severe pain in the left side and back every month for the past nine years. She was married at twenty-one, but has had no children. On ether examination a normal vagina was found extending in- ward for 5 cm., but no apparent opening could be made out between the vagina and the pelvic organs above. Bimanual examination of the left side showed a uterus apparently larger than normal. The cervix was separated from the vagina by a distance of at least 1 or 2 cm. and apparently was not connected with it by adhesions or any bands of tissue. The cervix projected to the left. Operation, June 4, 1903. An attempt was made to form a new cervical canal, but this was given up because no connec- tion could be made out between the cervix and body, and also 203 204 ADENOMYOMA OF THE UTERUS because the external os was not patulous. Through the abdominal incision the following conditions were made out : On the left side was a small rudimentary uterus, 3 by 1.5 cm. There was no cervix and the organ was directly connected with a band of tissue, the latter in turn being connected with the cervix on the right side. Above the uterus was a large flattened tube with a normal fimbriated extremity and a normal ovary. On the right side the uterus was well developed and a little larger than normal. The cervix was poorly formed and had no external opening. The tube on this side had a normal fim- briated end and the ovary was normal. There were a number of A V 'bp\ V 7 ' "M. 1 ? V v r~ n V, > i'-j / \ : V / ,•- Vaj. \ Fig. 57. — Adenomyoma in one horn of a bicornate uterus. (| natural size.) Gyn.-Path. 6764. The left horn, which was removed, is sketched, but the right horn is merely outlined. In this case there was no trace of any connection between either uterine horn and the vagina. adhesions to the upper part of the fundus and to the ovary, and several cysts containing clear fluid. Owing to the condition of the cornu on the left side, it and its appendages were removed. The patient made an uninterrupted recovery. Path. No. 6764 .—The globular body of the uterus is 5 cm. in diameter and covered with adhesions (Fig. 57). To it is attached a small left tube 5 cm. long, apparently normal, and an ovary measuring 3 by 2 by 1 cm. The lower third of the body of the uterus contains no uterine cavity. In the upper third is seen a cavity 1 cm. long. The lining mucosa apparently shows no change. ADENOMYOMA IN ONE CORNU OF A BICORNATE I TER1 8 205 On h i s t o 1 o g i c a 1 e x a m i n a I i o n i be uterine mucosa is found considerably thickened and the skein-like arrangement of the glands is particularly well marked. Seal tered every- where throu g li out t li e u t e r i ii e w all. particu- lar! y a 1) u n d a n I i n t h e v i e i n i t y o i* 1 li e in u c 8 a . are islands of uterine m u c o s a . These somet imea consist of large areas of mucous membrane and sometimes of a single gland surrounded by stroma and often much dilated. The muscle shows just the faintest tendency toward myomatous transformation. This is more evident macroscopically than microscopically. W i t h the naked eye the uterine mucosa can he traced directly into the d e p t h in places f o r a distance of 3 mm. We have here a diffuse adenomyoma in which the glands play the major role. It is particularly interest ing to find an adenomyoma in one half of a bicornate uterus. The histological picture in this case would lead one to infer that the glands first existed I and that the myomatous change was a secondary phenomenon. This is the first case that has suggested this origin to us. CHAPTER XVII DIFFUSE ADENOMYOMA OF THE BODY OF THE UTERUS OCCURRING IN CASES OF SQUAMOUS-CELL CARCINOMA OF THE CERVIX Since the appearance in 1903 of a previous communication, 1 in which I reported a case of squamous-cell carcinoma of the cervix associated with diffuse adenomyoma of the body of the uterus, I have examined five similar cases. The simultaneous occurrence of both these processes in six cases in the records of one laboratory certainly indicates that the coexistence of these two diseases is no rarity. When we see what a large number of adenomyomata have been detected when the uteri are carefully and systematically ex- amined, and knowing how wide-spread is squamous-cell carcinoma of the cervix, it is little wonder that these two processes are fre- quently found in the same uterus. The symptoms of the carcinoma of the cervix would naturally completely overshadow those of the adenomyoma. Consequently the marked extension of the uterine glands into the depth would not be suspected until after removal of the uterus. Gyn. No. 12,918. Path. No. 9841. Squamous-cell carcinoma of the cervix; diffuse adenomyoma of the uterine walls with direct extension of the uterine mucosa into the depth (Fig. 58). H. G., married, aged forty-two, black. Admitted May 9, 1906; discharged June 2, 1906. The patient has been married twenty-four years and has had four children, the oldest nineteen, the youngest fifteen. The clinical history is of little importance, as the symptoms of the carcinoma of the cervix and adenomyoma of the body merge so imperceptibly one into the other. 1 Cullen, Thomas S.: Adenomyoms des Uterus, Berlin, 1903. 206 ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 207 Operation. Pan-hysterectomy. The entire growth was apparently not removed. The appendages were adherenl to the T" MM '■»■>-*•; ■^ *&>§>* W0H» /J .%/»* -;*T" ^. « . - •'" J. * ,^t^- v. - 'rr:~ b B Fig. 58. I >iffuse adenomyom \ i\ thb bodt of THE i i ERi s. (6 diameters. G y n.-Path. 9841. The section is From the upper part of the uterus, a indicates the ut iM-ine cavity and b and b' the normal thickness of i he mucosa. The surface epithelium is intact and the glands are of the normal appearance, but the mucosa is everywhere flowing into the under- lying myomatous muscle, as is particularly well seen at C, d, and i . Section- at another level would show that the apparently isolated islands / and g are also continuous with the mucosa lining the uterine cavity. posterior surface of the uterus and were enlarged. The patienl made a very satisfactory recovery. Her highesl post -operative tempera- ture was 101.8° F. 208 ADENOMYOMA OF THE UTERUS Path. No. 9841 . — The specimen consists of the uterus entire. It' is 10 cm. in length. The cervical portion presents a worm-eaten appearance and this growth apparently extends to the cut surface anteriorly. Upward the growth can be traced as far as the internal os. In the body of the uterus the muscle varies from 2 to 2.5 cm. in thickness. On making an examination through the right cornu we find that the inner zone of muscle over an area 2.5 cm. in diameter presents a diffuse myomatous thickening. There is an area covered by muscle 6 mm. in thickness. Exactly the same con- dition is noted on the left side, except that the myomatous muscle extends almost entirely through the wall. The uterine walls are covered, both anteriorly and posteriorly, with dense adhesions. The tube on the right side is involved in adhesions and is the seat of a hydrosalpinx. On the left side we have a typical follicular hydrosalpinx. Histological examination was made of sections embracing the uterine cavity and the anterior and posterior walls. Even with the dissecting microscope a most complete idea of the condition is obtainable. The surface epithelium is intact, the glands are normal, and the mucosa is seen penetrating the muscle in all directions. Nearly everywhere in the depth one is able to trace the continuity of the islands of mucosa with that lining the uterine cav- ity (Fig. 58). In the depth we have large areas of uterine mucosa, some of them 5 mm. in thickness. Occasionally some of these deep-seated uterine glands are dilated. At one point in the depth is a miniature uterine cavity, 9 mm. in length, varying from 2 to 3 mm. in diameter. It is lined with one layer of epithelium which has taken up a great deal of blood pigment. Beneath this is a zone of stroma separating it from the muscle. The cavity is filled with blood — the remains of the former menstrual flow. The inner layers of the uterine muscle show diffuse myomatous transformation. We have here a squamous-cell carcinoma of the cervix, diffuse adenomyoma of the anterior and of the posterior uterine wall, with the gland elements originating from the mucosa. ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 209 / Gyn. No. 9971. Path. No. 6150. S q u a in u s - c ell c a r c i n m a f 1 h e c e r v i x (Fig. .V.) : diffuse a deno- 111 y m a of t h e body of the uter- u s . A. S., married, aged forty, white. Admitted October 8, 1902; dis- charged November 12, 1902. Complaint: Uter- ine hemorrhage and a watery discharge. The patient has been married twenty-four years and has had four children; the oldest twenty-three, the youngest seventeen. Fig. 59. — Squamous-cell carcin- oma OFTHE CERVIX; DISCRETE, SUBPERITONEAL AND INTER- STITIAL MYOMATAJ DIFFUSE ADENOMYOMA OF THE POSTE- RIOR OTERINE WALL. (Natural size. 1 Gyn . No. 9971. Gyn.- Pa 1I1. X ... 61 •">(). The lower picture represents the cervix with a small cuff of vaginal mucosa sur- rounding it. The cervix presents a roughened and slightly nodular appearance due to the carcinoma. From tlic upper picture we see that the growth has invaded the cervix to a considerable extent . Situated in the fundus are two discrete myomata. The posterior wall shows diffuse myomatous thickening and at several points, indicated by ''. discrete myomata are scattered throughout the diffusely thickened myomatous tissue. Histological examination shows islands of mucosa scattered abundantly throughout the diffuse myoma. 14 210 ADENOMYOMA OF THE UTERUS The labors were normal. The patient was well until May of this year, when she had a slight hemorrhage and later noticed a slight serous discharge, which was irritating. Operation .—On examination of the cervix so strong was the suspicion of carcinoma that a complete hysterectomy was done. The appendages were adherent to the posterior surface of the uterus and the cervix was released with a great deal of difficulty. After operation there was excessive nausea and fecal vomiting for several days. For the first ten days the patient's life hung in the balance, but later on convalescence was rapid. The highest post- operative temperature was 100° F., on the second day. Path. No. 6150 . — The specimen consists of a myoma- tous uterus which has been removed entire. The myoma devel- oping in the anterior wall is 4 cm. in diameter. Below this and posterior to it is a similar one. The uterus is 12 cm. long and 6.5 cm. broad. The anterior lip is denser than the posterior and suggests a new growth. On careful examination both lips are seen to present a finely granular appearance (Fig. 59). The uterine cavity measures 3.3 cm. in length. The posterior uterine wall is fully 3 cm. in thickness and presents a fine diffuse myomatous appearance. On histological examination the cervix is found to be the seat of a squamous-cell carcinoma. This has not been entirely removed. Sections from the posterior wall of the uterus show that it is everywhere infiltrated with irregular islands of uterine mucosa. The tissue is made up of diffuse myomata. In the anterior wall there is a thickening of the uterine mucosa, but it is normal. In the examination of mairy sections only at one point is noted a slight tendency for the mucosa to extend into the depth, and one cannot with any degree of certainty say that there is a direct continuity with the glands in the endometrium. We are here dealing with squamous-cell carcinoma of the cervix, interstitial myomata, and diffuse adenomyoma of the posterior wall. ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 211 C. H. I. No. 511. Path. No. 8426. S <| u a in 11 iis-ccl I c a r c i n m a I t h c c c r v i x : diffuse a (1 e n in y (» in a f t li e b d >' W i 1 h the g 1 a n (1 elements c o m i n g f r in 1 h e in 11 c s a . E. J. lv., married, aged sixty, white. Admitted March 21, L905; died March 24, 1905. Complaint: Uterine hemorrhages and pain. (The patient had a definite squamous-cell carcinoma of the cervix which obscured the other symptoms.) The patient has had ten children, the eldest thirty-six, the youngest ten years; no mis- carriages. In September, 1904, she was paralyzed on the right side. It was three months before she regained complete control over her right hand. Operation . — Complete hysterectomy was performed. The patient did well for the first day, was restless on the second day. There was complete suppression of urine, although the ureters had been carefully dissected out and had been found to be in no way obstructed. She soon became cyanosed and there was muscle twitching; she died on the second day after operation. Path. N o . 8426 . — The specimen consists of the uterus and of a part of the vagina; also of the tubes and ovaries. The cervix is the seat of an extensive carcinoma which involves the posterior lip and a portion of the vagina. There are also some nodules in the vagina. Posteriorly the growth apparently extends to the line of incision and out into the left parametrium. The body of the uterus looks normal. On histological examination the cervix pre- sents a far advanced squamous-cell carcinoma. The chief interest is centered in the endometrium. The uterine walls are atrophic, and with the low power one can see very large blood-vessels in the outer layers. These show beginning oblitera- tive changes. The muscle of the uterine wall is exceedingly dense and looks myomatous. T h e e n d o in e t r i u in i s a t r p hie. but at s e v e r a 1 points w e c a n trace it e x t e n d - i n g a 1 o n g dist a n c e into the d e p t h . We have here a mild grade of adenomvoma. 212 ADENOMYOMA OF THE UTERUS Diagnosis. — Squamous-cell carcinoma of the cervix; moderate diffuse adenomyomatous formation in the body of the uterus. Gyn. No. 12,060. Path. No. 8602. Squamous-cell carcinoma of the cervix; diffuse adenomyoma of the body of the uterus with the glands originating from the mucosa. L. N., married, aged fifty-six, white. Admitted April 18, 1905; discharged May 21, 1905. The patient has had four children, the youngest fourteen years old. The menopause occurred two years ago. Operation . — Panhysterectomy. As the growth was far advanced the operation was fraught with much difficulty. The highest post-operative temperature was 101.4° F. The patient made a satisfactory recovery. Path. Xo. 8602 . — The specimen consists of the uterus, which is almost normal in size, and of the appendages. The uterus with the enlarged cervix is 9 cm. in length, 6 cm. in breadth, and 4 cm. in its antero-posterior diameters. Anteriorly it is smooth and glistening. Posteriorly it is almost free from adhesions. The cervix has been converted into a crater-like cavity approximately 5 cm. in diameter. The outer vaginal portions of the cervix are normal, but posteriorly and anteriorly it is wanting, the tissue presenting an eaten-out wormy appearance. Anteriorly the growth extends almost to the cut surface. On section, macroscopically the growth can be traced for at least 1 cm. into the underlying tissue. The uterine muscle shows little or no thickening, but the inner layers are somewhat coarser than usual. The mucosa varies from 1 to 2 mm. in thickness. Histological examination shows a typical squa- mous-cell carcinoma of the cervix with a good deal of small round- cell infiltration along the margins. The cervical glands are con- siderably dilated and the stroma in the cervical portion has not quite the ordinary appearance and somewhat resembles muscle. ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 213 Sections from the mucosa show thai the surface epithelium is in places intact; at many points, however, it has been mechanically removed. The glands are normal in size, bul at other points are dilated, and the cell protoplasm is undergoing disintegration. At some points we have isolated glands penetrating the muscle and extending into the depth in funnel-shaped forms. In ot h e r places t w r t h r e e g lands can be t r ;i C e d for at least 4 mm. i n t o the u n d e r 1 y i n g t issue. This extension into the depth is noted at several points, and in the underlying muscle are islands of perfectly normal mucosa. The muscle surrounding the uterine cavity is denser than usual and is undergoing a diffuse myomatous transformation. The muscle in the outlying portion is fairly normal. We have here an adeno- myoma in which the gland elements are derived from the uterine mucosa. Diagnosis . — Primary squamous-cell carcinoma of the cer- vix; diffuse adenomyoma of the body of the uterus. Gyn. No. 12,304. Path No. 8890. Squamous-cell carcinoma of the cervix. The chief interest lies in the adenomyoma of the body. L. S., aged fifty, white. Operation, August IS, 1905. Pan- hysterectomy. Sections from the endometrium show that t h e m u c o s a c a n be in places traced for at 1 e a s t 3 or 4 mm. into the u n d e r 1 y i n 12; m u s c 1 e . It shows a typical myomatous picture. We have here a diffuse adenomyoma with carcinoma of the cervix. Gyn. No. 3126. Path. No. 493. S q u a m o u s - c e 1 1 c a r c i n m a of t h e c e r v i x Fig. 60). A d e n m y o m a f the bod y f t h e u t e r u s . L. E. II., white, aged fifty-six, a widow. Admitted October 21. L894; discharged November 25, 1894. The patient entered the 214 ADENOMYOMA OF THE UTERUS hospital complaining of pain in the rectum and lower part of the back. She had had some hemorrhage. Two paternal aunts had died of phthisis, and her mother of cancer of the uterus at forty-nine years of age. Her paternal grandmother was also supposed to have died of cancer of the uterus. Menstrual History . — The periods commenced at six- teen; they were always regular, but painful during the first few years. She suffered from membranous dysmenorrhcea. For the last ten years there has been an offensive odor at the menstrual period. The menopause occurred at fifty-three. She had had several chil- dren. Present Illness . — For five or six years before the menopause, which occurred three years ago, the patient suffered with irregular and severe hemorrhages from the uterus. From the time of the menopause no hemorrhages occurred, but the patient complained of nervousness. In July of this year she noticed a yellowish vaginal discharge. In August she complained of pain in the lower abdomen and of some swelling in the legs. In July and August the desire to urinate was constant. These symptoms have subsided since then. The bowels are markedly constipated and defecation is accompanied by hemorrhage. There is, however, no tingeing of the stools with blood. The patient is very anaemic and nervous, but there is no marked emaciation. Operation . — The carcinoma of the cervix was curetted away as far as possible with the finger. After thorough cleansing of the uterus the vagina was incised, an area around the margin of about 1 cm. of normal mucosa being loosened up with the cervix. An abscess between the uterus and rectum was then opened and about 2 c.c. of creamy pus escaped. The vaginal edges were brought together so that the diseased area of the cervix was completely walled off. The abdomen was then opened and the uterus removed from above. Considerable difficulty was experienced, however, on ac- count of the extension of the growth to the broad ligament. The patient made a good recovery and was discharged on November ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 215 25th. The nervous symptoms were, however, prominent. Re- appearance of the growth was noted and the patienl died sixty days after operation, apparently of exhaustion. Gyn.-Path. No. 493. The specimen consists of the ■^S^SBBA m^y A 8 Fig. 60. — Commencing diffuse adenomyoma of the body of the uterus associated "WITH ADVANCED SQUAMOUS-CELL CARCINOMA OF THE CERVIX. t ,''„ natural size.) Gyn.-Path. No. 493. A, The lower part of the cervix and surrounding portions of the vaginal vault arc replaced by a new growth having a shaggy surface due to myriads of finger- like outgrowths. Laterally this growth extends practically to the broad ligament attachment: upward its confines are indicated by the letters a. a. The upper part of the cervix and body seem little altered. At b is a small polyp. The mucosa in the upper part of the cervix and in the body is very thin hut smooth. />'. a longitudinal section of .t. The extent of tin 1 growth in the posterior wall is clearly outlined at a. The cystic cervical polyp is seen at c. The posterior wall is made up of two distinct portions, an outer consisting of normal muscle and an inner pre- senting a diffuse myomatous appearance. This coarse tissue extends directly to the mucosa. At '/ is a small discrete myomatous nodule. From the text it will lie noted that the uterine walls show a commencing myomatous transformation and that the glands in many places pene- trate the muscle for a distance of mm. uterus with its appendages intact. The uterus measures 8 by 6 by 3 cm. and both anteriorly and posteriorly is smooth and glisten- ing. Occupying the outer portion of the cervix, both anteriorly and posteriorly, is a worm-eaten and in part papillary-like surface (Fig. 60). In the latter portion the little elevations are found to 216 ADENOMYOMA OF THE UTERUS consist of small finger-like or knob-shaped processes, some of which apparently branch. Anteriorly the growth extends out to the vagina, while posteriorly it involves the vault for at least 1.5 cm. On section it is found that only the outer portion of the cervix is implicated and that the cervical mucosa for a distance of 2.5 cm. is still intact. Several of the cervical glands are dilated, and projecting into the canal is a small polyp. The uterine cavity is 3 cm. long. Its mu- cosa, which appears to be less than a millimetre in thickness, is smooth and glistening. Situated on the left side of the cavity is a pale bluish-white polyp 1 cm. long, 1.2 cm. broad, 4 mm. thick. The tubes and ovaries present their usual appearance. Histological Examination . — The worm-eaten cer- vix shows considerable necrosis of its surface. The underlying tissue is everywhere infiltrated by masses of cells having a finger-like or branching arrangement. Some of these have been cut across and appear as circular nests. Scattered throughout the alveoli are numerous areas in which the cell protoplasm stains intensely with eosin. The concentric arrangement of the cells is suggestive of epithelial pearls. The new growth appears to extend nearly to the margin of the incision. Whether or not it has been entirely removed, it is impossible to say. The tissue surrounding the alveoli shows marked small round-cell infiltration along the advancing margin of the growth. The cervical glands, just within the external os, are normal, but as one approaches the internal os many of them are dilated. The uterine mucosa near the internal os and also that throughout the cavity shows considerable dilatation of its glands and scattered throughout the stroma are numerous small round cells. Pene- trating the muscle in many places to a depth of 9 mm. are bunches of very small glands, which are separated from each other and also from the muscle by the usual amount of stroma. They are abnormal dippings-down of the mu- cosa, which do not, however, show the least sign of malignancy. The uterine wall shows some hyaline degeneration. The muscle tends to become myomatous and in one place contains a myoma 4 ASSOCIATED SQUAMOUS-CELL CARCINOMA OF CERVIX 217 mm. in diameter. The uterine polyp consists of mucosa and a few of its glands are dilated. The appendages are practically normal. D i a g n o s i s . — Squamous-cell carcinoma of the cervix ; ex- tension of the uterine glands into the muscular walls, which show a tendency to become myomatous; small interstitial myoma; nor- mal appendages. CHAPTER XVIII ADENOCARCINOMA AND ADENOMYOMA OCCURRING INDEPENDENTLY IN THE BODY OF THE SAME UTERUS The following case is interesting on account of the fact that an adenocarcinoma of the body of the uterus and a small but typical subperitoneal adenomyoma are associated in the same uterus. Of course, the one is in no way dependent on the other. Gyn. No. 5782. Path. No. 2084. Adenocarcinoma of the body of the ut- erus (Fig. 61); small myoma in the anterior wall; small adenomyoma in the posterior wall; hysterectomy. M. K., aged fifty-six, admitted January 12, 1898, complaining of pain in the lower abdomen. The menses were irregular, oc- curring at intervals of from two to six weeks. They were very painful and lasted from three to seven days. They ceased four years ago. About a year and a half ago a bloody discharge was noticed which at times was clotted. During the last six months it has been frequent, but at no time has it been offensive. The patient has been married twenty-one years. She has had one child and no miscarriages. She has never been strong, and during the past year has had severe pain in the lower abdomen extending down the legs. At present the bowels are constipated. On Jan- uary 12th the cervix was dilated and a small amount of tissue was removed for examination. The uterus was slightly enlarged but freely movable. Two nodules could be seen on the posterior sur- face. Gyn. -Path. No. 2075 . — The specimen consists of a con- siderable amount of curettings. The tissue is composed of small pieces which do not present the smooth glistening surface of normal 218 ADENOCARCINOMA AND ADENOMYOMA 1 \ THE SAME I TER1 - 219 mucosa. They are finely gi out-growths. ( )n histological examination adenocarcinoma of the body of the uterus was found and hysterectomy was advised. The uterus was re- moved in the usual way. The patient madeagood recovery and was discharged February 15, 1898. Gyn.-Path. N o . 2 8 4 . — The specimen con- sists of the uterus with the appendages. The uterus is 8 cm. in length, 5.5 cm. in breadth, and 5 cm. in its an- teroposterior diameter. Its surface is deep red in color and free from adhesions, but projecting from the posterior portion is a small, firm nodule 1.2 cm. in diameter (Fig. 61). The outer surface of this no- dule is covered with a calcar- eous plate 2 mm. in thickness. On section the growth is found to be continuous with the uterine muscle, with which it is intimately associated, the sharp line of demarcation so characteristic ofmyomata be- ing wanting. The calcareous deposit has extended into the nodule at one point. The c mucosa is finely granular and ly granular or .-how minute, papillary-like Adeno -carcinoma. Adeno- •myoma. - Mvci Fig. n one side is a discrete myoma, while on the opposite side is an adenomyoma. ( )ne tube is markedly distended with pus and has been densely adherent, as is indicated by adhesions. One ovary is much enlarged and occupied by a new growth. Histological examination showed that the growth was a primary adenocarcinoma of a totally different type from that occupying the uterus. There were in this pelvis five distinctly independent patho- logical processes. We often make a very positive diagnosis before operation, only to find, when the abdomen is opened, a condition totally different from that we had expected. Xo surgeon could possibly have given an accurate diagnosis in such a case as this. From the contour one might readily have diagnosed a multinodular and adherent my- omatous uterus. The carcinoma could, of course, have been readily recognized upon examination of scrapings from the body. CHAPTER XXI DIFFUSE MYOMATOUS THICKENING OF THE UTERUS BUT NO GLANDULAR INVASION Whenever the uterus is the seat of diffuse myomatous thicken- ing, adenomyoma will immediately be suspected. On histological examination in the vast majority of cases, gland elements will be found scattered throughout the growth. There are a few cases, however, in which the diffuse growth exists and yet no invasion of glands has occurred. The following cases belong to this group. In Sanitarium No. 1847 there was also a suppurating submucous myoma. In Case No. 12,221 the increase in size of the uterus was due in part to a diffuse myomatous thickening, but chiefly to a recent pregnancy. Even in cutting the uterus open adenomyoma was suspected, and not until the histological examination showed no gland invasion, and decidual cells were demonstrated, was an exact diagnosis made. H. A. K. Sanitarium 1847. Path. No. 8346. Diffuse myomatous thickening of both the anterior and posterior uterine walls; b r e a k - i n g d o w n o f a submucous myoma with suppu- ration, producing in all probability a mild endometritis of the body and of the cervix; normal appendages on the left side; Graafian follicle c y s t on the right. W. J., aged thirty-four, married. Admitted March 1, 1905; discharged April 12, 1905. The patient has been married eleven years, has had two children and no miscarriages. Labors normal. The menses have been irregular and profuse for the last year, oc- curring every three weeks. For the last two weeks she has noticed a vaginal discharge. The patient has a sallow appearance; the 230 DIFFUSE MYOMATOUS THICKENING OF THE DTERUS 231 haemoglobin is 50 per cent. There was apparently a passage of a small tumor from the vagina a few week.- ago. Since then there have been chills and fever accompanied by a good deal of abdominal pain in the region of the ovaries. Path. Xos. 8 346 and 8 3 46 J. —The specimen con- sists of the uterus, about twice the natural size, the left normal tube and ovary, the right tube, and a cystic right ovary. The body of the uterus itself is 10 cm. in length, 9 cm. in breadth, and 8 cm. in its antero-posterior diameters. It is smooth and glistening. The thickening in the uterus is found to be due to a diffuse thickening in both the anterior and posterior walls. The anterior wall varies from 2 to 4.5 cm. in thickness; the posterior from 2 to 3 cm. in thick- ness; and projecting from the fundus into the cavity is a submu- cous myoma, 2.5 cm. in diameter. In the vicinity of this are hard areas rather difficult to explain. In the myoma there are areas of hyaline transformation. The uterine cavity itself is 6 cm. in length, the mucosa 1 mm. in thickness. At first it looks as if we had a dif- fuse adenomyomatous thickening of both the anterior and posterior walls, but at no point macroscopically is one able to trace the mucosa into the depth. The left tube and ovary are normal. The right tube is normal. The ovary is somewhat thickened and contains one cyst, approximately 4 cm. in diameter, and adjoining this is an oval cyst, 6 cm. in its longest diameter. The inner surfaces of these are perfectly smooth, and one would have soon merged into the other. They seem to be Graafian follicle cysts. Histological E x a m i n a t i o n . — The cervical glands are in places much dilated, and covering the surface of the cervix are here and there quantities of polymorphonuclear leucocytes which have come down from the body of the uterus. The stroma is to a slight extent infiltrated with small round cells. There is, however, very little infiltration of the cervix itself and the glands in the depth are perfectly normal. Sections from the body of the uterus show a submucous myoma, which to a great extent has been transformed into hyaline material. We have here and there spindle cells, chiefly fibrous in character, and in other places cells which have taken up 232 ADENOMYOMA OF THE UTERUS yellowish-brown pigment, evidently the remains of old hemorrhages. Here also we have thrombosed vessels. The surface of the myoma consists essentially of granulation tissue containing polymorphonu- clear leucocytes in its meshes, and covering the surface are fibrin and quantities of leucocytes. In this tissue are large and small blood-vessels. The majority of these are filled with fibrin and leucocytes. In other words, there has been coagulation necrosis. At no point do we find any evidence of glands in the depth. Sections from the larger cyst of the right ovary show that it is lined with cuboidal epithelium, the nuclei being situated in the middle of the cells. There is no doubt that the growth is a Graafian follicle cyst. Diagnosis . — Diffuse myomatous thickening of both the an- terior and posterior uterine walls; breaking down of a submucous myoma with suppuration, producing a mild endometritis. The appendix in this case shows chronic inflammation. Gyn. No. 12,221. Path. No. 8832. Thickening of a recently pregnant uterus which clinically gave symptoms simulating myoma. The uterus on removalwas strongly suggestive of a diffuse a d e n o m y o m a t o u s con- dition. L. D., aged thirty-seven, married, white. Admitted July 7, 1905; discharged August 4, 1905. The diagnosis on admission was infected submucous myoma. The patient began to menstruate at fifteen, was regular until after the birth of her first child, but has been somewhat irregular since then. She has been married for eighteen years, and has had seven children and one miscarriage at the eighth week, a year and a half ago. She had some irregular bleeding several months ago. Five months ago she ceased bleeding, but the last two months she has been in bed. The periods recurred, appearing every two or three weeks. The hemorrhages were profuse. It is rather difficult to get the exact date of the last period. The patient has lost 9 pounds in the two weeks previous to her admission to the DIFFUSE THICKENING OF PREGNANT UTERI - 233 hospital. Her haemoglobin is 02 per cent, unci she presents a rather emaciated appearance. Ope r a fc i o o . Vaginal hysterectomy. The highest post- operative temperature was 1()().2° F. She made a satisfactory re- covery. Path. No. 8832. — The specimen consists of the uterus. It is 10 cm. in length, 7 cm. in breadth, and 6 cm. in its anteropos- terior diameters. It is free from adhesions. The cervix looks nor- mal. The posterior uterine wall varies from 1 to 3.5 cm. in thickness and presents a coarse appearance. In the anterior wall the mucosa is 2 mm. in thickness, in the posterior it reaches 5.6 mm., where there is localized thickening. The general appearance is very sug- gestive of adenomyoma. On histological examination the cervix is found to present a rather suspicious appearance. We have an intact vaginal epithe- lium, then a proliferation of the cervical epithelium, the glands having formed many new and smaller ones. The proliferation in places is solid and here suggests squamous epithelium. At other points there is loss of the surface epithelium, and we have typical granulation tissue. There has evidently been an inflammation here, giving rise to the proliferation. The infiltration, however, is not wide-spread, as in the underlying stroma it is not extensive. In the body of the uterus the mucosa in places is intact and the glands look normal or are somewhat dilated. At other points the surface con- sists entirely of necrotic tissue or of canalized fibrin, and deeper still are small glands and a few decidual cells in the stroma. The blood- vessels in the mucosa show a marked change. The cells are swollen and are typical decidual cells. In the stroma there is a good deal of small round-cell infiltration and at a few points what appear to be villi, devoid to a great extent of their epithelial covering. For a short distance into the muscle we can trace glands, and deep in the muscle there are what appear to be decidual cells together with swollen muscle fibres. In this case, as seen from a clinical standpoint, the diagnosis of probable myoma of the body of the uterus was made. The uterus 234 ADENOMYOMA OF THE UTERUS was enlarged and there was evidently uterine hemorrhage and a certain amount of discharge. Moreover, the menstrual history was not satisfactory. Even after the uterus had been removed the thickened wall strongly suggested adenomyoma, but, as we see on histological examination, there are typical evidences of pregnancy. There is no discrete myoma, although there is a definite tendency toward myomatous thickening. CHAPTER XXII ADENOMYOMATA OF THE UTERINE HORN Meyer has very justly divided these into two groups according to their situation and source of origin. The uterine mucosa is con- tinued up into the cornu, where it becomes very thin, there being merely the surface epithelium, a small amount of stroma of the mucosa, and a few "lands. The mucosa becomes still thinner, and at the interstitial portion of the tube, which is within the uterine horn, gradually passes over into the tubal epithelium. This epithe- lium is identical in character with that lining the uterine cavity, but the peculiar stroma found in the uterine mucosa is entirely wanting and no glands are present. ADENOMYOMATA ARISING FROM THE UTERINE PORTION OF THE UTERINE HORN These consist of small diffuse thickenings of the uterine cornu. As a rule, they are not larger than 1 centimetre in diameter, but occasionally may reach the size of a walnut (Fig. 65, p. 243). They consist of gland-like spaces, usually cystic, and are surrounded by a diffuse myomatous muscle. The cysts are lined with cylindrical ciliated epithelium and contain desquamated epithelium and blood. Where the glands are much dilated, they may lie in direct contact with the myomatous muscle, but the smaller ones are separated from the muscle by the characteristic stroma of the mucosa. The myo- matous tissue seems to be circularly arranged around the gland spaces, and it frequently appears as if the myomatous thickening was due almost entirely to the irritation set up by the glands. These myomata may In 4 near the tube lumen, in the vicinity of tin 1 peri- toneum or lie near the broad ligament. The origin of the gland ele- ments was referred by von Recklinghausen and others to the Wolf- fian duct, but in the last few years their continuity with the uterine 235 236 ADEXOMYOMA OF THE UTERI'S glands has been traced, and it is probable that the majority, if not all, of these adenomyomata owe their glandular elements to the uterine mucosa. The only difference between these and the diffuse growths in the uterine cavity is their small size and their relative poverty in gland elements. When we remember that the glands in the uterine horn are few and far between, this scanty glandular distribution is readilv understood. ADENOMYOMATA FROM THE TUBAL PORTION OF THE UTERINE HORN These growths, likewise situated in the uterine horn, also con- sist of small myomata containing isolated gland-like spaces or small cj^sts. These spaces are lined with a single layer of cylindrical, ciliated epithelium. They may be situated in the inner muscular layers of the tube or penetrate nearly to the peritoneal surface on the one side, or to the mesosalpinx on the opposite side. They differ from those originating in the uterine portion of the uterine horn in that the epithelium rests directly on the muscle instead of being- separated from it by the characteristic stroma (Fig. 64, p. 237). The reason for this was at first sight difficult to understand, but after von Franque, 1 Meyer, 2 Gottschalk, 3 and Lockstaedt 4 had shown conclusively that the gland-like spaces were nothing more than pro- longations outward of the tubal mucosa, the solution was clear, as in the tubal mucosa the characteristic stroma of the uterine mucosa is wanting. The origin of the gland-like spaces in these growths was likewise formerly attributed to remains of the Wolffian body, but we now know that the majority of these represent prolonga- tions outward of the tubal mucosa, probably followed second- arily by the myomatous development, as is evidenced by the fact 1 Yon Franque. 0.: Salpingitis nodosa isthmiea unci Adenomyoma Tubae. Centralbl. f. Gynaek., 1900, Bd. xxv, S. 660. 2 Meyer: Ztschr. f. Geburtshulfe und Gynaekologie, Bd. xlii, H. 1. 3 Gottschalk: Demonstration zur Enstehung der Adenome des Tubenisthmus. Ztschr. f. Geburtshulfe und Gynaekologie, 1900, Bd. xlii, S. 616. ' 4 Lockstaedt, Paul: Ueber Yorkommen und Bedeutung von Driisenschlauchen in Myomen des Uterus. Monatsschr. f. Geb. u. Gyn., 1898, Bd. vii, S. 188. A.DENOMYOMATA OF THE UTERINE IIOUN 237 that those outgrowths are often found independent of the myo- matous growth. Clinically, these small myomata in the uterine horns are of little importance. They are not recognized until the organ has been removed for some other cause, usually myomata or pus tubes. For a period of over five years (1893-1898) we had sections taken w % P-.o '> v^l .f<7 & v :*&. ss& C3 *© % '£*0 ,\ 1 Fig. 64. — Adenomyoma of the oterine horn. (8 diameters.) Gyn.-Path. No. 4 8 20. o is a cross-section of the Fallopian tube; b the outer or peritoneal surface; c the tissue m>ar the broad ligament. Scattered everywhere throughout the tissue, which under a higher power was seen to be myomatous, are round, oval or irregular, elongate glands, occurring singly or in bunches. These were lined with cuboidal or cylindrical epithelium which in most places rested directly on the muscle. This appears to be an adeno- myoma originating from the tubal portion of the uterine horn. from both uterine horns as a routine procedure, and found groups of these gland-like spaces, with or without myomatous thickening, to be very common. CASES IN WHICH ADENOMYOMATA WERE DETECTED IN THE UTERINE HORN In this group we have not attempted to divide the cases into those originating from the uterine portion of the horn and those derived from the tubal portion, but have included them all in the same class. 238 ADENOMYOMA OF THE UTERUS Gyn. No. 11,572. Path. No. 7800. Subperitoneal and interstitial uterine my - omata; adenomyoma of the left uterine horn; normal appendages. R. J. R., aged thirty-three, black, married. Admitted September 27, 1904; discharged October 27, 1904. The patient has been mar- ried thirteen years, but has never been pregnant. Operation . — Hysterectomy. The patient made a satis- factory recovery. Path. No. 7800 . — The specimen consists of a greatly enlarged uterus and of the tubes and ovaries. The body of the uterus is normal in size, but springing from its surface are several small pedunculated myomata. In the left uterine horn is a distinct thickening, the nodule being 1.5 cm. in diameter. The tube lies perfectly free. Attached to the fundus by a pedicle, 2.5 cm. in diameter, is a large myomatous tumor, 20 by 15 by 10 cm. It is irregular and nodular. The tumor and the uterus are free from adhesions. The appendages are apparently normal. Sections from the nodule in the left horn show what appears to be the lumen of the tube surrounded by several definite glandular areas. Embedded in this stroma and scattered throughout the nodule is a diffuse myoma. There are gland spaces lying in direct contact with the muscle. These glands are lined with one layer of high cylindrical epithelium. They appear to have originated from the uterine portion of the tube, although it is impossible to state this with certainty. Diagnosis . — Subperitoneal and interstitial uterine myomata. Adenomyoma of the left uterine horn; normal appendages. Path. No. 3721. A small uterus with somewhat suspicious changes; adenomyoma of the left uterine horn; cystadenoma of the right ovary with carcinomatous changes; cystadenoma of the left ovary. ADENOMYOMATA OF THE UTERINE HORN 239 The specimen consists of the uterus, both tubes, and a cysl on each side. The uterus is exceedingly small and as far as can be determined measures 4 cm. in Length, 3 cm. in breadth and 1.1 cm. in thickness. The uterine walls are very soft and wary from 7 in 9 mm. in thickness. The cavity is seen as a slit -like depression. It is 3 cm. in length. The mucous membrane is 2 mm. in thickness. The anterior and posterior surfaces of the uterus are smooth save for a few delicate adhesions. On histological examination the uterine mucosa shows marked senile atrophy. Its surface is smooth. The glands are moderate in amount and in some places are considerably dilated. The epithe- lium, as a whole, is lower than usual. The glands are flattened. Some are irregularly arranged and present little papillary growths. Immediately beneath the left cornu is a nodule. This is com- posed of myomatous tissue containing glands lined wit h a l< >wc< tlumnar epithelium of uniform appearance. On the right side there is a cystadenoma, portions of which show carcinomatous changes. ( )n the left side there is a simple cystadenoma. Diagnosis . — Small uterus with suspicious change : adeno- myoma in the left uterine horn; cystadenoma of the right ovary with carcinomatous change; cystadenoma of the left ovary. Gyn. No. 6635. Path. No. 2845. A d e 11 o m y o m a in the u t e r i n e h r n w i t h c m - m e 11 c i n g subperit n e a 1 a d eno m y o ma . P., aged thirty, white. Operation, January 14, 1899. Sections from the uterine wall show that the mucosa reaches 5 mm. in thick- ness. An oblique section through the stump of the right tube shows a small lumen of the tube with irregular outlines, lined with normal, low, cylindrical, epithelial cells. Situated some distance from the tube, surrounded by a definite circular zone of muscle, is an island of mucosa, perfectly normal in character. This is surrounded in numerous places by irregular glands lined with cylindrical epithe- lium and filled with desquamated epithelium and old hemorrhage. We have here the foundation for a subperitoneal adenomyoma. 240 ADENOMYOMA OF THE UTERUS Gyn. No. 3805. Path. No. 892. The tube at the uterine horn is re presented by three gland spaces instead of a lumen. M. W., aged thirty-one. September 22, 1895. Pathological diagnosis : Right hydrosalpinx, left perisalpingitis, gland-like spaces in the uterine cornu. We have sections from the left uterine horn. The uterine horn is represented by three glands instead of a lumen, a very unusual picture. This is readily recognized, as we have the two definite layers of muscle surrounding them. We have here gland-like spaces which are irregular or round, some of them oblong. They are lined with cylindrical epithelium and characteristic stroma. This is the first case in which on examination of the uterine horn we have found the lumen represented by three distinct spaces. Gyn. No. 3715. Path. No. 843. Adenomyoma of the uterine horn. E. S., white. August 15, 1895. Diagnosis: Remnants of an old endometritis; commencing abscess in the right uterine cornu; gland-like spaces in the uterine cornu; double perisalpingitis; double perioophoritis. On examination of sections from the left uterine horn we find in the upper part a few small gland-like spaces a short distance beneath the peritoneum. These are round or oblong on cross-section and beneath the tube we also find some gland spaces. All the glands are lined with cylindrical epithelium. Some of them are rather complex, and instantly suggest an origin from a Wolffian duct; others resemble uterine mucosa. The tube lumen is much degenerated and is filled with pus. Gyn. No. 3395. Path. No. 649. Partial atrophy of the uterine mucosa; gland -like spaces in the uterine horn. Right side: chronic salpingitis, miliary abscess of the ovary. Left side: chronic salpingitis and perioophoritis. H., white. March 30, 1895. Sections from the uterine horn A.DENOMYOMAXA OF THE [JTERINE HORN 24] show numerous adhesions and some gland-like spaces. These are small and round on cross-section. They are lined with cylindrical or cuboidal epithelium and are filled with desquamated epithelium. They lie in direct contact with the muscle. Tlie tissue is evidently the seat of chronic inflammation, as is evidenced by the presence of many small round cells. Sections from the left tube show only one or two gland-like spaces and there is much less evidence of inflam- matory reaction. Gyn. No. 3401. Path. No. 647. Partial a t r o p h y of t h e u tori n e m u c o s a . gland-like spaces in both uterine horns, ac- cessory ostium of the right tube, large simple hydrosalpinx of the left tube; slight ad- hesions on both sides. Examination of the uterine cornu with the low power is most confusing at first, and one is hardly able to recognize the cross- section of the tube. Surrounding the tube on all sides, but particu- larly between the tube and the peritoneum covering the surface, are colonies of glands. Covering one surface are numerous adhesions consisting chiefly of omentum. The gland-like spaces to a great extent communicate with one another, as is evidenced by the little bridges here and there. Some of the gland spaces lie almost beneath the peritoneum and seem to be foreign to the uterus. The majority, however, are in direct contact with it. They are lined with cuboidal or cylindrical epithelium. The picture is a most interesting one. On the left side sections from the cornu show a similar condition, although the picture is not so confusing. We are able to trace a definite channel which looks very much as if it were an outgrowth of the uterine mucosa. In this case we have a portion of adeno- myomatous tissue definitely (ait off and forming an independent subperitoneal adenomyoma. In none of these do we find much evidence of stroma. Hi 242 ADEXOMYOMA OF THE UTERUS C. H. I. No. 1517. Path. No. 10,669. Adenomyoma in both uterine horns (Fig. 65) ; diffuse adenomyoma of the uterus; minia- ture uterine cavity. S. E. W., married, aged forty-three. Admitted December 2, 1906. The patient has not been well for the last five or six years. Her periods during this time have been profuse, at times lasting as long as twelve days. She has had no children and no miscarriages. She has had some retention of urine at times; at other times there is frequency of micturition. There has been leucorrhcea for five or six years. Operation . — Hystero-myomectomy and appendectomy. The patient made a satisfactory recovery. The highest post-opera- tive temperature was 101.6° F. Path. No. 10,669 . — The specimen consists of a multi- nodular, myomatous uterus, 10 cm. in length, 13 cm. in breadth, and 11 cm. in its antero-posterior diameters. The uterus is every- where smooth and glistening. The increase in size is due to sub- peritoneal, interstitial, and submucous myomata. The largest nodule, 8 cm. in diameter, is situated anteriorly and to the right. The uterine cavity is very small and is much distorted. In the left uterine horn is an area of thickening (Fig. 65). This is directly continuous with the tube and is 4 cm. in length, and varies from 1 to 2.5 cm. in breadth. It appears to be cystic and on section presents a sieve-like or polypoid appearance. There are also irregular cystic spaces, varying from 1 to 5 mm. in diameter. At least seven or eight of these are seen in one cross-section. The right tube is occluded, and reaches 4 cm. in diameter. The ovary is slightly mutilated. The right tube at the uterine horn presents an area of thickening 1.5 cm. in diameter. On section this horn is also seen to contain cystic spaces, one of them at least 3 mm. in length. Histological Examination . — Sections taken from the right uterine horn show a most instructive picture. Cross- section of the tube shows that it is perfectly normal. Just to one side is a miniature uterine cavity lined with one layer of epithelium. A.DENOMYOMATA OF THE UTERINE llo|{\ 243 In oilier portions there are numerous uterine glands, the majority of which are dilated. Some lie in direcl contact with the muscle. Others are separated from it by a small amount of stroma. A most interesting picture is noted in some places, namely, that the bunches of uterine glands are surrounded by a circular layer of myomatous 96 ,■ $*■ V/ ■/M J f the Round Ligament. Johns Hopkins Hospital Bulletin, 1898. 2 Von Herff: Ueber Cystomyome und Adenomyome der Scheide. Verhand- lungen der Deutschen Gesellsch. f. Gyn., L897. 3 Pick, Ludwig: Die Adenomyome der Leistengegend und des hinteren Schei- dengewolbes; ihre Stellung zu den paroophoralen Adenomyomen der Uterus und Tubenwandung, v. Recklinghausen's Arch. f. Gynaek.. Bd. lvii, 461. 252 ADENOMYOMA OF THE UTERUS and, as noted, the tumor may be situated in one or both round liga- ments, in the labium majus or in the posterior vaginal vault; or such growths may occur simultaneously in the inguinal region and vaginal vault. Clinical History . — These nodules are usually of slow growth. In our own case it had been present eight years ; in Blumer's case for twenty -three years. The tumors may appear as early as the twentieth year, as in Blumer's case, or as late as the forty-second year, as noted in Aschoff's case. Thej^ are most common during the child-bearing period. The tumor at first causes little annoyance, but with its increase in size there is pain on walking, probably on account of the intimate association of the tumor with the surround- ing structures, as well as considerable distress on menstruation. At the period the lump may be increased in size and become very pain- ful, again diminishing in size after the flow is over. Prognosis . — Our case was of eight years' duration, and on histological examination gave no sign of malignancy, proving that the growth was benign in character. Blumer's case is even more convincing, as it had been under observation twenty- three years, the growth in that time not becoming larger than a hen's egg. Microscopic examination also showed its harmless character. Treatment . — Excision of the nodule is indicated solely on account of the discomfort produced by its presence. ORIGIN OF ADENOMYOMATA OF THE ROUND LIGAMENT As in the case of adenomyomata of the uterus, controversy has arisen as to whether the growths are derivatives of the Wolffian or of the Mullerian duct. Many authors claim that portions of the Wolffian duct have been nipped off during the development of the embryo and have been carried down the round ligament, and that in after-life they develop. They base their assumption on the fact that the Wolffian duct comes in close contact with the round ligament prior to its descent to the inguinal region. They also think that the gland elements of the adenomyoma bear some resemblance to por- tions of the Wolffian duct. Those dissenting from this view hold A.DENOMYOMATA OF THE ROUND LIGAMENT 253 thai there is strong evidence that misplaced portions of Miiller's duct are responsible for the growth of these tumors. As has been noted, the glands in these adenomyomata cannot be distinguished in many instances from normal uterine glands. They are small, round, and lined wit h cylindrical ciliated epithelium. Furthermore, they are surrounded by the characteristic stroma of the normal uterine mucosa. Clinically, it has been noted that these growths may have a sympathetic relationship with the menstrual period, as seen in their increase in size at thai time, followed in the intermen- strual period by a diminution in their volume. This increase in size is undoubtedly due to the hemorrhage into the glands at the periods, as is proved by the hemorrhagic contents at operation. In our case menstruation had commenced on May 18th and ceased on May 23d or just three days before operation; and on making sections the glands were found filled with well preserved blood. A further point in favor of the Miiller's duct origin is that these adenomyomata resemble in every particular the diffuse adenomyomata of the uterus, in which the "lands are seen to be direct derivatives of the uterine mucosa. As was said when discussing the origin of adenomyomata of the uterus, there is no other place in the body in which mucosa similar to normal uterine mucosa is found, and furthermore no other mucous membrane that periodically discharges blood. These round ligament adenomyomata fulfil every requirement of normal uterine mucosa. It would be unwise to say absolutely that these growths cannot possibly be derived from remains of the Wolffian duct, but the evidence is overwhelmingly in favor of the Miiller's duct origin. Before concluding a consideration of these cases we must briefly refer to the case reported by Martin 1 in 1891. A patient aged seventy consulted him about a rapidly growing tumor. He opened the abdomen and removed 1 12 litres of chocolate-colored fluid from a tumor springing from the left round ligament. This was attached to the ligament by a definite pedicle. Pommorsky, who made the microscopic examination, found that the cyst containing the choco- 1 Martin A.: Xur Pathologie des Ligamentum rotundum. Ztschr. f. Geb. u. Gvn., Bd. xxii, S. 1 1 \. 254 ADEXOMYOMA OF THE UTERUS late-colored fluid had very thin walls, and that its inner surface was in places covered by clots. The pedicle of the tumor contained several small cysts which were filled with clear fluid and which com- municated with one another. One of these cysts was lined with low cylindrical ciliated epithelium. It is quite probable that this was an adenomyoma of the round ligament situated nearer the uterine horn than usual. I noted in speaking of adenomyoma of the uterus that when the tumor became intraligamentary, as in the case represented in Fig. 43 (p. 151) , or in those of Breus and Kroenig, large cysts developed. These were filled with chocolate-colored fluid and at some points small cysts were still visible. In adeno- myoma of the round ligament situated in the inguinal region or in the labium ma jus, we have a continual surrounding pressure, as in the uterus. In Martin's case, on the other hand, there was nothing to prevent cystic formation. The process appears to be analogous to the cystic development occurring in subperitoneal or intraliga- mentary adenomyomata of the uterus. ADENOMYOMATA OCCURRING IN BOTH THE RIGHT AND LEFT ROUND LIGAMENT IN THE SAME INDIVIDUAL (Figs. 67 and 68) Gyn. No. 3891. L. N., aged thirty-seven. Admitted October 18, 1895. The patient has been married thirteen years and had one instrumental labor seven years ago. Her menses commenced at fourteen and were regular until the birth of the child, since which time they have occurred every three weeks, have been very copious, and have lasted from four to five days. The latter part of each period has been ac- companied by a good deal of pain, which persists for several days after the flow. The last menstrual period occurred two weeks be- fore admission. About eight years ago the patient noticed a slight swelling in the right inguinal region. This has gradually enlarged, more especially during the last two years. She has had severe cut- ting pain in the nodule and radiating to the back. This has been most severe after exertion or during the menstrual period. The patient is much debilitated. The vaginal examination is negative. ^DENOMYOMATA OF THE ROUND LIGAMENT 255 The mass occupies the upper part of the righl labium, is irregularly ovoid and firmly fixed in I he deeper tissues. It is, however, movable lo the extent of one cent iniet re. October L9th: An oval incision was made over the site of the nodule. The mass was freed laterally and posteriorly. Above il was closely connected with a hand of tissue, 1 cm. broad. This proved to be the righl round Ligament. The round ligament was traced upward to the internal ring, and midway bel ween the external and internal ring it contained a nodule, 1 by .6 cm. The round liga- ment was pulled down, clamped, and cut off at the internal ring. Several enlarged lymph-glands were then dissected out. The pillars of the ring wen 1 brought together with silver wire and the round liga- ment was sutured into the canal. The patient was discharged on November 3, 1895. Gyn.-Path. No. 926. The specimen consists of a piece of tissue measuring 7 by 4 by 3.5 cm. One surface of this is covered with normal skin. The un< ler- lying tissue is composed of fat, embedded in which is an exceedingly firm nodule, measuring 3.5 by 3 by 2 cm. (Fig. 67). This nodule on section is composed of interlacing bundles of fibres which form a dense network. Scattered throughout the nodule are many small. irregular, pale, translucent, homogeneous areas. On examining the specimen after hardening in Midler's fluid some of the homo- geneous areas are found to contain round, oval, or irregular space-. Histological E x a m i n a t i o n . — The nodule is to a great extent composed of non-striped muscle fibres which wind in and out in all directions, but do not show any concentric arrange- ment. In many places the muscle fibres arc 1 swollen and the cell protoplasm contains large quantities of yellowish-brown granular pigment. At several points the muscle has undergone hyaline de- generation. This is especially noticeable around blood-vessels. The blood-supply is abundant . Scat tered here and t here 1 hroughoul the muscle substance are small islands of adipose tissue. Travers- ing the nodule in all directions arc 4 glands (Fig. 68). Some of these 256 ADEX0MY0MA OF THE UTERUS are small and round on cross-section; the others are cut lengthwise. These glands are surrounded by stroma similar to that of the uterine mucosa. It would be impossible to distinguish some of these from uterine glands. A few of the glands present slight dichotomous branching. Some of them contain round masses of protoplasm, scattered throughout which are several nuclei. These giant cells appear to be cross-sections of tufts of epithelium. In many places the glands present a peculiar arrangement and correspond to von Recklinghausen's pseudo-glomeruli, which consist of stroma re- sembling that of the uterine mucosa. They contain numerous Fig. 67. — Adenomyoma of the round ligament. (Natural size.) Gyn.-Path. No. 9 2 8. The figure represents a longitudinal section of the tissue removed. The greater part consists of fat and the surface is covered with skin. Occupying the lower part is an oval area, dark in color and composed of fibres running in all directions — the myoma. Passing off from it are numerous strands which merge into the adipose tissue. The small dark areas in the myoma represent dilated gland cavities. The large and small dark masses in the adipose tissue are hemorrhages. For the histological picture of the adeno- myoma see Fig. 68. capillaries and may have one or more glands situated in their depth. In some places there has been hemorrhage into their stroma. The pseudo-glomeruli are half-moon-shaped, cone-shaped, or irregular in contour. They are covered with one layer of cylindrical ciliated epithelium. What corresponds to Bowman's capsule consists of a layer of cells resting directly upon the muscle fibres. The cells of the capsule opposite the convexity of the glomerulus are almost flat. On passing off laterally they are seen to be cuboidal or cylin- drical. The cells of the so-called capsule are directly continuous with those of the pseudo-glomerulus. The space between the cap- A.DENOMYOMATA OF THE ROUND LIGAMENT 257 sule and the glomerulus may be empty. Many, however, contain desquamated epithelial cells, some of which are vacuolated and have brown, granular pigment in their interior. Numerous spaces con- tain blood-COrpuscles. On tracing one of the spaces laterally it is found to be directly continuous with the lumen of a gland. The capsule forms one wall of the gland and the pseudo-glomerulus the other (Fiii'. OS). In other words, the space between the capsule and the so-called glomerulus is nothing more than a dilatation of the . «r Fig. 68.— Adenomyoma of the Round Ligament. (20 diameters.) Gyn.-Path. No. 9 28. The section is taken from the oval nodule in Fig. t>7. The framework consists of non-striped muscle fibres cut chiefly longitudinally. Scattered throughout the muscle are glands which occur singly or in groups. They arc round, oval or irregular and show some branching. All are lined with one layer of cylindrical epithelium and even the smaller ones are surrounded by a definite stroma which with the high power is seen to be identical with that of the uterine mucosa. In the right lower corner is adipose tissue. A few stray fat cells arc found in the myoma. In the left upper corner is a so-called pseudo- elomerulus. inland cavity or of a miniature uterine cavity. In numerous places the gland epithelium on one side is found to he cylindrical; on the other side, cuboidal or almost Hat. On examining these more closely it is found that where the epithelium is separated from the muscle by a moderate amount of stroma it is cylindrical, hut where the epithelium rests directly upon the muscle, it is invariably cuboidal or flat. A few small glands are seen Lying directly between muscle bundles. 17 258 ADENOMYOMA OF THE UTERUS Extending into the myomatous growth from the periphery are numerous bands of connective tissue. The adipose tissue surround- ing the myoma shows considerable hemorrhage. The skin cover- ing the surface of the specimen is normal. Unfortunately we were not able to obtain the smaller nodule of the round ligament for ex- amination and cannot say whether it was an adenomyoma or not. The patient was readmitted on May 25, 1897. Shortly after the previous operation she noticed a swelling in the opposite (left) in- guinal region immediately above the pubes. This has gradually increased in size and is quite painful. The menstrual period has not been regular, occurring at intervals of from three to five weeks. The last menstruation commenced May 18th and ceased May 23d. On May 26th I removed the nodule with little difficulty and found that it was directly continuous with the left round ligament. Gyn.-Path. No. 1741 . — The specimen consists of an irregular mass, approximately 3 cm. in its various diameters. It comprises a firm central portion, 1.5 cm. in diameter, and is sur- rounded on all sides by adipose tissue. Traversing the central por- tion are numerous delicate fibres and at several points are brown or yellow homogeneous areas. Several pin-point cavities are demon- strable. At one point is a semicircular slit, 2 mm. long, and in the immediate vicinity an irregular cavity averaging 3 mm. in diameter. The walls of this cavity are rather uneven and are slightly granular. Histological Examination . — The adipose tissue in the outlying portions is comparatively normal, but as one ap- proaches the firm nodule the blood-vessels increase in number and size. Young capillaries are found wandering in between the fat cells, the fat cells becoming gradually separated from one another. At the margin of the firm nodule the growth is composed almost ex- clusively of connective tissue. Here and there this connective tissue encircles round or oval clumps of cells having oval, some- what deeply staining nuclei. Scattered between these are a few small round cells and occasionally polymorphonuclear leucocytes. Such areas are very striking on account of their richness in nuclei, \l>i;\o\n o\l \T.\ OF THE ROl ND LIGAMENT 259 in contrasi to the surrounding tissue, which is poor in cell elements. The cellular areas resemble closely the stroma of the uterine mucosa. <)n passing toward the centre of the nodule similar areas are found containing one or more glands lying in their centre or al the peri- phery. These glands, according to the angle al which they have been cut, are round, elongate, or slightly branching. Their epithe- lium is cylindrical, apparently ciliated, and their nuclei are oval and situated at some distance from the bases of the cells. Iii short , these glands cannot he distinguished from uterine glands. The majority of the gland cavities are completely filled with blood and desquamated epithelial cells. The stroma of the central portion of the nodule is composed almost entirely of non-striped muscle fibres, and here the glands are abundant and present a more complicated picture. They are branching, form narrow* channels and little bays, and in places can he traced in their continuity for at least 4 mm. On one side of the gland there is usually a considerable amount of stroma separating the epithelium from the underlying muscle. At such points the epithelium is cylindrical, but on the opposite side, where the cells rest directly on the muscle, it is frequently flattened. There are a few areas corresponding to von Recklinghausen's pseudo- glomeruli. Some of these contain glands, others do not. The nodules in both round ligaments are typical adenomyomata. SUMMARY In cases of adenomyoma of the uterus we usually find a diffuse myomatous thickening of the uterine muscle. This thickening may be confined to the inner layers of the anterior, posterior, or lateral walls, but in other cases the myomatous tissue completely encircles the uterine cavity. This diffuse myomatous tissue contains large or small chinks, and into these chinks the normal uterine mucosa flows. If the chinks are small, there is only room for isolated glands, but where the spaces are of goodly size large masses of mucosa flow into and fill them. We accordingly have a diffuse myomatous growth with normal mucosa flowing in all directions through it. The mucosa lining the uterine cavity is perfectly normal. After a time portions of the diffuse myoma may be nipped off and are carried toward either the outer or inner surfaces of the uterus. If they become submucous growths, they are gradually expelled. If they pass toward the outer surface, they become either subperi- toneal or intraligamentary. We have accordingly divided adeno- myomata into the following groups: 1. Adenomyomata in which the uterus preserves a relatively normal contour. 2. Subperitoneal or intraligamentary adenomyomata. 3. Submucous adenomyomata. A diffuse adenomyoma presents a very coarse appearance, owing to the fact that the myomatous muscle bundles run in all directions. In the spaces between bundles and occasionally surrounded by cir- cular rings of muscle we find spaces filled with translucent and slightly punctiform tissue — areas of uterine mucosa. Sometimes its direct connection with the mucosa of the uterine cavity can be traced. Often are noted cyst-like spaces scattered throughout the diffuse myoma. These are filled with a chocolate-colored fluid and are lined 260 SI MMARY li< *» 1 with a definite membrane, often 1 i<> 2 mm. thick. They are mini- ature uterine cavities and the chocolate-colored fluid is old men- strual Mood thai could not escape. When an adenomyomatous nodule becomes subperitoneal, the menstrua] flow in the growth may gain the upper hand and the myoma become cystic, the contents, of course. being formed from the accumulation of old menstrual blood. Sympt onis.* -Our youngest patient was nineteen, our oldest sixty. The disease is most prevalent Let ween the thirtieth and sixtieth years; it does not in any way tend to sterility. Lengthened menstrual periods are the first symptom. The flow gradually assumes the proportions of hemorrhages and event- ually the period may become continuous. At the period there is often discomfort, and occasionally a grind- ing pain in the uterus, evidently due to the increased tension, since all the islands of mucosa scattered throughout the diffuse myoma naturally swell up at the menstrual period, and thus increase the size of the organ. In over two-thirds of our cases there was no intermenstrual dis- charge. This is perfectly natural, as in these cases the uterine mucosa is normal and no disintegration of tissue is going on. Clinically the diagnosis of diffuse adenomyoma is rela- tively easy, for the following reasons: 1. The bleeding is usually confined to the period. 2. There is usually much pain, referred to the uterus, at the period. * While von Recklinghausen was carrying mi his work on the pathology of adenomyoma W. A. Freund was carefully analyzing the symptomatology in such cases to determine, it possible, whether the clinical picture was sufficiently charac- teristic to enable the surgeon i<> make a diagnosis before operation. In contrast with his findings, our experience p>es to show that neither an infantile condition of l he uterus nor sterility is in any sense a prominent feature. Von Etosthorn (Med. Klin. Berlin, L905, 1. 201 203), in a recent publication. reports two cases, in one of which the clinical picture before operation strongly sug- gested diffuse adenomyoma. He says that in the future, with our increased knowl- edge, a provisional diagnosis of adenomyoma is sometimes possible before operation. 262 ADENOMYOMA OF THE UTERUS 3. There is usually no intermenstrual discharge of any kind. 4. The uterine mucosa is perfectly normal and may be rather thick. No other pathological condition of the uterus, as a rule, gives this characteristic picture. Treatment . — The patient's health is often gradually under- mined by the uterine hemorrhages, and the only way to control them is to remove the uterus. A supravaginal hysterectomy is all that is necessary. The ovaries should be saved. The prognosis is good, as the glands of the adeno- myoma are perfectly normal uterine glands and are surrounded by the characteristic stroma of the mucosa. Origin . — The glands in the adenomyoma originate, in the vast majority of the cases at least, from the uterine mucosa. The reader will be thoroughly convinced of this after studying the vari- ous histological pictures in the book. Cause . — The cause of adenomyoma is still unsolved. INDEX OF CASES ARRANGED ACCORDING TO THEIR GYNECOLOGICAL NUMBERS HNS Hopkins Hommt ai < lyn. No. < }yn. Nn. < lyn. No. Gyn. No. ( lyn. NO. ( i\ n. No. Gyn. No. ( Ivn. No. Gyn. No. ( lyn. No. ( ivn. No. ( ivn. No. ( Ivn. No. ( Ivn. Nil ( lyn. No. Gyn. (lyn ( ;>-n ( ivn (lyn ( lyn ( lyn No. No. No. No. N... No. No. ( lyn. Nn. ( Ivn. No. (Ivn. No. • lyn. No. ( Ivn. No. Gyn. No. Gyn. No. ( lyn. No. < lyn. No. (Ivn. No. Gyn. No. (lyn ( ivn (Ivn < lyn (Ivn Gyn No. No. No. No. No. No. ( lyn. No. ( lyn. Nn. ( lyn. No. ( lyn. No. ( lyn. No. i lyn. No. ( lyn. No. ( lyn. No. i'.-.::; 2699 2706 27 1 I •-'To I 2806 3126 3136 3192 3204 3293 3379 3395 . 3399 . 3401 . 3418 . 3600 . 3614 . 3715 . 3805 . 3809 . 3891 . :;sos 1364 . til.". . 5768 5782 . 5973 . cits:; . 6240 . 6635 lis.-,.-, lis.-,.-, 7D11 . 7153 . 7569 . 7 s.V.i . 8438 , si 117 . 8780 9024 9069 . 9457 . 9637 9788 9971. 1031 1 17 93 29 r,l 12 17 213 7o 52 50 r.i-2 2 17) 240 244 241 8 INS 23 240 240 31 27.4 Uiii '.17 190 :, I 218 158 68 200 239 160 149 108 34 ss 109 223 128 1 19 L38 33 60 139 85 209 101 PAGE Gyn. No. L0516 203 (Ivn. No. L0519. 86 (Ivn. No. los72 L63 Gyn. No. 11120 100 Cvn. No. 112.V2 Ill (ivn. N... L1363 loo Gyn. No. 11572 238 (Ivn. No. lls.-,i) 10 (Ivn. N... 12036 145 (Ivn. No. 12000 212 (Ivn. No. L2080 »7, (Ivn. No. 12221 (Ivn. N... 12304 21:; Gyn. N... L2358 117 Cvn. N... 12:;so _M0 (Ivn. No. L2585 no Gyn. No. L2599 22 Cvn. No. 1207s lot Cvn. N... 12681 11 Cvn. No. 12807 82 Gyn. No. 12841 83 Cvn. N... 12918 206 Gyn. No. 1204 1 95 San. San. San. San. San. San. San. San. San. San. San. No. No. No. No. No. No. No. No. No. No. No. Hi'. I 1453 1 552 ls(7 1 852 1872 1913 1931 L944 21 II 217- ■ Howard A. Kelly 62 115 105 -_' 110 122 20 123 in 103 ( 'Imrcli Home and Infirmary. Case No. G. L. Hunner) 99 \.i. 51 1 Thomas Cullen 1 21 1 Case No. 1019 Thomas Cullen 113 Case No. 1517 Thomas Cullen) 212 Dr. W. W. Russell's patient 67 Emergency Hospital, Frederick, Md. Thomas Cullen) 119 1 >r. Joseph Price's case 228 263 INDEX OF GYNECOLOGICAL-PATHOLOGICAL NUMBERS Gyn, ( iyn.- ( ivn.- Gyn.- < ;>...- Gyn.- (ivn, Gyn, Gyn, Gyn, Gyn.- Gyn.- Gyn, Gyn.- Gyn.- Cyn, Gyn, Gyn, <;>-.., (Ivil, Gyn, Gyn, Gyn, Gyn, Gyn, Gyn, Gyn.- Gyn, ( ivn.- Gyn, Gyn, ( ivn.- Gyn, Gyn, Gyn, Gyn, Gyn, Gyn, (Ivn, Gyn, Gyn, Gyn, Gyn, Gyn, Gyn, Gyn. Gyn. Gyn. Pal Pal Pal Pa1 Pal Pat Pal Pat Pal Pat Pat Pat Pat Pat Pal Pat Pat Pal Pat Pat Pat Pat Pat Pal Pat Pat Pat Pat Pat Pat Pat Pat Pa1 Pat Pat Pal Pat Pat Pat Pat Pal Pat Pal Pal Pal Pal Pat Pat i. No. i. Nn. i. No. i. No. i. No. i. Nil ,. No. i. Xd. .. X.i. 1. X... .. X... i. X... .. No. ,. No. i. No. i. No. i. No. i. No. i. No. .. No. i. No. i. Xd. i. No. l. No. l. X... l. No. i. No. i. X.i. i. No. .. No. No. i. Xn. .. No. i. X... .. No. .. X... i. X... i. No. i. X... l. Xn. i. Xn. i. No. i. No. i. Xn. .. X... i. Xd. .. Xd. i. Xd. 163. 245. 246. •_'7 1 . 290. 193. 197. :.■_>;». 526. 583 . 633. hi;.. 647. 649. 659. 661. i 77. 7NN. 843. ss| . 892. 928. 934. 1170. l'_'(>7. 1711. L758. 2066. JOIN. 2075. 2084. •'•'"id 2356. 2532. 2845. :;ui7. 3289. 3429. 3721. 3903. U22. 1656. 1820. |s:;s. 1966. :.is:. 17 29 93 61 !'_' 17 213 7.") 52 ;,() 1 :•!•_> 245 244 241 240 17s 8 iss JA 240 :-tl 240 2.-..-. 166 97 190 258 62 .".1 179 2 IS 2is 1 58 68 21 1( ) 239 160 108 34 238 ss L09 223 237 l_'s I I'.i IMS Gyn.- Gyn.- Gyn, <;>•„, Gyn, ( iyn.- ( Ivn.- Gyn, < ,VII, ( iyn.- Gyn, Gyn, Gyn, ( iyn.- < ryn, ( Ivn.- Gyn, Gyn, Gyn, Gyn, Gyn, Gyn, , 185 and chorioepithelioma, differentiation, L83 and endometritis, differentiation, 184 and large and dilated uterine glands with overgrowth of struma of mucosa, differen- tiation, L80 and myoma, differentiation, 182 and polypi, differentiation, 1 78 and proliferation of stroma of uterine mucosa associated with copious uterine hemor- rhages, differentiation, 1 80 and salpingitis, differentiation, 184 and sarcoma, differentiation, 183 and tubal pregnancy, differentiation, 184 and venous sinuses in uterine mucosa, differ- enl iat ion. 1 79 arising from uterine portion of uterine horn, 235 benign character of, cases illustrating, 188 cases of diffuse, 8 causes of, 199, 262 cervical. !(>."> clinical picture in. 1 73 commencing, 20, 29, 31, '■>'■>. 50, 52, <>7. 83 condition of tubes and ovaries in, 171 diagnosis of, 175, 261 differential, 177 diffuse, cases of, 8 and squamous-cell cancer of cervix, 206 hypertrophy of cervix and. _'on V.den< myoma, diffuse, of uterine horn, 235, 246 origin of, 193 prognosis in, 187, 262 symptoms of , ] 73, 261 treatment of, 186, 261 discharge in, 1 7:; discrete, 60, I 10 in left uterine horn. 100 of utero-ovarian ligament .ill from tubal portion of uterine horn, 236 hemorrhage in, 17:; incidence of, 17 1 in one horn of bicornate uterus, 203 in right and left round ligament in same person. 25 1 interst itial, P'' s intraligamentary, 1 15 case of, 149 cystic, 1 18 of round ligament . 250 origin of, '-'.YJ of uterine horn, 29, 52, 67, LOO, 1 17. 119, 235, 237, 239, 240, 241,242, 244, 245, 246 decidua developing in adenomyoma of, 246 origin of, 1 93 pain in, 1 73 physical examinat ion in, 1 75 prognosis in, 187 relat ion of, to pregnancy, 1 7 1 submucous, 156 cases of, 1 19, 158, L60, 161, 163 origin of, !'.»•"> subperitoneal, l'_\"> cases of, 114,128 cystic, 128 origin of, 19 1 summary of, 260 treatment of, 186 uterus preserving relatively normal contour. 2 cases of, s cystic glands in, 6 cyst-like spaces in, :> dilated glands ill. 6 elands in, I. 5, 7 26; 268 INDEX Adenomyoma, uterus preserving relatively nor- mal contour, histological ap- pearances, 5 islands of glandular tissue in, 6 thickening in, 2, 3 uterine mucosa in, 5 vaginal discharge in, 173 Adhesions, pelvic, 31, 46, 50, 67, 82, 84, 97, 103, 109, 138, 149, 245 Age at which adenomyoma occurs, 174 Atrophy of uterine mucosa, 133, 240, 241, 244 Bicornate uterus, adenomyoma in one horn of, 203 Canal, von Recklinghausen's, 7 Carcinoma and adenomyoma, differentiation, 175, 185 squamous-cell, of cervix, diffuse adenomy- oma of corpus, 206 Cervical adenomyoma, 165 Cervix, double, 161 hypertrophy of, and diffuse adenomyoma, 200 squamous-cell cancer of, diffuse adenomy- oma of corpus, 206 Chorioapithelioma and adenomyoma, differ- entiation, 183 Cyst, Graafian follicle, 82 of ovary, 34, 50, 60, 82, 93, 97, 166, 238, 245 tubo-ovarian, 29 Cystadenoma of ovary, 97, 238 with carcinomatous changes, 238 Cystic adenomyoma, subperitoneal, 128, 132 glands in adenomyoma in which uterus pre- serves relatively normal contour, 6 intraligamentary adenomyoma, 148 spaces in uterine horn, 119, 243 Cyst-like spaces in adenomyoma in which uterus preserves relatively normal contour, 5 Cysts, multiple, in subperitoneal myoma, 128, 132 Decidua developing in stroma of adenomyoma of uterine horn, 246 Diagnosis, 175 differential, 177 from abortion, 183 from cancer, 185 from chorio-epithelioma, 183 from endometritis, 184 from large venous sinuses in the mucosa, 179 Diagnosis, differential, from marked prolifera- tion of the stroma of the mucosa, 180 from myomata, 182 from polypi, 178 from salpingitis and endometritis, 184 from sarcoma. 183 from tubal pregnancy, 184 from very large and dilated uterine glands with overgrowth of stroma of mucosa, 180 Dilated glands in adenomyoma in which uterus preserves relatively normal contour, 6 Discharge in adenomyoma, 173 Double cervix, 161 vagina, 161 Edema of uterine mucosa, 50, 128, 133 Endometritis, and adenomyoma, differentiation, 184 chronic, 45 slight, 22, 41, 117 subacute, 64 Endometrium, gland hypertrophy of, 140, 149, 246. (See Mucosa.) Fallopian tube, left, pregnancy in, 246 accessory ostium of, 241 tubes, condition of, in adenomyoma, 171 Gland hypertrophy of endometrium, 140, 149, 246 Gland-like spaces in uterine horn, 240, 241, 244, 245 Glands, cystic, in adenomyoma in which uterus preserves relatively normal contour, 6 dilated, in adenomyoma in which uterus preserves relatively normal contour, 6 in adenomyoma in which uterus preserves relatively normal contour, 4, 5, 7 uterine, large and dilated, with overgrowth of stroma of mucosa, adenomyoma and, dif- ferentiation, 180 Glandular tissue, islands of, in adenomyoma in which uterus preserves relatively normal contour, 6 uterine polyp, 75,97, 178 Graafian follicle cyst, 82 Hauptkanal of von Recklinghausen, 7 Hematosalpinx, 109 Hemorrhage, into and thickening of uterine mucosa, 24 I \ I ) E X Hemorrhage from venous sinuses in uterine mucosa, adenomyoma and, differentiation, IT'.* in adenomyoma, lT.'i Hydrosalpinx, 29, 166, 241 Hypertrophy, gland, of endometrium, 140< 149, 246 nt cervix ami diffuse adenomyoma, 200 I.vtkusti ii \i. adenomyoma . 138 Intraligamentary adenomyoma, I 15 case of, 1 I'.t cysl ic, l I s Ligament, round, adenomyoma of, 250 origin, _'.v_' right and left, adenomyoma in, in same person. '_'."> ( utero-ovarian, discrete adenomyoma of, 141 Miliary abscesses of ovary. 240 Miniature uterine cavities, 3, 69, 100, 141. 161 Mucosa, uterine. ;i trophy of, 133, 240, 241, '_' 1 1 edema of, 50. 128, 133 hemorrhage into and thickening of. 24 hypertrophy of, 140, 149, 246 in adenomyoma in which uterus preserves relatively normal contour. ■>. 97, 166, 238, 241 witli carcinomatous changes, 238 miliary abscesses of. 2 K) papillocystoma of, 166 P \i\ in adenomyoma, 173 Papillocystoma of ovary, 1 * • » » Pathological changes, multiple, in the pelvis 228 Pelvic* adhesions, 24, 31, :;.;. 34, 16 17 07, 82, 84, 97, 103, 108, 109, 138, 1 19, 166, 171. Jin. 245 Pelvis, pathological changes i: Physical examination in adenomyoma, 17.'» Polyp, ami adenomyoma. differentiation, 17^ glandular uterine, 7.">. 07 Pregnancy, in lefl Fallopian tube, 246 relation of adenomyoma to. 17 1 tubal, and adenomyoma. differentiation, 1M Proliferation of stroma of uterine mucosa asso- ciated with copious uterine hemorr adenomyoma and. differentiation, 180 Purulenl salpingitis, acute. 10 Eioi \ii ligament, adenomyoma of. 250, 252 right ami left . adenomyoma in. in -aim- person, 254 Salpingi : 1-. 84, 171 acute purulent. 16 and adenomyoma. differentiation, 1M chronic. 46, 240, 244 Sarcoma and adenomyoma, differentiation, 183 Sinuses, venous, in uterine mucosa, and adeno- myoma, differentiation, 179 S.|iiainous-cell cancer of cervix, diffuse adeno- myoma of body, -06 Stroma of uterine mucosa, proliferation sociated with copious uterine hemorr e adenomyoma and. differentiation, l^n Submucous adenomyoma. 149, 156, 158, 160, mi. 103 cases of. 1 58 origin of. 195 Subperitoneal adenomyoma. 114. 125, 138, 139, 1 XI. 1 t:. cases of, 128 cystic, 128, 132 origin of. p.i 1 multiple cysts in. 128, 132 Thickening, and hemorrhage from uterine mu- cosa , 2 l in adenomyoma in which uterus pr< - relatively normal contour. _' diffuse 'if uterine wall, but no glandular invasion. 1 t. 22, 1. 230 Tubal portion of uterine horn, adenomyoma from. 236 pregnancy and adenomyoma, differentiation. 184 270 INDEX Tubes, condition of, in cases of adenomyoma, 171 Tubo-ovarian abscess, 47 cyst, 29 Uterine glands, large and dilated, with over- growth of uterine mucosa, adenomyoma and, differentiation, 180 horn, abscess in, 244 adenomyoma in, 29, 52, 67, 100, 117, 119, 235, 237, 239, 240, 241, 242, 244, 245, 246 tubal portion of, adenomyoma from, 236 uterine portion of, adenomyoma arising from, 235 mucosa, atrophy of, 133, 240, 241, 244 edema of, 50, 128, 133 hemorrhage and thickening of, 24 hypertrophy of, 140, 149, 246 in adenomyoma in which uterus preserves relatively normal contour, 5 Uterine mucosa, polypi of, 75, 97, 178 stroma of, proliferation, associated with copious uterine hemorrhages, adenomy- oma and, differentiation, 180 venous sinuses in, and adenomyoma, differ- entiation, 179 polyp, 75, 97 walls, adenomyoma of, 2, benign character, 188, 190 myomatous thickening of, 14, 22, 23, 64, 230 Utero-ovarian ligament, discrete adenomyoma of, 141 Uterus, bicornate, adenomyoma jn one horn of, 203 Vagina, double, 161 Vaginal discharge in adenomyoma, 173 Venous sinuses in uterine mucosa and aden- omyoma, differentiation, 179 Von Recklinghausen's canal, 7 .SJJmY,^ 8 ]*. un| versitv libraries III III 0023818662 ^*J ^ '\"i 9 *W>*- ^? // PPW* 1