OFFSITE co>.rrscN?N^^f^?m° ' HEAL7M HX64168123 ^^^^.^^^^,0, RG371 C894 - RECAP The Distribution of Adenomyomas Containing Uterine Mucosa By THOMAS S. CULLEN, M. B. Baltimore PROPERTY OF COLUMBIA University Geo. Crocker Special Research Fund Columbia SSnitier^itp mt^eCttpoflrtngork CoHtge of ^fjpgitians! anb ^urgeong Hibrarp THE DISTRIBUTION OF ADENOMYOMAS CONTAINING UTERINE MUCOSA BY Thomas S. Cullen Professor of Clinical Gynecology in the Johns Hopkins University and Visiting Gynecologist to the Johns Hopkins Hospital Reprinted from the Archives of Surgery September, 1920, Vol. I, pp. 215-283 Copyright, 1920 American Medical Association Press Five Hundred and Thirty-Five North Dearborn Street CHICAGO PREFACE This paper was the address in Surgery before the Western Surgical Association in Kansas City, Decem- ber. 1919. I have had it reprinted in order that my friends may have it in separate form. I wish to express my indebtedness to Mr. Max Brodel, Director of the Department of Art in Medicine, for the excellent illustrations. Oct. 1, 1920. Thomas S. Cullen. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/distributionofadOOcull THE DISTRIBUTION OF ADENOMYOMAS CONTAINING UTERINE MUCOSA* THOMAS S. CULLEN, M.B. BALTIMORE At a meeting of the Johns Hopkins Hospital Medical Society in March, 1895, I reported my first case of adenomyoma of the uterus, and since then I have been on the lookout for tumors of this character. From time to time the results of my labors have been recorded either in book form or in the literature. I have been amazed at the widespread distribution of these tumors consisting of nonstriped muscle with islands of uterine mucosa scat- tered throughout them. In May, 1919, I read a short paper on the subject before the New York State Medical Society at Syracuse. This fragmentary article was published ^ a few months later. In the present paper I shall not attempt to cover the literature on the subject, but I shall confine my remarks to a description of the cases and of the pathologic material that I have personally observed since reporting my previous cases. Thus far I have found uterine mucosa in ten places in the body as indicated in Figure 1, and I shall therefore discuss the subject under the following heads : 1. Adenomyoma of the body of the uterus. 2. Adenomyoma of the rectovaginal septum. 3. Adenomyoma of the uterine horn, or of the fallopian tube. 4. Adenomyoma of the round ligament. 5. Uterine mucosa in the ovary. 6. Adenomyoma of the utero-ovarian ligament. 7. Adenomyoma of the uterosacral ligament. 8. Adenomyoma of the sigmoid flexure. 9. Adenomyoma of the rectus muscle. 10. Adenomyoma of the umbilicus. * Address in surgery delivered before the Western Surgical Association in Kansas City, December, 1919. *From the Gynecologic Department of the Johns Hopkins University and of the Johns Hopkins Hospital. 1. Cullen, T. S.: The Distribution of Adenomyomata Containing Uterine Mucosa, Am. J. Obst. 80:130 (Aug.) 1919. ADENOMYOMA OF THE BODY OF THE UTERUS These tumors may be limited to the anterior or posterior walls of the uterus, or they may form a mantle or zone just outside the uterine mucosa. When the uterus is cut open, it is noted that the anterior or posterior wall, or both, are thickened. This increase is due to a coarsely striated condition of the muscle directly beneath the uterine mucosa. Where the uterine walls are especially thick, the diffuse myomatous growth may be several centimeters in thickness. Scattered throughout the diffuse growth, one often notes small cystlike spaces filled with chocolate-colored contents, and not infrequently with a loupe one can detect here and there uterine mucosa penetrating into the diffuse growth. Occasionally a cystlike space, 1 cm. or more in diameter, may be found in the thickened uterine wall. Such a space will usually be lined with a velvety membrane about 1 mm. thick, and the cavity will be filled with the characteristic chocolate-colored contents — old menstrual blood. The line of demarcation between the normal outer uterine mus- cular wall and the diffuse myomatous growth just beneath the mucosa is invariably sharply defined, but the two are nevertheless so closely blended that it would be absolutely impossible to separate them. Occa- sionally such a uterus will contain one or more small discrete myomas. The histologic picture in a typical case is very characteristic : The uterine mucosa is often of normal thickness and looks perfectly natural, but as we approach the underlying diffuse myomatous tissue the mucosa is seen to penetrate it in all directions, sometimes as an indi- vidual gland; but often large areas of mucosa are seen extending into the depth. In favorable sections, one can follow a prolongation of the mucosa half way through the uterus. Where the diffuse myomatous growth ends, the outward extension of the glands also ends. In the course of time, portions of the diffuse adenomyoma may project into the uterine cavity and be expelled through the cervix as submucous adenomyomas. In other instances a portion of the growth is forced to the outer or peritoneal surface forming a subperitoneal adenomyoma. Such a myoma is prone to become cystic, and the cyst cavity or cavities will be filled with chocolate-colored contents. Symptomatology. — It is not difficult to figure out to what symptoms an adenomyoma of the uterus will usually give rise. In the first place, the mucosa lining the uterine cavity is perfectly normal, hence, as a rule, we shall have no intermenstrual discharge. With the advent of the menstrual period, however, the patient will not only lose her normal quota of blood, but this will be greatly increased by the flow coming from the large areas of mucosa which are scattered through- out the diffuse myomatous growth. There will, as a rule, be a great deal of pain in the uterus at the period due primarily to the swelling of the mucosa which is scattered throughout the uterine walls. The small and medium-sized cystic spaces filled with chocolate-colored fluid are due to the accumulation of old menstrual blood in areas where the continuity of the mucosa with the uterine cavity has been interrupted. Such areas also undoubtedly add to the feeling of distention and discomfort at the period. Fig. 1. — The various points at which I have found uterine mucosa: 1, in adenomyoma of the body of the uterus; 2, in adenomyoma of the rectovaginal septum; 3, in adenomyoma of the uterine horn or fallopian tube; 4, in adenomyoma of the round ligament; 5, in the hilum of the ovary usually unaccompanied by a myomatous growth; 6, in the utero-ovanan ligament; 7, in the uterosacral ligament; 8, in the sigmoid flexure; 9, in the rectus muscle; 10, in adenomyoma of the umbilicus. On bimanual examination, the uterus is found to be normal in size and perfectly smooth, or, on the other hand, it may be two or three times its normal size and slightly nodular. The introduction of a uterine sound usually reveals a normal cavity, and on curettage normal mucosa is invariably found. From the chnical findings one can often make a fairly accurate diagnosis of adenomyoma. Generally speaking, removal of such a uterus is clearly indicated. Frequently this proves rather difficult on account of the tendency for such an organ to become densely adherent to surrounding structures. I have discussed adenomyomas of the body of the uterus in such detail elsewhere ^ that a further consideration of the subject here would be superfluous. Case 1. — A bicornate uterus zvith diffuse adenomyoma of the right horn. Pregn-ancy in the right fallopian tube. Adenomyoma and hydrosalpinx of the left tube. Large cyst of the left ovary (Figs. 2, 3, 4, 5 and 6). History (Church Home and Infirmary, No. 19173). — Mrs. H. T., aged 36, admitted to the Church Home and Infirmary, May 21, 1918, and referred to me by Dr. Marshall G. Smith, complained of an abdominal tumor, increasing pain in the right lower abdomen and vaginal bleeding. The menstrual periods as a rule had been regular, lasting two days, and she had had pain in the right lower abdomen. Latterly the periods had been irregular. The last normal period began probably Feb. 25, 1918. During March and April, she had had no menstrual period, but had suffered from the usual right-sided pain. She again had noted a flow on Maj^ 1, which had lasted one daj\ Two days had elapsed and then she had had a flow for seven days. The patient had been married twice, but had had no children and no miscarriages. On examination under anesthesia, I made out what appeared to be a myo- matous uterus which extended well up toward the umbilicus. Operation and Result.— Operation was performed May 28. When the abdo- men was opened we found the tube on the right side 4 cm. in diameter, and adherent in the pelvis. The uterus was bicornate, and the right side was three times the natural size. The surface of one of the nodules had a brownish appearance suggestive of an adenomyoma. On the left side was an ovarian cyst which filled the pelvis and was glued down by adhesions. We removed the structures from left to right and then took out the appendix which was tied down. The abdomen was closed without drainage. The patient made a good recovery and was discharged, June 18. Examination of Specimen (Gyn. Path. No. 25515). — The specimen consists of the pelvic structures intact (Figs. 2 and 3). The uterus has been ampu- tated through the cervix. This portion consists of a right and left uterine horn. The right horn is 9 cm. long and 5.5 cm. broad. This has two or three small bosses projecting from its surface, the largest being 1.5 cm. in diameter. The surface of the last and some of the others and also the adjoin- ing peritoneum has a rusty appearance, instantl}^ suggesting adenomyoma. On the anterior surface of the uterus are a few adhesions, on the posterior surface, many fanlike adhesions. Intimately blended with the right enlarged uterine horn is a left uterine horn. The two horns are separated from each other by a cleft, about 1.5 cm. deep anteriorly, but very shallow posteriorly. The left horn to the point of amputation of the cervix is 7 cm. long and about 3 cm. broad. 2. CuUen, T. S. : Adenomyoma uteri diffusum benignum, Johns Hopkins Hos- pital Reports 6:133, 1896; Adenomyome des Uterus, Berlin, August Hirschwald, 1903; Adenomyoma of the Uterus, J. A. M. A. 50:107 (Jan. 11) 1908; Adeno- myoma of the Uterus, Philadelphia, W. B. Saunders Company, 1908. On section, it is seen that both the right and the left horns have separate cavities. These apparently unite near the external os. The right horn on section presents the typical picture of adenomyoma (Fig. 4). The anterior wall of the right horn reaches a thickness of more than 4.5 cm. There is no vestige of normal muscle persisting. The entire wall of the uterus both anteriorly and posteriorly shows the striated picture characteristic of adenomyoma, and scattered everywhere throughout both the anterior and posterior walls are chocolate-colored areas varying from 1 mm. to 5 mm. in diameter, while small chocolate-colored cysts are also found in the myomatous nodules on the surface of the uterus. The walls of the left uterine horn present the normal appearance. The right tube near the uterus is about 8 mm. in diameter. As it passes outward and downward, it reaches a diameter of 4 cm. On section, it is found to be filled with what looks like organized blood (Fig. 3). Fig. 2 (Case 1). — A bicornate uterus with adenomyoma of the right horn; right tubal pregnancy; enlarged left tube, the inner end showing adenomyoma (Fig. 6), the outer end hydrosalpinx; left ovarian cyst. For the finer details see Figure 3. The left ovary has been transformed into a thin- walled multilocular cyst, 16 cm. in diameter. Its walls in places are as thin as parchment. The left tube at the uterine cornu is fully 1 cm. in diameter. As it passes outward it comes to measure about 2.5 cm. in diameter, and the walls are very thin. Histologic Examination. — Right Uterine Horn : Sections have been made embracing the entire thickness of the uterus (Fig. 5). The musculature is divided up into diffuse whorls, varying from 5 mm. to 3 cm. in diameter. Some of these are oval or circular; others are lonjg and run parallel to the cavity of the uterus. Scattered everywhere throughout the walls of the uterus are dark areas containing minute cavities in their centers. Some of these cavities have a definite lining fully 1 mm. in thickness. In various places are oval or irregular cystlike spaces varying from 1 to 4 mm. in diameter. The majority of these are partially filled with blood. Even with the naked eye the diagnosis of diffuse adenomyoma occupying both the anterior posterior uterine walls is perfectly evident. With a higher power, islands of normal-appearing uterine mucosa are seen scattered everywhere throughout the diffusely thickened uterine walls, and the glands extend right up to the peritoneal surface. Even the isolated glands are accompanied by the characteristic stroma. In this case, the muscular tis- sue immediately around the islands of mucosa is unusually dense. Some of Fig 4 (Case 1).— Adenomyoma of the right uterine horn. This is a longitudmal section through the right horn of the uterus shown in Figure 3. The entire body of the uterus shows a diffuse myomatous thickening, and scattered throughout the walls are small cystlike spaces. These were in the main filled with chocolate-colored contents. The diffuse adeno- myoma extends right up to the peritoneal surface at most points. At the fundus a discrete myomatous nodule can be seen. For the low power picture of the adenomyoma see Figure 5. the blood at the menstrual period has undoubtedly escaped to the peritoneal surface, thus accounting for the rusty appearance noted on the surface of the uterus at operation. This is the most widespread adenomyoma of the uterus that I have ever seen. The mucosa lining the cavity of the uterus is perfectly normal. In a few places, however, it shows some tendency to extend into the underlying muscle. 8 Right Side : Sections from the blood clot in the right tube show t^-uantities of placental villi. On some of these both Langerhans' layer and syncytium are still visible, and one is also able to make out syncytial buds. At other points, the villi have lost all trace of epithelium. No cellular structure is visible in the stroma, and the cells are recognized as mere shadows. Their contours are still perfectly preserved. We are dealing with a right-sided tubal pregnancy, and as we look back over the history we find that the menstrual cycle strongly indicated extra-uterine pregnancy, but that the relatively large size of the pelvic masses completely overshadowed the enlargement of the tube. Left Side : As was noted macroscopically, the left tube even near the uterus is unusually large. A section taken 2 cm. beyond the uterine horn is 1 cm. in diameter. Even with the low power it is noted that it is almost solid (Fig. 6). Its center is occupied by diffuse myomatous tissue, and scattered everywhere throughout this are glands which resemble in every particular uterine glands. The majority of these lie in direct contact with the muscle, but here and there are several glands embedded in the characteristic stroma of the uterine mucosa. Some of the glands are dilated and at one or two points we can see miniature uterine cavities. We have in this tube an adeno- myoma of the uterine type, and I am totally at a loss to e>;plain its mode of origin. Sections from the large ovarian cyst show that the largest cavity is lined with epithelium that is almost flat. In the walls of this large cyst are a few glandlike spaces lined with cuboidal epithelium. The cyst walls are composed of laminated fibrous tissue. In this case, we have a most unusual combination : a bicornate uterus, the right horn of which presents a most beautiful example of diffuse adenomyoma ; a right tubal pregnancy; adenomyoma of the inner end of the left tube and a hydrosalpinx of its outer end, and finally, a large multilocular cyst of the left ovary apparently of the retention cyst variety. ADENOMYO'iVIA OF THE RECTOVAGINAL SEPTUM ^ I wish to lay unusual emphasis on this group of cases. Many of you have undoubtedly seen them, but may not have recognized them. They are of unusual importance, and, if overlooked, will in time cause the patient to become a chronic invalid, and in some instances will undoubtedly lead to her death. In 1913, Dr. D. S. D. Jessup of New York, knowing my interest in adenomyomas, sent me specimens of two tumors of this class. The mail on the following morning brought me the Proceedings of the Royal Medical and Chirurgical Society of London, containing Cuth- bert Lockyer's splendid article on "Adenomyoma of the Rectovaginal Septum." These two communications set me thinking, and I at once felt sure that two of my cases undoubtedly belonged in this category, 3. Cullen, T. S. : Adenomyoma of the Rectovaginal Septum, T. A. M. A. 62:835 (March 14) 1914; Tr. South. Surg. & Gynec. A. 26:106, 1913; A Further Case of Adenomyoma of the Rectovaginal Septum, Surg., Gynec. & Obst. 20:260 (March) 1915; Adenomyoma of the Rectovaginal Septum, Bull. Johns Hopkins Hosp. 28:343 (Nov.) 1917. f ts. n Fig. 3 (Case 1). — Diffuse adenomyoma of the uterus. This is a longitudinal sein slit a, noted in the lower and right portion of the picture, represents the uterine c: whole present the usual appearance. The posterior wall of the uterus is somewhat a diffuse myomatous thickening, and where the muscle is arranged in whorls then are dilated, forming round, oval, or irregular cyst cavities. The glands extend righ n adenomyoma of the uterus. "^ 7. : da to ,_. a, \ through the right horn of the uterus shown in Figures 3 and 4. The longitudinal J It can be traced upward and toward the left: The glands of the mucosa on the ■kened and the anterior wall markedly so. The greater part of the uterus presents nearly always a gland or a colony of glands in its center. Many of the glands to the peritoneal surface. The picture is that of a most pronounced diffuse although the histologic examination had given no inkling of such a condition. I had many more sections made and was finally rewarded by finding in each case the typical picture in other portions of the specimen. Since then I have been on the lookout for this condition and have had nineteen cases. Adenomyoma of the rectovaginal septum usually starts just behind - the cervix, and on bimanual examination, one can feel in this region a small, somewhat movable nodule scarcely more than a centimeter in diameter. The rectal mucosa at this time can be made to slide per- fectly over the tumor. As the growth increases in size, it spreads out laterally and at the same time becomes blended with the adjacent anterior rectal wall. Later it may invade the broad ligaments, encircling the ureters, or may envelop pelvic nerves. With the extension of the growth, it may push down into the posterior vaginal vault forming definite and well-formed vaginal polypi, and finally, it may break into the vagina. The histologic picture is typical of adenomyoma ; even the vaginal polypi consist of nonstriped muscle and uterine mucosa covered over by vaginal mucosa. Where the growth has definitely broken through into the vagina, we have normal-appearing uterine mucosa lining por- tions of the vaginal vault. The clinical picture in adenomyoma of the rectovaginal septum is typical. In the early stages, the patient comes complaining of much pain just before and at the beginning of the period especially at the time of defecation. On bimanual examination a small nodule is felt directly behind the cervix. When the process is more advanced, the growth may measure 2 or 3 cm. across and may bulge slightly into the rectum, while in some cases there is already marked thickening of the anterior rectal wall for a distance of several centimeters, and at the period there may be some rectal bleeding. The growth sometimes encircles one or both ureters. At the period, the tumor tissue naturally swells up, and it may so constrict one or both ureters that there is a damming back on one or both kidneys with consequent pain in the renal region. In other cases when the pelvic nerves are caught in the growth, excruciating pelvic pain may be experienced as soon as the tumor becomes congested at the time of menstruation. Occasionally, as the growth progresses, the polypoid condition in the vaginal vault directly behind the cervix becomes very prominent, and in those cases in which the growth breaks through the vaginal mucosa, there may be a menstrual flow from the vaginal vault even when a supravaginal hysterectomy has been performed some years before for uterine myomas. Finally, if nothing is done, the pelvis 10 may become so choked with the growth that the patient dies from the extreme loss of blood coupled with partial intestinal obstruction. In the early stages of the growth, this condition should be readily diagnosed. It cannot at this time be confused with any other pelvic lesion. Treatment. — In the very early stages it may be possible to open up the vaginal vault just behind the cervix and remove the tumor. As Fig. 6 (Case 1). — Adenomyotna of the left fallopian tube. This section was taken from the left tube seen in Figure 2, about 2 cm. distant from the uterine horn. Here the lumen of the tube is almost completely replaced by a diffuse myomatous growth with isolated glands or groups of glands scattered throughout it. The majority of the glands lie in direct C9n- tact with the muscle, a few are surrounded by the characteristic stroma of the uterine mucosa. Quite a number of the glands in the outlying portions have become dilated, form- ing small cysts. Hitherto I have never seen the lumen of the tube occupied by an adeno- myoma. The distal end of the tube formed a hydrosalpinx. a rule, however, it involves the posterior part of the cervix and cannot be shelled out. When the nodule is 1 cm. or more in diameter and is still freely movable, the abdomen should be opened, the ureters isolated and the uterus with a cuff of vaginal mucosa removed. If the vagina is cut Fig. 7 (Case 2). — Adenomyoma of the rectovaginal wall as seen on vaginal inspection. This water color of the uterus and accompanying vaginal cuff was made by Mr. Brodel shortly after operation. The cervix itself is practically normal. Projecting from its surface are a few small Nabothian follicles. Just posterior to the cervix is a slightly bluish black cystic area about 6 mm. in diameter. This bluish black appearance is, of course, due to the accumu- lation of old menstrual blood in a small cystic area in the adenomyoma. The uterus itself is little if any enlarged. For the appearance of the adenomyoma on section, see Figure 8, and for the microscopic picture, see Figure 9. 11 completely across, one can then lift the uterus and vaginal cuff up and with more ease separate the adherent vaginal cuff from the rectum. Sometimes it will be necessary to remove a wedge of the adherent anterior rectal wall with the uterus. In cases in which the growth is widespread, a preliminary perma- nent colostomy is imperative. Later the pelvic structures can be removed en bloc. The removal of an extensive adenomyoma of the rectovaginal septum is infinitely more difficult than a hysterectomy for carcinoma of the cervix. When a hysterectomy has been performed, and a small portion of the growth has been left on the rectum, radium seems to have held the rectal growth in check. Since my last paper on adenomyoma of the rectovaginal septum appeared I have had ten more cases. The majority of these were early cases, and it is in the early cases that we naturally get the best results. History will undoubtedly repeat itself. Twenty-five years ago, a subacute or chronic appendix was rarely removed ; but appendix abscesses were drained. Now the appendix is, in the vast majority of cases, removed in time. In less than ten years, I feel sure that the surgeon will recognize and operate on these adenomyomas of the rec- tovaginal septum long before the wall of the rectum or the broad liga- ments have been involved. Given a small nodule directly behind the cervix with little evidence of pelvic infection, the diagnosis is relatively certain. If the abdomen is then opened and the rectum is found lifted up and adherent to the posterior part of the cervix, the chances are nine out of ten that an adenomyoma of the rectovaginal septum exists. When early operation is performed in these cases, a certain number of our "mild pelvic inflammatory cases" that heretofore have gone from bad to worse will be cured. In the first week of November of this year, I saw three early cases of adenomyoma of the rectovaginal sep- tum ■ — - all of the patients being residents of Baltimore. Recently I received a letter from a surgeon in South America in which he sketched his case from the early to the inoperable stages. The history is so graphically given that I believe we shall all profit by hearing it. Valparaiso, Oct. 18, 1918. Dear Sir : Having found your articles on "Adenomyoma of the Recto-Vaginal Sep- tum" of special interest, I take the liberty of sending you details of a case which was a puzzle to two other surgeons and myself until I luckily saw a synopsis of your article on this disease in Surgery, Gynecology and Obstetrics. The said article cleared up a mystery which I had been trying to solve for months, as it is impossible to find details of such cases in well-known text- 12 books in English, German or French. I think it will be of interest for you to know of such a case and hope you will have patience to read this letter which I make as short as possible. Mrs. H., aged 30, nullipara, of good health, married two years ago, con- sulted us (in British and American Hospital) at the beginning of December, 1917, complaining of lumbago. On making a vaginal examination, we asked her about the menses which she said had been of late painful on the right side; the uterus was normal in position, size, consistency, etc. On the right side, the ovary was painful, but the puzzle was that she had a nodule espe- cially hard and painful near the uterus which we took to be localized para- metritis. We advised her to take douches, baths, ichthyol suppositories, etc., but seeing we got no result and that the pain was excruciating during the next period we decided to make a laparotomy. On January 3, we performed a median laparotomy finding a right ovary large and of a very dark, unhealthy color. The nodule mentioned before was in the broad ligament right over the vagina, and it being impossible to remove it by abdomen, we resolved to leave it. The uterus was normal so we left it as it was, removing the ovary. For three months, the patient experienced relief in symptoms, but on the fourth month menstruation was very painful and the pain radiated down to the thigh. We made again a vaginal examination and greatly to our dis- a,ppointment found now two hard nodules, the same one as before much increased in size and a second one in the recto-vaginal septum which was easier to touch by rectal examination. The pain on palpation was terrible, so we had to give the patient a few drops of ether to examine carefully. Seeing the condition of afifairs, we had a consultation with a third surgeon and he was as much puzzled as we were. We decided to remove these little tumors by the vaginal route. On May 28, we removed the two tumors by the vaginal route and our pathologist reported adenocarcinoma of an unusual type. Looking for some information on this subject, I came across the article already mentioned and immediately sent for the more lengthy article in the Johns Hopkins Bulletin which I received the day before yesterday and which has cleared up the condition of affairs to us and corrected the pathologist's diagnosis. Unluckily our patient's condition is now too bad for us to think of doing a complete hysterectomy and we think she will not live very long. She has not had as yet any rectal hemorrhage, but she has had ovarian insufficiency, very irregular menstruation and her general state is very poor. Locally the condition of the pelvis is one firm mass as you say, like glue. As I have not been able to procure your former articles, I beg your patience to answer one or two questions by post. Where does this abnormal muscular and glandular tissue come from? From the uterus, or are these sometimes remains of fetal tissue or rather embryonic tissue which suddenly give rise to the growth? Thanking you for the special service rendered to us through your articles and hoping you will let me know of any further researches in this line, believe me. Yours truly, John Wilson, M.D. 13 REPORT OF CASES OF ADENOMYOMA OF THE RECTOVAGINAL SEPTUM HITHERTO UNPUBLISHED Case 2 (Septum Case 10). ~ Adenomyoma of the rectovaginal septum recognized as an indurated area just posterior to the cervix, and by a small bluish black cyst shining through the vaginal mucosa (Figs. 7, 8 and 9). History (C. H. I. No. 18650).— Mrs. M. L., aged 41, was admitted to the Church Home and Infirmary, March 6, 1918, complaining of pain in the right ^l-' :-- *^ recto-vag. septum of fhf' ntir^f ^^^^■^^^T"'^^™^ °^ ^>^ rectovaginal septum. This is a longitudinal section rv,t Examination of Specimen (Gyn. Path. No. 24989).— The specimen consists of the uterus, right tube and ovary and appendix. The uterus is 8 cm. long, 6 cm. broad and 4.5 cm. in its anteroposterior diameters. The anterior sur- face of the uterus is smooth, the posterior surface is covered by a few shaggy adhesions, but is for the most part smooth. Projecting from the posterior surface of the cervix near the internal os is a nodule 2 by 1 cm. (Fig. 14). This is irregular. It blends into the cervical tissue, but the line of demarca- tion is sharply defined. Its superficial portion invades the surrounding adi- pose tissue. It contains a few minute brownish areas. The vaginal portion of the cervix shows some laceration. The uterine mucosa reaches 6 mm. in thickness. The right tube is normal. The right ovary contains an unruptured corpus luteum, and the peritoneum over this area has been adherent. Histologic Examination.— Tht mucosa of the vaginal portion of the cervix is normal. The cervical glands present the usual appearance. The nodule pro- jecting from the posterior surface of the cervix consists of nonstriped muscle and fibrous tissue. Scattered throughout it are small irregular islands of uterine mucosa (Fig. 15). Near the point where the growth was attached to the rectum is a rather large area of mucous membrane showing the characteristic gland hypertrophy now and then noted in the mucosa of the body of the uterus. This is a typical case of adenomyoma of the rectovaginal septum. Case 6 (Septum Case 14). — Extensive adenomyoma of the rectovaginal septum; extension to the surface of the right fallopian tube; uterine mucosa on the surface of the right ovary (Figs. 16, 17, 18, 19, 20 and 21). History (Gyn. No. 24887).— L. G., aged 40, white, was admitted to the Johns Hopkins Hospital, May 9, 1919, complaining of dysmenorrhea and menorrhagia. The patient had been in the hospital in 1912 (Gyn. No. 18377). At that time I performed a partial resection of both ovaries, released pelvic adhe- sions and removed the appendix. She was again admitted to the hospital in 1915 (Gyn. No. 20850). At that time Dr. Neill, the resident, incised and cauterized a Bartholin's gland abscess. The patient's menses were fairly regular and lasted seven days. There was a very profuse flow. The last period was April 20. There was no intermen- strual bleeding. The patient had always had very severe dysmenorrhea. This had become more distressing during the last year. The most acute pain was experienced a day before the period started. During the twenty-four hours before the onset of the flow the patient was nauseated, vomited, had extreme abdominal pain and pain in the back. These symptoms were getting worse. The patient had been married fifteen years. She had one child, fourteen years ago, and no miscarriages. Examination.— Tht patient was a rather delicate, undernourished, middle- aged woman. Her hemoglobin was 75 per cent., white blood cells, 11,000. The lower abdom,en was prominent, due to a hard mass extending up from the pelvis and reaching to within about 4 cm. of the umbilicus. The outlet was moderately relaxed and the cervix was high up in the vaginal vault. It was continuous with the abdominal tumor. Operation.— M^Y 12, 1919, on examination under ether, the pelvis was found to contain a large mass about the size of a five-months' pregnancy. On the surface of this and also posteriorly, a hard nodule could be felt. In the rectovaginal septum on the left side was a dense indurated mass. 24 When the abdomen was opened, the uterus was found to be quite sym- metrical and enlarged from the fundus to the cervix. The right tube was filled with fluid and was adherent to the uterus. The intestines were adherent to the posterior surface of the uterus. The culdesac was indurated, and the rectum was adherent well up on the posterior surface of the uterus. It was also firmly attached to the left broad ligament. The left tube was partly obscured by adhesions, and the left ovary was buried in adhesions. As a Adeno myoma myoma all of tube Adeno myoma In ovary Cervix Submucous fibroma Fig 16 (Case 6). — Widespread adenomyoma of the rectovaginal septum; extension to the surface of the right ovary and tube. The supravaginally amputated uterus was 13 cm. kmg and 11 cm. broad. Its anterior surface was smooth, its posterior surface covered by adhe- sions. Occupying the posterior surface of the cervix and extending well up on the body ot the uterus was a diffuse and hard growth. This consisted of typical adenomyoma (i^igs. 17, 18 and 19). The right tube and ovary formed one large sohd mass, and on the surface ot both tube and ovary was typical uterine mucosa (Figs. 20 and 21). This is the most wide- spread distribution of an adenomyoma of the rectovaginal septum that I have ever seen. matter of fact, the left tube and ovary and the sigmoid flexure formed one solid mass. The operation was begun by separating some loops of bowel from the pelvis, then the left round ligament was cut; the left tube and ovary were clamped off at the uterus and left temporarily in place. The bladder was pushed down 25 .2 6 -" o O 1-. s -^ u 26 and the right round ligament was cut, the right ovarian vessels were then clamped and cut. After this procedure, it was found possible to lift the uterus well up, and we then realized that without doubt we were also dealing with an adenomj'oma of the rectovaginal septum. Dissection was gradually carried down on the posterior surface of the cervix as far as possible, and a supra- vaginal amputation performed. Better exposure could now be obtained, and the stump of the cervix was dissected free. The rectum was densely adherent to the hard mass occupying the lower and posterior part of the uterus, the posterior part of the cervix and the adjacent rectovaginal septum. During manipulation a little dark blood escaped from the rectovaginal septum. To Fig. 18 (Case 6). — This picture is an enlargement of the area a in Figure 17. One sees numerous uterine glands surrounded by the typical stroma of the mucosa. A few of the glands are dilated. In the upper part of the picture is an area of characteristic stroma covered over by one layer of cylindric epithelium. have removed entirely the diffuse growth of the rectovaginal septum would have been an impossibility. As it was, it was one of the most difficult hyster- ectomies I ever attempted. The ureters were not exposed on either side, but they could be seen through the pelvic peritoneum ; they were well removed from the point where the uterine vessels were controlled. The cut edge of the vaginal mucosa was then controlled all the way round, and then the broad ligaments were obliterated as far as possible. Notwith- standing our attempts to leave a smooth surface, a small amount of raw area still remained in the culdesac. Two cigaret drains were placed in the pelvis 27 and brought out through the vagina. The abdomen was then closed in the usual manner. The patient lost a considerable amount of blood during the operation but left the table in good condition. She was discharged, June 1, 1919. There was no induration in the pelvis and she felt well. We shall watch the subsequent history in this case with a good deal of interest as some of the adenomyomatous growth was of necessity left adherent to the rectum. Examination of Specimen (Gyn. Path. No. 25003). — The specimen consists of the enlarged uterus with its detached cervix and of the appendages from both sides The supravaginall}^ amputated uterus is 13 cm. long and 11 cm. in its anteroposterior diameters. The anterior surface of the uterus is smooth, the posterior surface at the fundus is covered by shaggy adhesions. The greater ^JfpfS**:. Fig. 19 (Case 6). — Adenomyoma of the rectovaginal septum. This is a section from the adenomyoma of the rectovaginal septum shown in Figure 16. The uterine mucosa is unusually abundant, forming fully half of the section. Even with the very low power it will be noted that many of the glands show hypertrophy. part of the posterior surface over an area approximately 7 cm. from above downward and 12 cm. from side to side presents a rough and ragged appear- ance. This is the area that will prove to be of the greatest interest, the appearance being due to a widespread adenomyoma occupying the posterior surface of the uterus and cervix (Fig. 16). The increase in size of the uterus is in large measure due to the presence of a submucous myoma 10 cm. in length. This projects into the uterine cavity from the posterior wall. The anterior wall of the uterus varies from 1.5 to 2 cm. in thickness, and the mucosa from 1 to 7 mm. The mucous membrane over the surface of the submucous myoma is very thin, in most places being not over 0.5 mm. thick. 28 The widespread raw area which occupies the greater part of the posterior surface of the uterus has a very ragged appearance. As noted from the description of the operation, this area had literally to be cut away from the rectum. On incising the raw area, one notes a coarse striation of the tissue, and at various points are small brownish specks. Histologic examination will show that this is adenomyomatous tissue. The lower portion of the cervix was removed after the fundus had been taken away. The vaginal portion of the cervix shows some eversion of the cervical mucosa. Right Side : The tube and ovary form a conglomerate mass which has been densely adherent to the side of the uterus as well as to the surrounding struc- tures. Notwithstanding this the fimbriated end of the tube is patent and Fig. 20 (Case 6). — Extension of an adenomyoma of the rectovaginal septum to the surface of the adherent fallopian ttibe. The gross appearance of the tube is shown in Figure 16. The folds of the tube look relatively normal. The solid black areas are blood vessels. On the surface of the tube at a-d is an area of typical uterine mucosa. It really looks as if the widespread adenomyoma of the rectovaginal septum has literally flowed over on the surface of the tube. appears relatively normal. The tubo-ovarian mass measures 10 cm. in length and at one point reaches a diameter of 5 cm. It is impossible to trace the continuity of the tube in its middle portion where it is intimately attached to the ovary and is covered by adhesions. The ovary contains at least two small corpora lutea cysts. Left Side : The appendages form an inseparable mass, 6 cm. long and about 4 cm. in diameter. They are embedded in adhesions, but the fimbriated end of the tube is patent. 29 Fig. 21 (Case 6). — Uterine mucosa on the surface of the ovary in a case of adenomyoma of the rectovaginal septum. For the gross appearance of the ovary see Figure 16. The miniature uterine cavity on the surface of the right ovary is represented by a. The lining mucosa resembles in every particular that of the body of the uterus. Some of the glands show hypertrophy. The mucosa of the adenomyoma of the rectovaginal septum seems to have overflowed to the surface of the adherent ovary. The same condition was noied on the surface of the corresponding tube (Fig. 20). 30 Flistologic Examination-. — Sections from the cervical mucosa show that it is normal (Fig. 17). Sections from various portions of the large raw area on the posterior surface of the body of the uterus and cervix present an amaz- ing picture (Figs. 17, 18 and 19). The tissue consists in large measure of nonstriped muscle, and scattered everywhere throughout this are tremendous areas of perfectly normal looking uterine mucosa. So abundant is the mucosa in many places that it forms at least one half or two thirds of the section. This mucous membrane in many places shows a tendency toward hj'pertrophy (Fig. 19). Its stroma shows a considerable amount of hemorrhage, and here and there a gland is dilated reaching a millimeter or more in diameter. This is the most widespread distribution of an adenomyoma on the posterior sur- face of the uterus that I have ever seen. . The mj-oma occupying the posterior^ wall of the uterus and projecting into the uterine cavity shows much hyaline degeneration. Sections from the right uterine cornu show that the tube at this point is perfectly normal, but sections further out, although showing a normal mucosa, reveal typical areas of uterine mucosa on the surface of the tube (Fig. 20). One gathers the impression that the uterine mucosa from the diffuse adeno- mj'oma on the posterior surface of the cervix and uterus has overflowed upon the adherent tube. On the surface of and intimately attached to the right ovarj^ is a miniature uterine cavity (Fig. 21); The glands of its mucosa show a moderate hyper- trophy. Other sections from the same ovary show a diffuse adenomyoma inti- mately blended with the ovarian tissue, so intimately attached that no line of demarcation can be detected. It must be remembered, however, that this ovary was firmly glued to and continuous with the diffuse adenom3'oma occupying the posterior surface of the uterus. Case 7 (Septum Case 15). — Adcnoviyonia of the rectovaginal septum (Figs. 22 and 23). History (Gyn. No. 24984). — C. B., aged 36, white, entered the Johns Hop- kins Hospital, June 12, 1919, complaining of pain in the left lower abdomen at the menstrual period. She also had severe headaches. The menses began at 13, were regular until six months ago when they appeared three times in a month; the last period was on June 7, the one previous on May 28. During the last two months the pain had been severe in the left lower abdomen. She gave no history of rectal bleeding at the menstrual period. Examination. — On pelvic examination, the cervix was found low in the vagina. The body of the uterus had dropped back, was irregular and nodular in outline. In the left side of the pelvis was a movable, cystic, rather tense mass about 8 cm. in diameter. Operation. — On examination under anesthesia in addition to the above find- ings, a small cystic mass could be felt on the right. June 14, the abdomen was opened and two cysts with rather opaque looking walls were seen in the pelvis. One lay up in under the left broad ligament, the other occupied the floor of the culdesac; both contained dark chocolate-colored fluid, in other words, there was a corpus luteum cj'st on each side. The cysts were resected and a small piece of ovarj' was left on both sides. After removal of the cj^st, there still remained a small adherent mass between the cervix and rectum, and there was no doubt that an adenomyoma of the rectovaginal septum existed. The ureters were isolated, the uterus freed on all sides and the vagina cut across. A small amount of adenomyomatous tissue was left adherent to the rectum. Near the completion of the operation, it was found that the left tube 31 and ovary had a very poor blood supply, and for this reason they were removed. The appendix, which was very long, was also removed. A drain was laid in the pelvis and brought out through the vagina. The abdomen was then closed. A considerable amount of blood was lost during the operation. The patient left the table in fair condition. She was discharged, July 5, 1919, in good condition. Examination of Specimen (Gyn. Path. No. 25120). — The specimen consists of the uterus and of the much mutilated a,ppendages together with the appendix. The uterus is 11 cm. long, 6 cm. broad and 4 cm. in its anteroposterior diameters (Fig. 22). The anterior surface is smooth. The posterior surface almost to the top of the fundus is covered by adhesions. Springing from the posterior surface of the cervix is a raised hard area 2.5 by 2 cm. The tissue here is exceptionally hard, and on section it presents a brownish black appear- ance. It extends into the posterior cervical wall nearly 1 cm. and spreads Adhesions .deno TYiyonta Fig. 22 (Case 7). — Adenomyoma of the rectovaginal septum. The posterior surface of the fundus is partially covered by adhesions. Springing from the posterior part of the cervix near the vaginal attachment is a well defined adenomyoma 2.5 by 2 cm. For the histologic picture, see Figure 23. out like the broad roots of a tree. It also encroaches slightly on the posterior vaginal wall. The mucosa of the vaginal portion of the cervix is somewhat everted. The mucous membrane lining the cervical canal and the cavity of the uterus presents the usual appearance. On account of mutilation it is impossible to tell which are the right and which the left appendages. One ovary has been converted into a thin-walled cyst, 7 cm. in diameter. The inner surface of this presents a dirty chocolate- colored appearance. It is a corpus luteum cyst. A .portion of the other ovary is covered by dense adhesions. It contains a corpus luteum cyst, 4 cm. in diameter. Accompanying the specimen is one fallopian tube which is perfectly normal. As noted from the history, one tube and part of one ovary were left 32 33 in place. We had in this case corpora lutea cysts on both sides, and these were covered by adhesions while both tubes were normal. The appendix is very hard, 9 mm. in diameter. The lumen of the appendix is not over 1 mm. in diameter. Hisfoloffic Examhuition. ~Tht cervical glands present the usual appearance. The mucosa lining the body of the uterus shows some small round cell infiltra- tion in the superficial layers. The growth on the posterior surface of the cervix consists of nonstriped muscle and fibrous tissue. Scattered throughout it are large and small islands of uterine mucosa (Fig. 23). The stroma of this mucosa shows a considerable amount of hemorrhage. Here and there a uterine gland lies in direct contact with the muscle. The picture is that of a typical adenomyoma of the rectovaginal septum. Mvoina Adenomyoma Fi&- 24 (Case 8;. — Multiple uterine myomas; adenomyoma of the rec.ovaginal septum. The specimen is viewed from behind. Scattered over the posterior surface of the uterus are several small myomas, and projecting into the left broad ligament is a mvoma 3.5 bv 2.5 cm. Occupying the posterior part of the cervix is a rather extensive aden'omvoma. This was densely adherent to the rectum which had been drawn up. For the histologic appearance of the adenomyoma, see Figure 25. Case 8 (Septum Case 16). — Adenomyoma of the rectovaginal septum; small multiple titerine myomas (Figs. 24 and 25). History (C. H. I. No. 22465).— C. W., aged 2,6. was referred to me by Dr. Carlton M. Cook, Oct. 9, 1919. She began to menstruate at 14, was regular; the flow was free and lasted from six to seven days. It was formerly painful for the first two days but now the pain persisted throughout the entire period and the patient had to remain in bed. Her last period ended a few days ago. It had persisted for ten days. Twelve years ago she had an abdominal operation ; several fibroids were removed, one ovary and part of the other were also taken away. 34 The patient has been worse since she had influenza in October, 1918. Examination. — The patient was admitted to the Church Home and Infirmary October 9, and operated on Nov. 4, 1919. On examining this patient under anesthesia, I felt a nodule, about 1 cm. in diameter, just posterior to the cervix and was instantly reminded of an adenomyoma of the rectovaginal septum. On the left side was an area of thickening, approximately 2 by 3 cm. As there were evidently many adhesions, a definite diagnosis could not be made. Operation and Result. — I made a median incision and found a few omental adhesions on the anterior abdominal wall. The left tube and ovary had been removed at a previous operation. The right ovary was densely adherent to the pelvic floor and also to an epiploic appendage. We decided that a removal of the uterus was indicated, more particularly as the cervix was adherent to the anterior surface of the rectum. The rectum was also drawn upward. We removed the uterus from left to right, amputating through the cervix and removing the left tube and ovary. Fig. 25 (Case 8). — Adenomyoma of the rectovaginal septum. For the gross picture, see Figure 24. The muscular growth is very dense, the glands few and far between. In the upper part of the picture is a definite gland lying in direct contact with the muscle, and the surface at a is covered by one layer of cylindric epithelium. After removing the uterus, I took out the cervix and it was necessary lit- erally to cut the posterior vaginal wall and the cervix away from the rectum. There was just the slightest area of thickening on the anterior rectal wall. After controlling all oozing, we examined the right ureter and found it nor- mal. The left ureter could not have been located without a great deal of dis- secting. The appendix was curled on itself and adherent. It was also removed. Two drains were left in the pelvis and brought out through the vagina. The patient left the hospital in excellent condition on Nov. 24, 1919. Examination of Specimen (Gyn. Path. No. 25477). — The cervix and body of the uterus when put together give a combined length of 8 cm. (Fig. 24). The uterus is 6 cm. broad and 4 cm. in its anteroposterior diameters. The anterior surface of the uterus is smooth, but nearly the entire posterior sur- face is covered by adhesions. Projecting from the posterior surface, high up, is a pedunculated bean-shaped myoma, 1.5 cm. long. There are also a few other minute myomas scattered over the surface of the uterus. Attached to the left side of the cervix and extending into the broad ligament is a myoma. 3.5 by 2.5 cm. Projecting from the center of the cervix posteriorly is a small raised area of thickening, about 1 cm. in diameter. This is where the rectum was attached to the cervix. The cavity of the uterus contains a pedunculated submucous myoma, 2 cm. in diameter. The thickening noted on the posterior wall of the cervix is hard and contains a few chocolate-colored areas. Histologic Examination. — Sections from the cervix show that the mucosa is normal. The growth on the posterior surface of the cervix consists of non- striped muscle and tibrous tissue. In the outlying portions it is interesting to Fig. 26 (Case 91. — Adenomyoma of the rectovaginal septum. The patient is shown in the knee-chest posture. Just behind the cervix and slightly to the left of the median line is a relatively globular nodule about 1.5 cm. in diameter. In this nodule were two bluish black cysts, only one of which could be clearly seen. The relation of the adenomyoma to the c«rvix and rectum is clearly indicated in the picture to the right. Althotigh no micro- scopic examination has been possible, still the diagnosis is certain. see the manner in which the diffuse myomatous growth is gradually replacing the adipose tissue. Here and there in the dittuse growtli is a uterine gland usually lying in direct contact with the muscle (.Fig. 25). Soine of the growth has. as was noted at operation, been left attached to the rectum. Case 9 (^Septum Case 17). — Adcnoinxonia of tlic rectovaginal septum (Fig. ze'). History. — Mrs. E. B. H.. aged 36. referred to me by Dr. Arthur Wegefarth, entered the Church Home and Infirmary Xov. 1. 1919 (Xo. 22461\ I had operated on this patient in 1917 for appendicitis. In August. 1919. while at 36 dinner, she was taken with sharp, excruciating pain beneath the right costal margin, and the pain radiated to a point just beneath the right shoulder blade. She was almost drawn double. This attack was followed by nausea and vomit- ing, and the pain was relieved only by morphin. Since then she had had eight similar attacks. The patient had been married twenty years and had one child, nineteen years ago. She also complained of pain in the left lower abdomen. Examination. — On making a pelvic examination, under anesthesia, I found the uterus normal in size. The cervix was normal, but just posterior and a little to the left was a rather globular nodule 1.5 cm. in diameter (Fig. 26). This seemed fixed to the cervix posteriorly, and on inspection it was found that projecting from the vaginal vault at this point were two bluish black cysts, about 2 mm. in diameter. On rectal examination, the nodule was made out much more clearly. It was directly beneath the mucous membrane, but the mucosa had not become adherent. It was a definite adenomyoma. Adeno myoma /agina Adeno myoma pressing on ureter Fig. 27 (Case 10). — Adenomyoma of the rectovaginal septum; discrete and independent adenomyoma in the right broad ligament pressing on and partially obstructing the ureter. Springing from the top of the uterus is a small myoma, and attached to the posterior sur- face of the uterus are a few adhesions. Occupying the posterior part of the cervix and extending upward is a diffuse adenomyoma. The right tube and ovary are normal. The left tube is normal, but the ovary contains a corpus luteum cyst. In the right broad ligament is a small discrete nodule pressing on the right ureter. It is also an adenomyoma. For the histologic picture of the adenomyoma of the rectovaginal septum, see Figure 28; for that of the broad ligament nodule, Figure 29. Operation and Result. — Nov. 4, 1919, I operated and as the patient was not complaining sufficiently of the pelvic condition, and as she had gallstones, I let the adenomyoma alone. I made a right rectus incision and exposed the gallbladder which contained a large number of small stones, the greater num- ber of which formed two conglomerate masses, each about 1.5 cm. in diameter. Some of the smaller stones were in the cystic duct. We removed the stones Z7 and drained the gallbladder. The patient was discharged much relieved, Nov. 29, 1919. A few weeks later she developed a pelvic abscess which opened spontane- ously into the vagina, and since then she has been perfectly comfortable. It may be necessary to remove the adenomyoma at a later date. Case 10 (Septum Case 18). — -Adenomyoma of the rectovaginal septum; dis- crete adenomyoma in the right broad ligament pressing on and partially obstruct- ing the right ureter (Figs. 27, 28 and 29). History. — Miss R. M., aged 42, was referred to me by Dr. Christian Deetjen on Feb. 27, 1919, com,plaining of pain in the left lower abdomen. This had been more or less constant for the last ten years and had been severe for four years. The patient had pneumonia ten years ago followed by empyema. She was admitted to the Church Home and Infirmary, Oct. 20, 1919 (No. 22402). Fig. 28 (Case 10). — Adenomyoma of the rectovaginal septum. The gross specimen is shown in Figure 27. Some of the glands are surrounded by the characteristic stroma, others lie in direct contact with the muscle. At that time a small cyst could be felt in the left side of the pelvis. Dr. Hiram Fried, the resident, felt that there might be some trouble with the ureters and suggested their catheterization. A distinct narrowing was felt on the right side not far distant from the bladder. Dr. Guy L. Hunner confirmed this finding. The right ureter was dilated on several occasions, and we finally operated on November 8. Operation and Result. — On opening the abdomen, I found a corpus luteum cyst, 4 cm. in diameter, on the left side. This was somewhat adherent. The rectum had grown fast to the posterior surface of the cervix and at this point the tissues presented a yellowish brown, rusty appearance. It was perfectly evident that we were dealing with an adenomyoma. We performed 38 « tn 3 a . o o„gS fe -S u o !- O 3 S •" O OT W 4) y ti _ 5 5 U O 5" ■" o 3^ « 1) "" p °^ ? M I C-) o.^*" ^ 0^2 39 a complete abdominal hysterectomy. The posterior vaginal wall separated from the rectum with some difficulty, but after removal of the uterus and upper vagina the bowel showed only a slight thickening. The rectovaginal growth had extended out into the right broad ligament. After its removal we could still feel a nodule far out in the broad ligament. This was 1 cm. in diameter, encroached markedly on the right ureter and had given rise to the obstruction that had been noted by Dr. Fried in his catheterization of this ureter (Fig. 27). I dissected out the ureter, drew it to one side and removed the nodule. Two drains were left in the pelvis and brought out through the vagina. The patient had an uneventful convalescence and was discharged Nov. 30, 1919. Examination of Specimen (Gyn. Path. No. 25486). — The uterus is 7 cm. long, 4 cm. broad and 3 cm. in its anteroposterior diameter. Anteriorly it is smooth. The posterior surface is covered by adhesions. At the fundus pos- teriorly is a myoma, 1.5 cm. in diameter, and below this a minute myoma. Springing from the posterior surface of the cervix, is a nodular thickening, 1.5 cm. in diameter, and extending off from this point is the nodule that was pressing on the right ureter. The uterine walls vary from 1 to 1.5 cm. in thick- ness, and in the fundus the muscle presents a very coarsely striated appearance reminding one somewhat of an adenomyoma. The uterine mucosa is rather thin. Right Side : The tube and ovary are normal. Left Side : The ovary contains a corpus luteum cyst, 3 cm. in diameter. The ovary is covered by a few adhesions. Histologic Examination. — The vaginal portion of the cervix presents the usual appearance. The cervical mucosa is gathered into folds and tends to form small polypi. A few of the glands are dilated, but the cervical mucosa as a whole is relatively normal. The section from the growth on the posterior surface of the cervix con- tains a young myoma, 3 mm. in diameter. The diffuse growth consists of nonstriped muscle and fibrous tissue. Scattered throughout it are small areas of uterine mucosa (Fig. 28). Few of these areas contain more than two uterine glands accompanied by the characteristic stroma. Here and there is a dilated gland. The nodule from the right broad ligament, the one that was pressing on the right ureter, consists for the most part of adipose tissue (Fig. 29). Scattered throughout the fat are a good many large blood vessels and passing off from these are young strands of connective tissue which tend to separate the indi- vidual fat globules from one another. The outer end of the growth consists of an irregular mass of fibrous tissue and nonstriped muscle. This fibromus- cular mass sends prolongations into the surrounding fat and in the nodule itself some fat still persists. Scattered throughout the muscular tissue are uterine glands occurring singly or in groups. When in groups, they are sur- rounded by the characteristic stroma which shows some hemorrhage. When singly, they lie in direct contact with the muscle. Some of the glands are dilated. This is a ca^e of adenomyoma of the rectovaginal septum. There is also a discrete adenomyoma apparently independent of the uterus and pressing on the right ureter. The preceding cases have come under my individual care. The following case of adenomyoma of the rectovaginal septum is a rather advanced one and is well worth recording. The operation was per- 40 formed at the Hebrew Hospital by Dr. Alfred Ullman, and the speci- men was sent to me for examination. The history was furnished me by Dr. E. H. Teeter. Case 11. — Adenomyoma of the rectovaginal septum. History. — M. H., aged 46, was admitted to the Hebrew Hospital, April 24, 1919, complained of bleeding for nine weeks, and that she felt very sore and tired all over. She had not had any previous illness. Her menses began at 13, were regular, and usually lasted from seven to nine days. The flow was always excessive and was accom,panied by pain in the left lower abdomen for three days. In June, 1918, her menses stopped for three months and then there was a little bleeding for a couple of days. The bleeding soon returned and had persisted for the last nine weeks. It had been very severe. On vaginal Libe Adenomyoma of left round ligament Myoma Fig. 30 (Case 12). — Adenomyoma of the left round ligament. The uterus contains several small discrete myomas. The left round ligament near its uterine attachment contains a spherical myoma, 1.5 cm. in diameter. This was adherent to the tube at its inner end. Lying between the round ligament nodule and the tube and adherent to both was a loop of small bowel. The left tube is unusually thick. Its fimbriated end is constricted but open. The tube on histologic examination showed slight inflammation. The ovary contained a corpus luteum. It was slightly adherent. For the low power picture of the adenomyoma of the round ligament, see Figure 31; for the higher power, Figure 32. examination, April 25, Dr. Teeter made the following note : "Vaginal outlet somewhat relaxed, cervix normal. The uterus and cervix are tied hard and fast and cannot be moved. The uterus itself is normal in size.* Just posterior to the cervix is a growth in the vaginal vault causing puckering of the vaginal mucosa. This growth is hard and is glued fast to the rectum. On rectal examination, the mass is found to be adherent to the rectum, but the growth does not involve the rectal mucosa." There was a profuse bloody discharge from the uterus and Dr. Teeter at once made a diagnosis of adenomyoma of the rectovaginal septum. 41 A complete abdominal hysterectomj^ was performed by Dr. Alfred Ullman on April 26, and the patient was discharged May 20. Examination of Specimen (Gyn. Path. Xo. 25513). — The uterus is 9 cm. long, 6 cm. broad and 5 cm. in its anteroposterior diameters. The anterior surface is smooth as is also the posterior surface. Just anterior to the insertion of the right tube is a myoma, 6 mm. in diameter . Springing from the posterior surface of the cervix and extending over to the right side and also involving the posterior vaginal wall is a hard, irregular ^ \ " Fig. 31 (Case 12). — Adenomyoma of the round ligament. This is a low power photo- micrograph of the round ligament nodule seen in Figure 30. Nearly one half of the tissue consists of islands of perfectly normal uterine mucosa. For the high power, see Figure 32. growth, 4.5 cm. broad and 2.5 cm. from above downward. It is exceedingly firm and where it involves the vagina are five or six dark brown areas of discoloration. These vary from 1 to 2 mm. in diameter. On section, the growth reminds one of myomatous tissue, and scattered throughout it are a few irregu- lar cavities filled with a yellowish brown or yellow material. The cavity of the uterus looks normal. 42 Histologic Examination. — Sections through the vaginal portion of the cervix and also through the adjoining vaginal wall reveal a normal mucosa. Beneath the vaginal mucosa the dense stroma contains isolated uterine glands. The small chocolate-colored cysts noted beneath the vaginal mucosa are filled with blood. They are lined with one layer of cylindric epithelium, and projecting into one of the cysts is a small knoblike elevation of typical stroma of the endometrium of the body of the uterus. Some of these cj'sts lie in direct contact with the surrounding muscular and fibrous tissue, others are separated by a definite endometrial stroma. The growth on the posterior surface of the cervix and involving the pos- terior vaginal wall consists of nonstriped muscle and fibrous tissue. Here and there small areas of adipose tissue have been enveloped. Scattered throughout the growth are isolated uterine glands and groups of glands. Nearly all of these glands are surrounded by the characteristic stroma, and some of them are filled with blood. The case is one of adenomyoma of the rectovaginal septum. It is in just such a case that we would later expect to find vaginal polypi had the opera- tion been delayed for a year or two. ADEXOMYOMA OF THE UTERINE HORN OR FALLOPIAN TUBE In addition to the diffuse adenomyoma of the uterus, one finds another variety of adenomyoma in this organ. These are the small adenomyomatous nodules noted in one or both uterine horns. They vary from a few millimeters to about 2 cm. in size and are often asso- ciated with an old inflammatory process in the tubes. These growths usually contain many isolated glands embedded in nonstriped muscle and inflammatory tissue. The glands usually lie in direct contact with the muscle and are devoid of the characteristic stroma. Adenomyoma of the uterine horn can, as a rule, hardly be looked on as a distinct clinical entity, but rather, I think, as part of the end-result of a mild inflammatory process. In a case (Gyn.-Path. No. 25515) in which we had a bicornate uterus, and a most extensive adenomyoma of the right cornu, the left tube 2 cm. beyond the uterine horn was 1 cm. in diameter. On his- tologic examination, it was found to be the seat of an adenomyoma. Some' of the glands lay in direct contact with the muscle, others were surrounded by the typical stroma of the uterine mucosa. I know of no other tube presenting such a picture. ADENOMYOMA OF THE ROUND LIGAMENT * In 1896, it fell to my lot to record the first growth of this character. Since then quite a number have been noted. Somewhere along the course of the round ligament, usually near the external ring, a nodule 4. Cullen, T. S. : Adenomyoma of the Round Ligament, Bull. Johns Hop- kins Hosp. 7:112 (May- June) 1896; Further Remarks on Adenomj-oma of the Round Ligament, Bull. Johns Hopkins Hos.p. 9:142 (June) 1898; Adenomyoma of the Round Ligament, and Incarcerated Omentum in an Inguinal Hernia, Together Forming One Tumor, Surg., Gynec. & Obst. 22:258 (March) 1916. 43 one or more centimeters in diameter is detected. On going carefully into the history, it will be noted that this growth swells perceptibly at the period. One patient was sent to me on the assumption that a hernia existed, but even in this case in the history it was recorded that the swelling was more painful and more prominent at the period. With the gradual increase in size of the nodule it may become intimately blended with the fascia. In my second case the diagnosis was easily confirmed at operation, even before any microscopic exam- ination had been made. The surrounding fascia had imbibed a large amount of golden yellow pigment — the remnant of old menstrual blood. Some of these growths can be removed very readily, others, how- ever, in time may become so intimately blended with the surrounding structures that they must be literally cut away. On histologic examina- tion, they are found to be made up of nonstriped muscle, fibrous tissue, and the characteristic uterine glands. Strands of fibrous tissue and nonstriped muscle spread out into the surrounding adipose tissue.. Just lately (April, 1920) we have encountered another case of adenomyoma of the round ligament in our clinic in the Johns Hopkins Hospital (Fig. 30). Case 12 (Gyn. No. 25776). — -History. — E. S., aged 36, white, was admitted to the Johns Hopkins Hospital on April 1, 1920, complaining of dysmenorrhea and of bleeding between periods. She had been married four years, but had had no children. Examination. — On pelvic examination, the outlet was found to be relatively intact. Protruding from the cervix was a small polyp. The body of the uterus was in retroposition, was irregular and apparently contained five or six small myomatous nodules. High up in the left vaginal fornix was a mass, 2 or 3 cm. in diameter. Operation and Result. — April 3, 1920, Dr. Leo Brady operated and found the uterus in retroposition. It contained several small myomas. In the left round ligament near the uterus was a nodule nearly 2 cm. in diameter. The tube was adherent to this and also to a loop of small bowel. The right appen- dages were free. After the loop of bowel had been freed, a supravaginal hysterectomy was performed. The patient made a satisfactory recovery except for a slight elevation of temperature during the first week following operation when there was a friction rub. This was thought to be due probably to a lighting up of an old pleurisy. She was discharged in good condition on April 21, 1920. Examination of Specimen (Gyn. Path. Xo. 25850). — The uterus, which had been amputated through the cervix, measures 5 cm. in length, 5 cm. in breadth and 4 cm. in its anteroposterior diameters. It contains several interstitial myomas. In the left round ligament near the uterus is a spherical nodule 1.5 cm. in diameter (Fig. 30). This is partly covered by adhesions. The left tube reaches a diameter of 1 cm. Its fimbriated end is constricted but open. The OA^-ary is normal in size. It contains a corpus luteum and is partly covered by adhesions. Histologic Examination-. — This shows that the nodule in the left round liga- ment is riddled with large islands of typical uterine mucosa (Figs. 31 and 32). 44 UTERINE MUCOSA IN THE OVARY In 1898 my colleague, Dr. William Wood Russell, reported a case in which the ovary, although showing little increase in size, contained large islands of uterine mucosa. The report of this case was published Fig. 32 (Case 12). — Adenomyoraa of the round ligament. For the gross appearance, see Figure 30, and for the low power picture, Figure 31. The round ligament nodule consists of myomatous tissue. It contains large quantities of normal uterine mucosa. in detail in the Bulletin of Johns Hopkins Hospital for that year, and the article is freely illustrated. Within the last year Dr. Charles Norris of Philadelphia sent me a section of a relatively small ovary containing a large island of normal uterine mucosa (Figs. ZZ and 34). 45 Dr. DeWitt B. Casler, of our department, at the 1919 meeting of the American Gynecological Society reported a unique case which has a definite bearing on this subject. The patient, a trained nurse, 38 years of age, had had excessive periods for one year. On examination the uterus was found to be three times its usual size. Hysterectomy was performed. The increase in size was due ta a diffuse myomatous thickening, and scattered throughout this diffuse growth were quantities of stroma identical with that of the uterine mucosa. This stroma, however, contained no glands. The tumor resembled in every par- ticular the picture of an ordinary adenomyoma of the uterus save for the fact that the glands were missing from the stroma. Fig. 33. — An ovary containing uterine mucosa. This is a very low power photomicrograph of a section through an entire ovary that was little enlarged. It was sent me by Dr. Charles Norris of Philadelphia. On the left is a relatively small cyst, c. At a in the sub- stance of the ovary is a large area of typical uterine mucosa. This is connected with an irregular cyst cavity. On the upper edge of the section is normal tubal mucosa, b. The tubes have evidently been intimately adherent to the ovary. In Figure 34 one sees a higher magnification of the mucosa. This patient after the complete hysterectomy still continued to menstruate regularly through the vaginal vault. A vaginal examination about three and one-half years after the hysterectomy revealed the fact that the ovary which had been left was perfectly normal in size. A little later it commenced to grow larger and when the abdomen was opened four years after the hyster- ectomy, this ovary was the size of a medium-sized grape fruit. On histologic examination great quantities of typical uterine mucosa were found scattered throughout the ovarian tumor, thus clearly explaining why the 46 patient had continued to menstruate without any uterus. The ovary contained all the essential elements, normal ova, and practically normal uterine mucosa, and the small tract left where the uterus had been removed supplied the neces- sary avenue along which the menstrual flow esca,ped. In the following case, in which the uterus was about three times enlarged as a result of interstitial and submucous myomas and in which the appendages were glued together by adhesions, the right ovary con- tained small areas of typical uterine mucosa. Fig. 34. — Uterine mucosa in the ovary. This specimen was sent me by Dr. Charles Norris of Philadelphia. For the low power picture, see Figure 33. The area of mucosa is sharply defined and consists of typical uterine mucosa embedded in the substance of the ovary. Case 13. — A myomatous uterus with adherent appendages on the right side, and on the left a small ovarian cyst containing uterine mucosa in its walls (Figs. 35 and 36). Examination of Specimen (Gyn. Path. No. 22505, Sept. 19, 1916).— The speci- men consists of the supravaginally amputated myomatous uterus together with the appendages (Fig. 35). The portion of the uterus present is 10 cm. long, 10 cm. broad and 10 cm. in its anteroposterior diameter. At the fundus anteriorly are a few omental adhesions. Occupying the posterior wall of the uterus is a myoma 8 cm. in diameter. Scattered throughout the anterior wall are several nodules, the 47 V v a a a to I" o cs u 0) c] o V, " ^ ' : ^■^^.^^"\y adenomyomi of the^rect^vSf s^ntum*^'^^^^ ^^^"" *°*""^ independent of a coexisting the sigmoid growth seen fn Figure 4^" Thl '' f Photomicrograph of a section taken from the underlying muscular walls^are Satly thickened'^^'so^ne"; d'tS^''^'^.''^ "°r^'- ^' ^ tissue were uterine glands surrounded hvtL m!o.- , .Scattered throughout the muscular brittle, and it was impossiWe to obtain th^n f ^''.^'^t^'st'c stroma. The tissue was unusually glands and stroma in the muscle sections. Nevertheless, at c we can recognize 58 Case 16 (Septum Case 19). — Adenomyoma of the rectovaginal septum with an independent adenomyoma in the sigmoid flexure near the pelvic brim, clin- ically closely simulating a carcinoma of the sigmoid and markedly narrowing the lumen of the bowel (Figs. 41, 42 and 43). History (Gyn. No. 23764. Gyn. Path. No. 23891).— Mrs. G. S., aged 26, was referred to me by Dr. Thomas E. Neill of Washington on Feb. 11, 1918. Her menses began at 13. When 14, thej- occurred every three weeks. She was dilated and curetted when 16, and was gradually having more comfortable periods. The flow now lasted three and four days, formerly it lasted from ten daj-s to two weeks. She had had severe headaches, but these had been ti_ Adeno myom^^l '///';// in lef-t rectu^jj Pig. 44. — Adenomyoma in the left rectus muscle, histologic picture, see Figures 45 and 46. Dr. Shallenberger"s case. For the diminishing. She had also had the marked intestinal symptoms referred to above. Her last period was two weeks before I saw her. She gave no history of any previous serious illness. Examination. — On pelvic examination, the outlet was found to be slightly relaxed, the cerv-ix pointed forward. Just behind the cervnx was a globular, somewhat lobulated mass, 2 cm. across, 2 cm. from above downward. It com- menced directly behind the cers'ix. The body of the uterus itself was normal in size, in good position, and no thickening could be made out on either side. On admission to the Johns Hopkins Hospital, the patient had hemoglobin of 78 per cent. She was in rather poor condition and I put her on forced 59 nourishment for two weeks before attempting any abdominal procedure. Dr. M. Bloomfield examined the lungs and found evidence of old tuberculosis in the left apex. Operation and Result.— April 4. 1918, we operated. First of all we grasped the posterior lip of the cervix and drew it forward, put a retractor in poste- riorly and then one on the right. We were then enabled to see an oval area. about 2.5 by 2 cm., directly behind the cervix (Fig. 41). This was slightly nodular and in the center of some of the nodules was a shiny condition indi- cating that at such points a small cyst existed. One or two of these were bluish black in color, and there was absolutely no doubt that we were deal- '■ ^ iS'i' irU ^. ^'1 ^. j<' „^ ^- :^>*- <-^ TT- ^'^" //.— Adenomyoma in the left rectus muscle. For the location of the tumor, see ^i'^^K : : ^ nodule consisted of nonstriped muscle and fibrous tissue, and scattered throughout it were areas of typical uterine mucosa. ing with an adenomyoma of the rectovaginal septum. The edge of the growth was slightly raised, probably 1 mm. from the surface of the vaginal mucosa. We made an incision posterior to the cervix, separated the cervix from the vagina and then on the right side we cut the vaginal mucosa near the growth and loosened it up as much as possible. We then packed the vagina tightly with gauze and made a median abdominal incision. The right tube and ovary were removed in order that we might get into the right broad ligament satis- factorily. We dissected out the right ureter, cut the right uterine artery and 60 then separated the bladder peritoneum from the anterior surface of the uterus to a point slightly beyond the median line. We gradually loosened up the growth in the right broad ligament from the peritoneum on the right side of the rectum for a short distance and then cut the vaginal mucosa around it so that we finally had the uterus shoved over to the left side and a button of the vaginal mucosa containing the growth still left attached to the rectum (Fig. 42). We had partly closed the vagina, after pulling the rectal growth down into it, when we noticed a constriction about six inches above where the rectal growth had been. Whether the growth in the upper part of the sigmoid was carcinoma or not it was impossible to tell. After examining the pelvic glands and also the liver and finding no evidence of metastases nor any enlarged lymph glands, I came to the conclusion that this might be another adenomyoma, although I had never seen one in such a position. We cut the peritoneum on either side of the sigmoid up as high as the pelvic brim, Fig. 46. — Adenomyoma in the left rectus muscle. For the location of the tumor, see Figure 44. Scattered throughout the myoma are areas of normal uterine mucosa. loosened up the rectum as far as possible without interfering with its blood supply and then pushed the sigmoid well down into the pelvis and drew the pelvic peritoneum over to the pelvic brim so we could wall off this area of the sigmoid. When we had finished the operation, the sigmoid had been pushed down extra,peritoneally. A drain was left in the lower angle of the incision down behind the uterus. The patient was in fair condition. We hoped at a later date to draw the bowel out through the vagina and perform an end to end anastomosis if possible. To have done anything more at the time would undoubtedly have caused the death of the patient. For the first twenty-four hours the patient did fairly well, but the next day she commenced to vomit a small amount of greenish fluid. There was a good deal of abdominal distention. 61 On March 7, the patient was delirious, vomited frequently, and was very- restless, tossing from side to side. On March 8, at 3 : 30 p. m., I performed an enterostomy, thinking there might be intestinal obstruction. The bowel was relatively smooth, but there was some infection low down in the pelvis. The patient died at 9 p. m. Necropsy Findings. — A definite peritonitis existed. The rectovaginal growth consisted of typical adenomyomatous tissue, and the tumor that projected in the sigmoid near the pelvic brim and markedly constricted the lumen of the bowel also consisted of characteristic adenomyomatous tissue (Fig. 43). Cuthbert Lockyer,^ in his excellent book on "Fibroids and Allied Tumors," gives us the best resume of the literature on adenomyoma. In it, he refers at length to an interesting case reported by Robert Meyer.*^ On referring to Meyer's article I found that the patient was 45 years of age, and that Professor Mackenrodt had performed a resection in 1907 as the patient had signs of stenosis of the bowel. Fig. 47 (Case 17). — Adenomyoma of the umbilicus. Dr. Guthrie's case. Projecting from the umlailical depression is a small tumor. This was 1.5 cm. long. On section it was seen to contain several small cysts. Some of them were yellowish brown color. For the low power picture, see Figure 48. For the higher magnification, Figure 49. The specimen consisted of a segment of the bowel 8 cm. in length. The bowel lumen over an area 1.5 cm. long was markedly narrowed, there being just a slitlike opening. The mesocolon at this point and also the overlying bowel mucosa were markedly thickened. In the mesocolon between the layer of fat and the muscular wall of the 5. Lockyer, Cuthbert : Fibroids and Allied Tumors, New York, the Mac- millan Company, 1917. 6. Meyer, Robert : Ueber entziindliche heterotope Epithelwucherungen im weiblichen Genitalgebiete und iiber eine bis in die Wurzel des Mesocolon ausgedehnte benigne Wucherung des Darmepithels, Virchows Arch. f. path Anat. 195 :487, 1919. 62 sigmoid was an irregular fanlike connective-tissue tumor, diffuse in character, and strongly suggesting an adenomyoma. The tumor pro- jected into the bowel and produced a folding of the overlying mucous membrane. On histologic examination, the mucous membrane of the bowel over the tumor folds was found to have practically disappeared, the surface consisting of granulation tissue. The tumor consisted of adenomyomatous tissue. Meyer's pictures leave no doubt that he was dealing with an adenomyoma of the sigmoid, an adenomyoma of a type resembling in nearly every particular that found in the uterus. This is the first case of this character that I have found any record of. It was clearly described in Cuthbert Lockyer's recent publication. On Oct. 24, 1919, I received a most interesting letter from my friend, Dr. G. Brown Miller of Washington, D. C, the contents of which have a definite bearing on the association of adenomyoma of the rectovaginal septum with secondary adenomyoma in the sigmoid. Mrs. P., aged 36, with no children, came to see Dr. Miller on June 26, 1919, complaining of profuse, prolonged and painful menstruation, pain in the pelvis and pain on defecation. She had recently lost a good deal of weight but was still well nourished although somewhat anemic. Vaginal examination showed the cervix to be large and liard, and a small polypoid tumor was protruding from the os. In the upper part of the poste- rior vaginal vault was an irregular, hard, nodular tumor mass the size of a walnut. It was intimately connected with the cervix, rectum and broad liga- ment. The rectal mucosa over the tumor was intact but was intimately adher- ent to the mass. The uterus was retroverted and moderately enlarged. A diagnosis of adenomyoma of the rectovaginal septum was made. The patient was sent to the Columbia Hospital and was operated on a few days later. I was assisted by Dr. Neill. When more carefully examined immediately before operation the nodules in the vaginal vault were seen to contain small bluish cysts the size of a pin. On opening the abdomen the first thing which attracted one's attention was a mass the size of a large lemon which was situated in the upper part of the rectum or lower sigmoid. This seemed to encircle the lumen of the bowel. The patient gave no history of hemorrhage from the bowel or of bloody stools. A total hysterectomy was performed. It was a difficult operation on account of the fixation of the uterus. In attempting to separate the growth from the rectum, an opening was made in the bowel after which the whole involve- ment of the rectum by the tumor was cut away and the rectum was sutured. No attempt was made to resect the growth in the sigmoid. The patient left the table in bad condition. Her pulse was rapid and she was much shocked. She improved and the next day was much better. I left town the following day and was hopeful that she might recover, but learned from Dr. Neill that about eight or nine days after the operation she apparently developed peri- tonitis and soon died. 63 Mahle and MacCarty " report a very interesting case of adeno- myoma of the sigmoid observed in the Mayo Clinic : Case 4. — The adenomyoma of the sigmoid occurred in a patient, aged 31, who had been married eleven years and pregnant once. She had had an appendectomy, salpingectomy, and partial oophorectomy performed elsewhere. At that time she was told that she had a tumor of the lower bowel which would Fig. 48 (Case 17). — Adenomyoma of the umbilicus. This is a low power picture of the umbilical tumor seen in Figure 47. The surface is covered with normal skin. Scattered everywhere throughout the tumor are glands, many of them cystic, and not a few surrounded by a definite stroma that stains rather deeply. For the higher power, see Figure 49. become a cancer. She presented herself at the clinic because of this tumor. Roentgen ray of the colon, and a proctosigmoidoscopic examination proved negative. 7. Mahle, A. E., and MacCarty, W. C. : Ectopic Adenomyoma of Uterine Type (A Report of Ten Cases), J. Lab. & Clin. M. 5:221 (Jan.) 1920. 64 At operation a tumor mass was found encircling the sigmoid, involving a segment of the bowel 4 cm. in length. The sigmoid and the bladder were adherent to a mass around the uterus. Twelve centimeters of sigmoid were removed as well as "tarry" cysts of both ovaries. Histologic examination of the sigmoid growth showed the char- acteristic picture of adenomyoma. Mahle and MacCarty refer to an adenomyoma of the sigmoid observed by Leitch. Further studies will undoubtedly bring to light other cases and it is highly probable that some cases heretofore considered to have been cancer were as a matter of fact adenomyomas. ADENOMYOMA OF THE RECTUS MUSCLE These growths are exceedingly rare. Dr. William F. Shallenberger of Atlanta kindly sent me a resume of the history of his case on Nov. 8, 1919. History. — Mrs. C. E. D., aged 34, had been married more than ten years. Nine and a half years ago she had an abortion. Curettage was performed for retained membranes and the dilator passed through the retroflexed uterus at the cervical uterine junction. The body of the uterus was torn half loose from the cervix before the accident was discovered. The patient evidenced considerable shock, was rushed to the hospital, the abdomen was opened and the damage repaired. Dr. Shallenberger also learned that the patient had a second pregnancy eight years ago. She went to term, had a normal labor but following labor a hematoma developed in the left broad ligament and vaginal wall. This had to be opened through the vagina. The patient's health has been very good since the last labor, aside from a slight attack of cystitis three years ago and a streptococcus infection of the foot six months ago. The menstrual history was normal in every way. Present Illness. — Three days ago the patient noticed a little soreness in the lower abdomen just to the left of the lower angle of the abdominal scar (Fig. 44). On feeling this area she noticed a small tender swelling. She thought that a hernia was developing. On inspection there was a slight fulness just to the left of the midline and slightly above the symphysis. On palpitation a small firm nodule could be felt apparently in the belly of the rectus muscle. This did not seem to be asso- ciated with the scar of the incision and there was no impulse on coughing or straining, and the nodule did not increase in size when the patient stood. Dr. Shallenberger thought he was dealing with a hernia or with a dermoid tumor of the rectus muscle. Treatment. — The patient was put to bed and an ice cap was placed over the lower abdomen. The pain and soreness were not relieved and the nodule apparently increased somewhat in size during the next four days. Dr. Shallen- berger then decided to remove the nodule. The entire lower end of the left rectus was removed. The tumor was about 2.5 to 3 cm. in length, about 1.5 cm. in breadth and 1.5 cm. thick. It had no definite ca,psule. 65 On cutting into the tumor Dr. Shallenberger found that it presented a dark grayish mottled appearance and that it was firm and fibrous in character. The operation was performed eleven months ago and the patient made an uneventful recovery. Sections from this growth sent to me by Dr. Shallenberger con- sist of nonstriped muscle. Scattered throughout this are areas of characteristic uterine stroma containing normal appearing uterine glands (Figs. 45 and 46). The cavities of some of the glands con- tain blood and in the stroma at some points is brown pigment. The tumor in the case reported by Dr. Shallenberger is without doubt an adenomyoma occurring in the left rectus muscle. It is the first one of this character that I have ever heard of. From its location it could not for a moment be confused with adenomyoma of the round ligament which, although it presents exactly the same histologic picture, is usually situated at or near the external or the internal ring. Mahle and MacCarty ' record two cases of adenomyoma of the abdominal wall : Case 2. — This patient, aged 30, complained of a tender lump, of two years' duration, in the lower abdominal wall, under a previous laparotomy scar. The lump was painful at the time of menstruation. On examination a palpable mass, 3 cm. in diameter, was found beneath the lower end of a median laparotomy scar; this was hard, nodular and painful to touch. It was apparently not attached to the uterus, and clinically, was thought to be a fibrous tumor in a previous laparotomy wound. At operation, the mass was removed ; it extended through the abdominal muscles, and was attached to the left tube about 4 cm. from the uterine horn. Case 3. — This patient, aged 46, had had a ventral suspension performed several years before and had been pregnant nine times, the last pregnancy occurring ten years before. She complained of lumps in the abdominal wall, which she had noticed for the last year. These lumps had not grown noticeably larger but had always been painful following menstruation. On examination, a mass was found in the suprapubic region, apparently in the abdominal wall, movable with it, and possibly connected with the fundus of the uterus. Clinically, it was thought to' be a fibrous growth, attached to the abdominal wall on a previously ventrosuspended uterus. At operation, the fundus of the uterus was found attached to the abdominal wall. The tumor, 8 cm. in diameter, was situated to the right of the midline, and extended down to the right side of the uterus. It was solid, with glandular, cystic areas filled with black pigment. Because of its extension into the retro- peritoneal tissue, and apparent inoperability, only a piece of tissue 6 cm. in diameter, was excised for diagnosis. ADENOMYOMA OF THE UMBILICUS From time to time a small thickening has been noted at the umbilicus in women during the child-bearing period. In some of these cases, the tumor has increased in size perceptibly at the menstrual 66 period, and in a few there has been a discharge of blood from the umbihcus at the period. (Jccasionally, small bluish black cysts have been noted in the tumor. Adenomyomas of the umbilicus are always small. On histologic examination, they are found covered over with normal skin. They consist of fibrous tissue and nonstriped muscle, and scattered through- Fig 49 (Case 17).— Adenomyoraa of the umbilicus. This section is from the umbilical nodule seen in Figure 47. In the center of the field is typical uterine mucosa. Some of the glands are dilated. out this are islands of typical uterine mucosa. When the history is characteristic, the diagnosis can be made with ease. It is not necessary for me to discuss this subject in detail, as I have devoted an entire chapter to adenomyomas of this region in my book on the umbilicus. G7 Removal of the umbilicus is all that is essential in these cases. I shall report briefly on the specimens of two cases of adenomyoma that have recently been sent me for examination. Case 17. — Adenomyoma of the umbilicus (Figs. 47, 48 and 49). History. — The specimen was sent me by Dr. Donald Guthrie of the Robert Packer Hospital, Sayre, Pa., in March, 1919. Dr. Guthrie says : "The patient is 46 years of age. She has had two children — the youngest 16 years of age. Menstruation has been regular. The patient has experienced severe pain around the umbilicus at the menstrual period. She has noticed this for two years, and at this time discovered an enlargement of the umbilicus. She never has had any discharge from it. At the menstrual period when the Fig. 50 (Case 18). — Adenomyoma of the umbilicus. The specimen was sent me by Dr. Lester Adams. The overlying skin is normal. The tumor is sharply circumscribed, has a whorled appearance, and has scattered throughout it cystic spaces and dark areas, some of them with glands in their centers. For the histologic picture, see Figure 51. 4 umbilicus was paining her, the patient experienced some inflammatory symp- toms of the bladder. She has become very nervous and fearful that she has a cancer." Dr. Guthrie sent me the specimen shortly after its removal. Examination of Specimen (Gyn. Path. No. 24792). — The specimen consists of the umbilicus and of the adjoining skin. The umbilical depression is filled with a small growth 1.5 cm. in diameter (Fig. 47). This on section appears firm, but scattered throughout it are a few cystic spaces, some of them yel- lowish brown — cancer was suspected clinically. 68 ¥'*'^l^ Fig. 51 (Case 18).— Adenomyoma of the umbilicus. The overlying skin is normal. _ Some of the glands are partially surrounded by a definite stroma, others he m contact with the myomatous tissue. For the low power picture, see Figure SO. 69 Histologic Ejicamination. — The low-power picture is well shown in Figure 48. The free surface is covered with normal squamous epithelium'. The greater part of the tumor is made up of colonies of glands embedded in a definite stroma. Quite a number of the glands are dilated and filled with grayish or brownish material. Here and there is a perfectly definite miniature uterine cavity. With a higher power it is seen that the matrix of the tumor is made up of connective tissue with bundles of nonstriped muscle scattered liberally through- out it. Everywhere throughout the tumor are glands. Some are minute and lie in direct contact with the muscle; others are larger and embedded m a rarefied stroma. Many occur in groups and are embedded in a stroma iden- tical with that of the uterine mucosa (Fig. 49). This mucosa is in some places so arranged that miniature uterine cavities occur. Some of the gland cavities are filled with blood, and here and there throughout the stroma of the growth are areas of yellowish brown pigment— the remnants of old menstrual blood. One could not wish for a more beautiful example of an adenomyoma of the umbilicus. Case 18.— Adenomyoma of the umbilicus (Figs. 50 and 51). History.— Ih'i?, specimen was sent me liy Dr. Lester Adams of the Eastern Maine General Hospital. Bangor, Me. M. G., aged il . was under the care of Dr. Hunt. An umbilical growth was removed on Nov. 8, 1916. About a year before the operation she had noticed pain at the umbilicus at the men- strual period, but at no other time. There was some increase in size of the umbilicus at the periods. Recently the pain and tenderness in the uml)ilical region had increased markedly. Examination of Specimen (Gyn. Path. No. 22657).— The specimen consists of a growth, 1.3 cm. in diameter, occupying the umbilical region. On section it is very dense, but at two points are small cysts, the larger being 2 mm. in diameter. On histologic examination, the overlying skin is found to be normal (Fig. 50). The tumor growth is made up of nonstriped muscle and fibrous tissue. Scattered throughout the tumor are large numbers of glands, some occur singly and lie in direct contact with the muscle. The majority, however, occur m groups and are separated from the muscle by a definite stroma (Fig. 51). This at some points is rarefied, but in other places is identical with that of the uterine mucosa. In at least one place is a miniature uterine cavity. Some of the glands are filled with blood, others with exfoliated epithelium and debris. In the outlyng portions of the tumor are colonies of sweat glands. This is another example of adenomyoma of the umbilicus. SUMMARY From the foregoing, we have seen that adenomyomas, consisting of a matrix of nonstriped muscle and fibrous tissue with typical uterine mucosa scattered throughout, are to be found in the uterus, rectovaginal septum, tubes, round ligaments, utero-ovarian ligaments, uterosacral ligaments, sigmoid flexure, rectus muscle and umbilicus, and that we occasionally find large quantities of normal uterine mucosa in the ovary. Adenomyomas form one of the most interesting groups of muscle that we have to deal with in the female pelvis. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2a(546)M2S G894 Gull en «6-37l C894